Urinary and faecal incontinence: psychological factors and management recommendations

BACKGROUND

Urinary and faecal incontinence substantially impacts upon physical health and is associated with significant psychological distress and reduced quality of life. Due to stigma and embarrassment, many patients do not present for management of their incontinence.

AIM

The objective of this article is to summarise the forms and causes of urinary and faecal incontinence, highlight the psychological mechanisms and psychopathology associated with incontinence, and provide management recommendations.

CONCLUSION

Urinary and faecal incontinence can have a significant impact on an individual's psychological wellbeing and quality of life. Psychological factors may either contribute to or arise from incontinence and should be addressed as part of the overall management plan.

The nature and impact of incontinence in men who have undergone prostate surgery and implications for nursing practice

AIM

The aim of this study was to increase knowledge and understanding of the nature and experiences of incontinence in men one or more years post prostate surgery.

METHODS

This descriptive study used a sample of convenience. Two hundred and twelve male participants who had undergone prostate surgery more than a year ago were asked about their experiences of incontinence. Participants were asked to fill in two questionnaires: The Expanded Prostate Cancer Index Composite and the Incontinence Impact Questionnaire. Participants were also asked about their prostate surgery, their health seeking behaviour in relation to incontinence, the type of discharge information they were given, and demographic information.

RESULTS

Sixty-six percent of participants indicated that, in the last four weeks, their overall urinary function had been a problem and 36.3% reported their bowel habits were problematic, which affected the quality of their lives. In addition, 41% of participants reported that they were not given discharge information regarding the possibility of developing urinary incontinence and sexual problems post prostate surgery.

CONCLUSIONS

Health care professionals should pay more attention to routinely providing information to all men regarding the possibility of developing incontinence or sexual problems post prostate surgery. This may assist them to better manage these problems.

[Update on fecal incontinence]

Fecal incontinence is defined as an accidental loss of stool or the inability to control defecation. There are three subtypes of fecal incontinence: passive incontinence, urge incontinence and soiling. About 8% of the adult population suffer from fecal incontinence, but only 1/3 consults a doctor. Beside the individual handicap, fecal incontinence has a huge socio-economic impact. Causes of fecal incontinence are changes in the quantity or quality of the stool and structural or functional disorders. Diagnostics encompass the medical history, clinical examination including the digital rectal examination, imaging (particularly endoanal ultrasound) as well as functional diagnostics (anal manometry and defecography). Nowadays, the most promising conservative treatment option consists of loperamide and biofeedback therapy. The most successful invasive method is the sacral neuromodulation.

Fecal incontinence: help for patients who suffer silently

Once you've identified patients with this embarrassing condition, achieving optimal outcomes hinges on your familiarity with advances like sacral nerve stimulation.

[Pelvic floor functions: from the beginning of the second phase of labor to the postpartum consultation]

Vaginal delivery can cause lesions of the various pelvic structures responsible for the mechanisms of continence. These lesions may perhaps be prevented in the future by measuring pressure generated during childbirth. Tear of the anal sphincter during childbirth is a marker of a global impairment of the urinary, ano-rectal and sexual pelvic functions in the short and medium term. Persistence of a defect of the anal sphincter is frequent in spite of immediate suture. The correlation between these defects and ano-rectal incontinence are not established in our experience. The quality of the contraction of the sphincter complex and pubo-rectal sling seems to play a more important role in ano-rectal continence after a traumatic childbirth.

[Functional outcome after hand-sewn versus stapled colonic J pouch anastomosis for rectal carcinoma]

STUDY AIM

The aim of this study was to compare the surgical and functional results of hand-sewn and stapled colonic J-pouch anastomoses after proctectomies for cancer.

PATIENTS AND METHODS

Over a 6-year period, 120 patients had a laparotomic conservative rectal excision with total mesorectal excision but without intersphincteric dissection, for cancer of the mid- and lower rectum: the colonic J-pouch anastomosis was hand-sewn for 49 and stapled for 71 patients. The functional results were assessed at 1 year, by a questionnaire completed by the patient.

RESULTS

Morbidity was 37% in the hand-sewn group and 38% in the stapled group (ns). Mean duration of surgery in the hand-sewn group was 288 minutes and in the stapled group, 246 minutes (p<0.001). At 1 year, the rate of perfect continence was 71% for the hand-sewn group and 76% for the stapled group (ns). Significantly, more patient from the hand-sewn groups used enemas (16% versus 3%, p<0.005). On the other hand, there was no significant difference between the two groups for wearing protection, urgency, number of stools a day or gas/stool discrimination.

CONCLUSIONS

There is no major difference in either the surgical or functional results between hand-sewn or stapled colonic J-pouch anastomosis by laparotomy for rectal cancer. Because it is simpler and faster to perform, a stapled pouch is preferable when the tumor site so permits.

Isolated Urinary, Fecal, and Double Incontinence: Prevalence and Degree of Soiling in Stroke Survivors

OBJECTIVES

To investigate the prevalence of isolated urinary and fecal incontinence and double incontinence in community-living stroke survivors and to assess the degree of soiling.

DESIGN

Community-based postal survey.

SETTING

Leicestershire, United Kingdom.

PARTICIPANTS

Sixty-four thousand seven hundred forty-nine community-dwelling residents (aged > or = 40) were randomly selected from the Leicestershire Health Authority register. Residents living in institutional settings were excluded.

MEASUREMENTS

Respondents were asked about previous stroke, urinary and bowel symptoms, and general health and demographic details including age, sex, and ethnicity. Urinary incontinence was defined as leakage several times a month or more often. Major fecal incontinence was defined as soiling of underwear, outer clothing, furnishings, or bedding several times a month or more often.

RESULTS

A 65% response rate to the postal survey was obtained, with the return of 39,519 eligible questionnaires; 4% (n = 1,483) reported stroke. Five percent of stroke survivors reported major fecal incontinence, with 4.3% reporting fecal and urinary incontinence and 0.8% reporting isolated fecal incontinence. Major fecal incontinence was four and a half times as prevalent in stroke survivors as in the nonstroke population, and stroke survivors were also twice as likely to report soiling of furnishings or bedding. Functional limitations influence the presence of fecal incontinence in the stroke and nonstroke population.

CONCLUSION

Fecal incontinence is common in stroke survivors, and the degree of soiling can be considerable. Future research needs to explore the effect fecal incontinence can have on the lives of stroke survivors and on how it can best be managed in those living in the community.

Levels of continence in children with cerebral palsy

Little is known about the levels of continence in children with cerebral palsy and what factors affect this. This study was conducted to determine levels of urine and stool continence in children with cerebral palsy in relation to their learning disability (LD) and mobility. The aim was to enable us to predict level of continence that can be achieved for these children with a given level of learning disability and mobility. Data were obtained from medical notes and by telephone interview on mobility, degree of learning disability and urine and stool continence of 55 children in Southern Derbyshire. Most of the children who have nil to moderate disabilities in learning and mobility were able to achieve a decent level of continence around a median age of three years. Therefore, their toilet training should be started at the usual age with ongoing support from parents/carers. In children with severe learning disability and severe immobility, the probability of continence is very slim after the age of eight years. After this age it may be better to divert resources to other aspects of care, for example nutrition and physiotherapy, to improve their quality of life.

Single-fiber electromyography correlates more closely with incontinence scores than pudendal nerve terminal motor latency

BACKGROUND

The investigation of fecal incontinence is important in deciding the most appropriate treatment. The presence of neuropathy has been shown to affect surgical outcomes adversely. Latency studies are of dubious value in assessing neuropathy; needle electromyography is the gold standard test. The relationship between these two tests and the symptoms of fecal incontinence has not been studied.

METHOD

A cohort of 57 patients underwent neurologic and symptom assessment using latency studies, concentric and single-fiber electromyography, and symptom assessment using the Cleveland Clinic Scoring System.

RESULTS

There was a significant correlation between left mean fiber density and Cleveland Clinic Scoring (correlation: 0.32, P = 0.02) but not between right or left latency studies.

CONCLUSION

Single-fiber electromyography gave relevant results that could be obtained easily on modern equipment. Latency values were not reliable.

Subtypes of anal incontinence associated with bowel dysfunction: clinical, physiologic, and psychosocial characterization

BACKGROUND

We hypothesized that functional anal incontinence with no structural explanation comprises distinct pathophysiologic subgroups that could be identified on the basis of the predominant presenting bowel pattern.

METHODS

Consecutive patients (n = 80) were prospectively grouped by bowel symptoms as 1) incontinence only, 2) incontinence + constipation, 3) incontinence + diarrhea, and 4) incontinence + alternating bowel symptoms. The Hopkins Bowel Symptom Questionnaire, the Symptom Checklist 90-R, and anorectal manometry were completed.

RESULTS

Significant group differences were found between subcategories of incontinent patients on the basis of symptoms. Abdominal pain was more frequent in patients with altered bowel patterns. Patients with alternating symptoms reported the highest prevalence of abdominal pain, rectal pain, and bloating. Basal anal pressures were significantly higher in alternating patients (P = 0.03). Contractile pressures in the distal anal canal were diminished in the incontinent-only and diarrhea groups (P = 0.004). Constipated patients with incontinence exhibited elevated thresholds for the urge to defecate (P = 0.027). Dyssynergia was significantly more frequent in patients with incontinence and constipation or alternating bowel patterns.

CONCLUSIONS

Distinct patterns of pelvic floor dysfunction were identified in patient subgroups with anal incontinence, based on the presence or absence of altered bowel patterns. Physiologic assessments suggested different pathophysiologic mechanisms among the subgroups. The evaluation of patients with fecal incontinence should consider altered bowel function.

Immediate repair of obstetric anal sphincter rupture: medium-term outcome of the overlap technique

PURPOSE

Overlap sphincteroplasty is gaining popularity in the primary repair of obstetric sphincter ruptures. This study was designed to evaluate the medium-term outcome of the overlap technique.

METHODS

Between August 1997 and October 2001, 31 consecutive females who were diagnosed with a complete third-degree or fourth-degree anal sphincter rupture underwent overlap sphincteroplasty immediately after delivery. Thirty of the females were followed-up for a median of 24 months. The outcome was assessed by clinical examination, anal endosonography, Wexner score, and pelvic floor electromyography.

RESULTS

Median 24 (range, 12-63) months after delivery, 23 females (77 percent) were free of symptoms of anal incontinence. Occasional incontinence to flatus and liquid stool occurred in 17 and 7 percent of patients, respectively. Seven percent of patients had a Wexner incontinence score of > 9. The maximum mean resting pressure was 55 (range, 20-90) mmHg, and the maximum mean incremental squeeze pressure was 37 (range, 14-95) mmHg. On anal endosonography, an unrecognized internal sphincter rupture was found in one and a failed repair in two females. Overlap of the external sphincter was demonstrated in 29 patients (97 percent). One female with anal incontinence and persisting external sphincter rupture underwent redo sphincteroplasty.

CONCLUSIONS

The median-term outcome of primary overlap repair for obstetric sphincter rupture is good; however, larger, randomized studies with a longer follow-up are needed to evaluate the advantage of this technique over the end-to-end technique.

Severity of fecal incontinence in community-living elderly in a health maintenance organization

An anonymous survey containing questions about the severity of fecal incontinence (FI)--frequency, amount, and type--and its correlates was distributed to community-living elderly at four managed-care clinics. Completed surveys were received from 1,352 respondents whose mean (+/-standard deviation) age was 75 +/- 6 years and 60% of whom were female. Approximately 19% reported having FI one or more times within the past year. Incontinence that soiled underwear or was of loose or liquid consistency was most common. More frequent FI and a greater amount of FI were significantly associated with loose or liquid stool consistency, defecation urgency, bowel surgery, and chronic health conditions. Therapies aimed at normalizing stool consistency or reducing urgency may be beneficial in lessening FI severity.

Functional fecal retention with encopresis in childhood

OBJECTIVES

The most common cause of encopresis in children is functional fecal retention (FFR). An international working team suggested that FFR be defined by the following criteria: a history of >12 weeks of passage of <2 large-diameter bowel movements (BMs) per week, retentive posturing, and accompanying symptoms, such as fecal soiling. These criteria are usually referred to as the ROME II criteria. The aims of this study were to evaluate how well the ROME II criteria identify children with encopresis; to compare these patients to those identified as having FFR by historical symptoms or physical examination; to determine whether 1-year treatment outcome varied depending on which definition for FFR was used; and to suggest improvements to the ROME II criteria, if necessary.

METHODS

Data were reviewed from the history and physical examination of 213 children with encopresis. One-year outcomes identified were failure, successful treatment, or full recovery.

RESULTS

Only 88 (41%) of the patients with encopresis fit the ROME II criteria for FFR, whereas 181 (85%) had symptoms of FFR by history or physical examination. Thirty-two (15%) patients did not fit criteria for FFR, but only 6 (3%) appeared to have nonretentive fecal soiling. Rates of successful treatment (50%) and recovery (39%) were not significantly different in the two groups.

CONCLUSIONS

The ROME II criteria for FFR are too restrictive and do not identify many children with encopresis who have symptoms of FFR. The author suggests that the ROME II criteria for FFR could be improved by including the following additional items: a history of BMs that obstruct the toilet, a history of chronic abdominal pain relieved by enemas or laxatives, and the presence of an abdominal fecal mass or rectal fecal mass.

Measuring fecal incontinence

The measurement of fecal incontinence is challenging. Because fecal incontinence is a symptom, the subjective perception of the patient must be the foundation of any evaluation of incontinence or the impact of incontinence. The lack of a criterion standard makes testing measures for reliability and validity more difficult. Despite this, many measures are available and can be divided into three broad categories: descriptive measures that do not provide summary scores; severity measures that assess the frequency and type of incontinence; and impact measures that assess the effect of incontinence on quality of life. The strengths and weaknesses of currently available measures are presented in this review.

[Dynamic graciloplasty in the treatment of severe fecal incontinence. French multicentric retrospective study]

The aim of this study was to retrospectively assess the safety and efficacy of dynamic graciloplasty performed in 5 French surgical centers involved in the treatment of fecal incontinence.

PATIENTS AND METHODS

Between March 1994 and March 2000, a total of 24 patients were treated with dynamic graciloplasty for fecal incontinence excluding case of anal reconstruction for cancer. Intramuscular leads and neurostimulators were implanted to stimulate the transposed gracilis. Continence and safety were evaluated using patients' records during hospitalisation and during the out-patient visit or further hospitalisation.

RESULTS

No death occurred. A successful functional outcome was reported for 19 patients (79%) during the follow up period. Twenty-two complications occurred including wound. Wound infection in 6 patients and tendon detachment in 4. One patient presented with an infected anal erosion leading to material explantation.

CONCLUSION

Dynamic graciloplasty is an effective procedure for patients with refractory fecal incontinence. However, the procedure has significant morbidity which seems to be correlated with the surgeons' experience. Moreover, this procedure should now be compared to the artificial anal sphincter.

Symptom indexes to assess outcomes of treatment for early prostate cancer

BACKGROUND

Patients' perceptions of treatment outcomes are important in the management of early prostate cancer, but few studies have offered reliable and responsive measures to assess the likely side effects of the most common treatments.

OBJECTIVE

To develop indexes of urinary, bowel, and sexual function, and related distress.

RESEARCH DESIGN

Prospective cohort study of the outcomes of treatment for early prostate cancer, with self-administered questionnaires completed before treatment, and 3 and 12 months afterward. Hypothesized indexes, based on a clinical model of pathophysiological side effects of treatment, were defined and evaluated with respect to reliability and validity.

SUBJECTS

Patients (n = 184) undergoing radical prostatectomy or external beam radiotherapy for early prostate cancer.

MEASURES

Urinary and bowel items pertained to frequency or intensity of symptoms of dysfunction; parallel items assessed symptom-related distress. Sexual dysfunction items assessed the quality of erections, orgasm, and ejaculation; distress was assessed by 2 items adapted from the MOS Sexual Problems (MOS-SP) scale. HRQoL was assessed by the SF-36 and Profile of Mood States.

RESULTS

Symptom and symptom-related distress indexes for urinary incontinence, urinary obstruction/irritation, bowel dysfunction, and sexual dysfunction were defined. Symptom and distress indexes in each domain were highly correlated. Responsiveness was substantial and varied by treatment in ways consistent with clinical experience. The indexes accounted for significant proportions of the variance in HRQoL measures.

CONCLUSIONS

These indexes may be used in monitoring outcomes of treatment for early prostate cancer.

Fecal incontinence in hospitalized patients who are acutely ill

BACKGROUND

Information about fecal incontinence experienced by patients in acute-care settings is lacking. The relationship of fecal incontinence to several well-known nosocomial or iatrogenic causes of diarrhea has not been determined.

OBJECTIVES

To determine the cumulative incidence of fecal incontinence in hospitalized patients who are acutely ill, and to ascertain the relationship between fecal incontinence and stool consistency, and between diarrhea and two well-known nosocomial or iatrogenic etiologies of diarrhea: Clostridium difficile and tube feeding. The relationship of fecal incontinence and risk factors for diarrhea associated with C. difficile and tube feeding in hospitalized patients was examined.

METHODS

Fecal incontinence, stool frequency and consistency, administration of tube feeding and medications, severity of illness, and nutritional data were prospectively recorded in 152 patients on acute or critical care units of a university-affiliated Veterans' Affairs Medical Center. Rectal swabs and stool specimens from patients were obtained weekly for C. difficile culture. C. difficile culture and cytotoxin assay were performed on diarrheal stools. HindIII restriction endonuclease analysis (REA) was used for typing of C. difficile isolates.

RESULTS

In this study, 33% (50/152) of the patients had fecal incontinence. The proportion of total surveillance days with fecal incontinence in these patients was 0.50 +/- 0.06. A greater percentage of patients with diarrhea had fecal incontinence than patients without diarrhea (23/53 [43%] vs. 27/99 [27%]; p = 0.04). Incontinence was more frequent in patients with loose/liquid stool consistency than in patients with hard/soft stool consistency (48/50 [96%] vs. 71/100 [71%]; p < 0.001). The proportion of surveillance days with fecal incontinence was related to the proportion of surveillance days with diarrhea (r = 0.69; p < 0.001) and the proportion of surveillance days with loose/liquid stools (r = 0.64; p < 0.001). Multivariate risk factors for fecal incontinence were unformed/loose or liquid consistency of stool (RR = 11.1; 95% confidence interval [CI] = 2.2, 56.7), severity of illness (RR = 5.7; CI = 2.6, 12.3), and age (RR = 1.1; CI = 1, 1.1).

CONCLUSIONS

Fecal incontinence is common in hospitalized patients who are acutely ill, but the condition was not associated with any specific cause of diarrhea. Because loose or liquid stool consistency is a risk factor for fecal incontinence, use of treatments that result in a more formed stool may be beneficial in managing fecal incontinence. However, treatments that slow intestinal transit should be avoided in patients with C. difficile-associated diarrhea.

Biopsychosocial treatment of defecation problems in children with anal atresia: a retrospective study

In a retrospective study, we examined whether multidisciplinary treatment based on a biopsychosocial approach and carried out by a pediatric surgeon, a child psychologist, and a pediatric physiotherapist is successful in reducing defecation problems (incontinence and/or constipation) in children with operated anal atresia (AA) (mean age 6.9 +/- 4.01 years). A second question was whether this treatment is successful in young children aged 2-5 years. The multidisciplinary approach consisted of standard medical treatment and a behavioral program to teach children and their parents adequate defecation behavior including an adequate straining technique. Forty-three children aged 2-16 years were included: 27 boys and 16 girls with AA, of whom 26 had high or intermediate and 17 low AA. Besides continence and constipation, defecation behavior and straining technique were evaluated. The children improved significantly during treatment in all aspects of defecation. No differences in effect of treatment were found between young children (2-5 years) and older ones, so this treatment seems to be equally effective in both age groups. This study demonstrates that both somatic and behavioral factors contribute to the persistence of chronic defecation problems. It is concluded that treatment of these problems in patients with operated AA should include behavioral modification techniques.

Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index

PURPOSE

The purpose of this research was to develop and evaluate a severity rating score for fecal incontinence, the Fecal Incontinence Severity Index.

METHODS

The Fecal Incontinence Severity Index is based on a type x frequency matrix. The matrix includes four types of leakage commonly found in the fecal incontinent population: gas, mucus, and liquid and solid stool and five frequencies: one to three times per month, once per week, twice per week, once per day, and twice per day. The Fecal Incontinence Severity Index was developed using both colon and rectal surgeons and patient input for the specification of the weighting scores.

RESULTS

Surgeons and patients had very similar weightings for each of the type x frequency combinations; significant differences occurred for only 3 of the 20 different weights. The Fecal Incontinence Severity Index score of a group of patients with fecal incontinence (N = 118) demonstrated significant correlations with three of the four scales found in a fecal incontinence quality-of-life scale.

CONCLUSIONS

Evaluation of the Fecal Incontinence Severity Index indicates that the index is a tool that can be used to assess severity of fecal incontinence. Overall, patient and surgeon ratings of severity are similar, with minor differences associated with the accidental loss of solid stool.

Comparison of subjective classification of stool consistency and stool water content

OBJECTIVE

The purpose of this study was to compare the stool consistency categorizations made by 39 adults with fecal incontinence and the percentage of water in their stools determined by lyophilization.

METHODS

Subjects collected all stools daily for 8 days during a baseline period and at the end of a fiber treatment period. Stool consistency was recorded as hard and formed, soft but formed, loose and unformed, or liquid. Aliquots of the stools were lyophilized to constant weight.

MAIN OUTCOME MEASURES

The main outcome measures were the percentage of stool water among stools in each consistency category and the correlation between subjects' stool consistency categorizations and the percentage of stool water.

RESULTS

The subjects were 8 men and 21 women, ranging in age from 30 to 89 years, who were participating in a study of the effectiveness of dietary fiber for treating fecal incontinence. A total of 1023 stool samples were analyzed. Significant differences in the mean percentage of water were found among the 4 stool consistency categories (hard and formed = 68% +/- 0.9%, soft but formed = 74% +/- 0.3%, loose and unformed = 80% +/- 0.4%, and liquid = 85% +/- 0.3%; P < .001). Ninety-six percent of the stools had a percentage of water within 2 SDs of the mean percentage of water of other stools in their consistency category.

CONCLUSION

This classification system of stool consistency is a valid and practical measure for clinical studies. It may be useful for clinicians and patients to evaluate outcomes of treatments directed at improving stool consistency.

[Differentiation of sphincter insufficiency and constipation after surgical anal atresia treatment: value of a new continence score]

Surgery of anorectal malformations was evaluated by continence scores, excluding constipation. The authors introduce a new score considering the case history and clinical parameters that differentiate sphincter insufficiency and overflow-incontinence due to constipation.

[Anal incontinence: proposal of an evaluation score]

Anal incontinence is a shameful disease in which degree of severity must be assessed to design a suitable treatment and to be able to quantly the degree of relief or cure of this ailment. Therefore we have set a score table on basis of: physical features of the leakage (gas, liquid or solid) relating it to the frequency (daily, weekly or monthly) (10 to 20 points), during night time, daily light or both (1 to 3 points), hability to perceive the leakage (1 to 2 points), diapers needed (0 to 1 point), social or work limitations (0 to 2 points) (see table N. 1). Adding point, 4 degrees of severity are determinated: 1. light (type 1): less then 5 points, 2. moderate (type 2): 6 to 10 points, 3. moderately severe (type 3): 11 to 15 points, 4. quite severe (type 4): 16 to 20 points, Comparing the score of the patient before and after treatment we shall be able to know whether he has cured, just relieved, or whether there been no response.

[Fecal incontinence in pediatric age: diagnostic-therapeutic protocol and possible surgical procedures]

Fecal incontinence or soiling always endangers the personality development of a children. For very severe cases, the patient will be limited on his educational and professional training as well as on his sexal life. The outlook of severe cases, the chances of completing school, the choice of professional training and of sexual life in the future will be limited. A corrective procedure for anorectal incontinence depends on the exact investigation of all factors contributing to continence. The aim of this paper is to analyze the diagnostic aspects concerning continence in order to choose for each patient the most appropriate procedure for the treatment of all disturbance of stool control. A long term review of 312 patient with MAR, Myelomeningocele and severe stipsis with soiling was undertaken to determine the level of continence achieved. The choice between conservative measures and surgical procedures depends on clinical and manometric findings.

[Adult fecal incontinence due to anal sphincter lesions: which preoperative preparations? Which surgical solutions?]

Management of fecal incontinence due to anal sphincter lesions involves a good preoperative evaluation. This tends to confirm the incontinence, to search its mechanism, and to classify it according to the type of sphincter lesion owing to manometry, ultrasonography, and defecography. The surgical option is discussed after failure of medical treatment and biofeedback. The aim of surgery is to restore the incontinence and to maintain the exemption function. The surgical procedures include the sphincter repairs, the sphincter substitution, or even colostomy. Among the procedures of sphincter repairs, the direct repair is performed for obstetrical ruptures or postsurgical lesions of the anal sphincter, and the pelvic floor repairs are performed for fecal incontinence with intact but poorly functioning sphincter. Failures of these conservative methods lead the surgeons to develop new techniques for anal sphincter substitution. Dynamic graciloplasty and artificial sphincter (both under evaluation) constitute currently the promising alternatives to colostomy.

Current urologic management of cloacal exstrophy: experience with 11 patients

PURPOSE

Since 1980 the authors have treated 12 infants with cloacal exstrophy (10 classical and 2 variants). Eleven patients had repair, and are all surviving. The initial phases of management that led to improved survival have previously been reported. Quality of life is now a major focus for the cloacal exstrophy patient. During the past 10 years, nine of the 11 patients had lower urinary tract reconstructive procedures. This review evaluates experience with reconstructive efforts to achieve bowel and bladder control and to improve the quality of life in this complex group of patients.

METHODS

Through review of patient charts and by patient interviews, data were collected to evaluate the ability to provide urinary and bowel control. A continence score was applied to provide a measure of success: voluntary control, 3; control with an enema program or intermittent catheterization, 2; incontinence with a well-functioning stoma, 1; and incontinence without a stoma, 0. The best continence score is 6 (genitourinary and gastrointestinal). Surgical complications, urodynamic and metabolic sequelae of continent urinary diversion were reviewed.

RESULTS

At the time of the authors' previous report, eight of 11 patients had a continence score of 2 or less. Currently, eight of 11 patients have a score of 3 or better (five with enteric stoma and continent urinary diversion, two with enema program and continent urinary diversion, and one with enema program and continent bladder). Urinary-diversion procedures have included two gastric augmentations and five gastric reservoirs, two of which have required subsequent bowel augmentation. Gastric augmentations carry a definite risk of metabolic problems with three of our patients demonstrating significant episodes of metabolic alkalosis. In addition, results of urodynamic monitoring suggests that gastric reservoirs may be less compliant than reservoirs formed using other bowel segments.

CONCLUSIONS

Modern principles of continent urinary diversion have been successfully applied to the cloacal exstrophy patient further improving their quality of life. Use of gastric flaps with preservation of intestinal length has been central to urologic reconstructive efforts. Use of stomach alone for formation of urinary reservoirs may produce suboptimal compliance, and composite ileogastric construction should be considered if the gastric flap is of marginal size.

[The classification and choice of the method of treatment in fecal incontinence in children]

Complex examinations of 682 children with fecal incontinence including the colonodynamic investigation, computed tomography of the pelvis and endorectal sonography have shown that disturbance of the reservoir function and defecation urge mainly take place in cases of functional disorders. Anal incontinence of an organic type can also arise without an injury of the sphincter apparatus as a result of prolapse of the mucose membrane or stenosis of the distal portion of the rectum. In such cases the operative treatment is indicated. In patients with the incompetent internal and partially injured external sphincter treatment should be started by conservative measures. When the function of the pubo-rectal muscle or of all the elements of the closing apparatus is disturbed the operative treatment is indicated. The operative correction is possible for neurogenic incontinence in order to create the ano-rectal angle. A classification of anal incontinence in children is proposed which takes into account the etiology, pathogenesis and allows the optimum treatments to be chosen.

Audit of sphincter repair. Factors associated with poor outcome

PURPOSE

This study was designed to critically analyze the outcome of sphincter repair and, if possible, to identify high-risk factors.

METHODS

Clinical and physiologic assessment was made of all sphincter repairs (42 patients) performed in one unit by two surgeons during five years.

RESULTS

Forty-two patients (10 men, 32 women) underwent sphincter repair. Only three of five men with anterior defects of the anorectum from perineal trauma were rendered continent. Only three of five men with defects from fistula operations became continent, but one improved by later graciloplasty. All six women with fistula-related injuries eventually achieved continence, but two required repeat sphincter repairs because of early breakdown from sepsis. The worst results were in 26 women with third-degree obstetric injuries, of whom 11 remain incontinent; poor results in this group were associated with gross perineal descent, obesity, and age older than 50 years; two or more of these factors indicated a poor outcome. Preoperative anorectal physiology did not identify a poor-risk group.

CONCLUSIONS

Poor results were identified in women with anterior defects from obstetric trauma, especially if they were obese, older than 50 years of age, and had perineal descent.

Use of the Minimum Data Set to rate incontinence severity

OBJECTIVES

To assess the relationship of the MDS incontinence severity ratings to direct measures of incontinence frequency.

DESIGN

Two methods of measuring incontinence were compared: the MDS rating as recorded by nursing home (NH) staff and physical checks for wetness performed by research staff.

SETTING AND PARTICIPANTS

A total sample of 293 older residents from nine nursing homes located in Iowa, the State of Washington, and the Los Angeles area were assessed once. A subsample of 49 incontinent residents were assessed twice, before and after the implementation of a prompted voiding program.

INTERVENTION

This study is a part of a larger study evaluating the use of a computer-aided incontinence management system (IMS). Incontinent residents were assessed, and, if they met predefined criteria, they were treated with prompted voiding.

MEASUREMENTS

Three measures of incontinence were used: the MDS rating recorded by NH staff, physical checks for wetness performed by NH staff while assessing residents for and treating them with prompted voiding, and physical checks for wetness performed independently by research staff.

RESULTS

There was a statistically significant correlation (r = .49; P < or = .001) between research staff wet checks and the MDS ratings, but wetness checks performed by NH staff had an insignificant correlation with MDS ratings (r = .003; P < 0.914). There was wide variability within and between NHs in the correlation. For residents who were placed on the prompted voiding program, the pre to post wet rate, as measured by research staff, improved significantly (from 28 to 14%; t = 6.73; df = 48; P < .001), whereas the pre to post MDS ratings did not change significantly (from 1.7 to 2.0; t = -1.42; df = 48; P < .075).

CONCLUSIONS

Although the MDS appears to identify incontinent NH residents accurately, its clinical utility may be limited by disagreements between actual wet check data and MDS categorical severity rankings for residents known to be incontinent. The wide variability between direct observational measures of wetness and the MDS scores denoting incontinence severity we observed may limit the potential usefulness of the MDS for detecting changes in incontinence severity. It is possible that more information and instructions are needed for staff completing the MDS if the goal is to discriminate between different levels of incontinence severity and measure changes over time in response to therapeutic interventions.

[Endoanal ultrasonography, defecography, and enema of the colon in the radiologic study of incontinence]

In the last 3 years, the authors examined 564 patients with disturbed anorectal function. Of 41 incontinent subject in this series, 30 were retrospectively analyzed to assess the diagnostic contribution of double contrast barium enema, defecography and endoanal sonography. The authors propose a classification of fecal incontinence based on imaging findings: indeed, rectal incontinence can be distinguished from pelvic and sphincteral incontinence. Large bowel enema and defecography are the examinations of choice if rectal incontinence is suspected on the basis of clinical history and possible endoscopic, manometric and electromyographic findings. Defecography is suggested if pelvic incontinence is suspected, while anal endosonography is the exam of choice in case of suspected sphincteral incontinence. Especially thanks to the recent availability of the latter technique, today radiologists can directly visualize the anal sphincteral apparatus and its lesions, yielding objective evidence of this type of incontinence too. The authors report on both limitations and indications of each diagnostic method and conclude by stressing the fundamental role diagnostic imaging plays today in the study of this disorder.

Ileal pouch pressures after defecation in continent and incontinent patients

After ileal pouch-anal anastomosis, a pouch/anal canal pressure gradient is present such that mean pressures in the anal canal exceed pressures in the pouch facilitating fecal continence. Such a relationship was not present in incontinent patients.

PURPOSE

Our aim was to evaluate characteristics of pouch pressures dynamically in continent and incontinent patients following ileal pouch-anal anastomosis (IPAA).

METHODS

A multichannel microtransducer catheter was positioned in eight continent patients and nine incontinent patients after IPAA. Twenty-four-hour recordings of pouch pressures and large pressure wave contractions were recorded when patients were awake, asleep, and after evacuation.

RESULTS

When patients were awake, pouch pressures were similar. However, nocturnal pouch pressures were higher in the incontinent group (P < 0.05). Large pressure wave amplitude was higher in incontinent patients when awake and asleep (P < 0.05). Moreover, pouch pressures failed to decline in the incontinent group after evacuation, unlike continent patients.

CONCLUSION

Compared with continent patients, incontinent patients after IPAA had persistently high phasic and basal pouch pressures at night and following pouch evacuation.

Study protocols and functional results in 86 electrostimulated graciloplasties

PURPOSE

This study analyzes different protocols adopted in 86 electrostimulated graciloplasties performed during the last eight years, comparing functional and manometry results in 63 patients.

METHODS

Electrostimulated graciloplasties were performed to construct a neosphincter after surgical removal of the anorectum for cancer in 75 patients and to substitute the anal sphincter in 11 fully incontinent patients. An intermittent stimulation protocol, using external devices, was applied in the first 68 patients, while long-term stimulation was carried out with implantable stimulators and intramuscular electrodes in the last 18 patients. Sixty-three patients remaining under study were evaluated by questionnaires, continence scores, and manometry.

RESULTS

In patients submitted to intermittent stimulation, continence was achieved in 71 percent of 42 "neosphincters" after rectal resection and in 33 percent of 3 incontinent patients. Adopting chronic stimulation, implantable stimulators and intramuscular electrodes, continence reached 100 percent and 83 percent, respectively. Significant differences were also observed in resting and voluntary pressure values between the intermittently and chronically stimulated patients. Incontinent patients showed after chronic stimulation significant increases in mean resting and maximum voluntary pressures: from 13.3 to 60.5 mmHg and from 32 to 103 mmHg, respectively (P < 0.01).

CONCLUSIONS

This study confirms the efficacy of chronic stimulation and the validity of a bilateral, "one-time" graciloplasty to reconstruct or substitute the anal sphincter.

Surgical management of anal incontinence

The complex nature of the continence mechanism is reflected in the difficulties experienced in the surgical management of patients with faecal incontinence. Apparent anatomical abnormalities may be identified but the functional outcome following surgery may be unsatisfactory. It is therefore important to improve both the selection of patients as well as the surgical procedures themselves. Selection of patients for appropriate treatment should be based on clinical findings as well as anorectal physiology tests. Most patients referred for assessment fall into one of six categories: incontinence with a normal sphincter; minor incontinence due to local anal conditions; direct sphincter injury; neurogenic ("idiopathic") incontinence; rectal prolapse; generalised neurological condition. Minor anal conditions causing incontinence must be carefully identified for appropriate treatment. A large amount of work has been done over the past ten years on the pathophysiology of major incontinence and new surgical procedures have been developed. A common difficulty is deciding whether anterior sphincter attenuation or neurogenic weakness is the dominant lesion causing incontinence; overlapping sphincter repair is indicated for the former and postanal repair for the latter. Anorectal physiology studies can be helpful in differentiating these conditions and are now used routinely in the assessment of patients.

[A new clinical evaluation scale for incontinence: its use in anorectal atresias]

We present a clinical scoring system to obtain a quantitative and accurate assessment of anorectal incontinence. We evaluate ten components, each of one is pointed between 0 and two, then overall incontinence punctuation (I.P.) is between 0 and 20. Variables define clinical data relative to patient's intestinal habits and hygienic methods, voluntary control degree of defecation and repercussion of patient's incontinence in social and physical capabilities. Punctuation lower than nine concerns to a poor continence; It is fair between nine and 14 points and 15 or higher punctuation indicates a good continence mechanism. This incontinence punctuation method (I.P.) has been applied to 23 patients, aged between two and 17 years, operated because high imperforate anus by PSARP procedure in 15 cases and by abdomino-perineal pull-through according to Romualdi-Soave technique in eight cases. We found statistic significative difference between the group of patients aged less than 5 years and the group aged between 5 and 10 years. There is not statistic significative differences between the two procedures used in surgical treatment, although I.P. is slightly higher in cases operated by PSARP procedure than in cases treated with Romualdi-Soave technique, when we compare the two groups with similar mean age.

Classification of incontinence

A clinical definition of incontinence and a clinical classification of its various forms is offered for consideration. The classification is part of a wider classification of handicaps being prepared to supplement existing classifications of diseases and disorders classified according to aetiology, systems, and anatomy. Nine handicaps (locomotor, visceral, visual, communication, intellectual, emotional, invisible, and "other") are distinguished. Incontinence is classified as a "disorder of excretion, which is itself one of four divisions of visceral handicap'.