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PubMed2002

Radio-frequency energy delivery to the anal canal for the treatment of fecal incontinence.

PURPOSE: In this prospective study we investigated the feasibility, safety, and efficacy of radio-frequency energy delivery deep to the mucosa of the anal canal for the treatment of fecal incontinence. METHODS: We studied ten patients with fecal incontinence of varying causes. All patients underwent anoscopy, anorectal manometry, endorectal ultrasound, and pudendal nerve terminal motor latency testing at baseline and six months. The Cleveland Clinic Florida scale for fecal incontinence (Wexner, 0-20), fecal incontinence-related quality of life score, and Short Form 36 were administered at baseline, 1, 2, 3, 6, and 12 months. Using conscious sedation and local anesthesia, we delivered temperature-controlled radio-frequency energy via an anoscopic device with multiple needle electrodes to create thermal lesions deep to the mucosa of the anal canal. RESULTS: Ten females (age, 55.9 +/- 9.2 years; range, 44-74) were enrolled and treated. Median discomfort by visual analog scale (0-10) was 3.8 during and 0.9 two hours after the procedure. Bleeding occurred in four patients (14-21 days after procedure), spontaneous resolution (n = 3) and anoscopic suture ligation (n = 1). At 12 months, the median Wexner score improved from 13.5 to 5 (P < 0.001), with 80 percent of patients considered responders. All parameters in the fecal incontinence-related quality of life were improved (lifestyle (from 2.3 to 3.4), coping (from 1.4 to 2.7), depression (from 2.2 to 3.5), and embarrassment (from 1.3 to 2.8); P < 0.05 for all parameters). Protective pad use was eliminated in five of the seven baseline users. At six months, there was a significant reduction in both initial and maximum tolerable rectal distention volumes. Anoscopy was normal at six months. CONCLUSION: Radio-frequency energy delivery to the anal canal for treatment of fecal incontinence is a new modality that, in this study group, safely improved Wexner and fecal incontinence-related quality of life scores, eliminated protective pad use in most patients, and improved patient quality of life.

Adult↗
PubMedDate not supplied

The surgical treatment of fecal incontinence with artificial anal sphincter implant. Preliminary clinical report.

BACKGROUND/AIMS: Fecal incontinence has a serious impact upon patients' quality of life. Several treatment methods are possible according to the pathophysiology of the disease. METHODOLOGY: Between March 1999 and February 2002 eight artificial anal sphincters (American Medical System - AMS) were implanted in seven patients affected with severe fecal incontinence; in one case the device was positioned in a patient who had previously undergone a Miles' resection. All cases were carefully selected according to appropriate diagnostic evaluation. The follow-up varies between 3 and 40 months. RESULTS: The prosthesis had to be removed in two cases; in one patient infection of the implant area occurred, while in the other case persistent perianal pain due to the presence of the device could not be tolerated by the patient. In the six patients that could be successfully treated with the artificial anal sphincter implant, it dramatically improved their quality of life. CONCLUSIONS: The success of the procedure allows the consideration that the artificial anal sphincter implant is the best treatment for severe fecal incontinence that cannot be solved with conservative therapy.

Adult↗
PubMed2005

The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence.

OBJECTIVE: The purpose of this study was to determine the relative effects of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence. STUDY DESIGN: This was a prospective, observational multicenter study of women presenting to 6 gynecology clinics. Demographic data collected included: height, weight, gravidity, parity, and number of vaginal deliveries. Patients were diagnosed with incontinence by questionnaire. Standard univariate logistic regression analyses' were performed to determine the contribution of pregnancy, mode of delivery, and BMI on the prevalence of urinary and fecal incontinence. RESULTS: One thousand and four women were enrolled over an 18-month period. Two hundred and thirty-seven and 128 subjects had urinary and fecal incontinence, respectively. Odds ratio (95% CI) calculated for the prevalence of urinary incontinence by pregnancy and mode of delivery were: any term pregnancy vs no term pregnancy was 2.46 (1.53-3.95), any term pregnancy but no vaginal deliveries (cesarean section only) vs no term pregnancy was 1.95 (0.99-3.80), any term pregnancy and at least 1 vaginal delivery vs no term pregnancy was 2.53 (1.57-4.07), and any term pregnancy but no vaginal delivery (cesarean section only) vs any term pregnancy, and at least 1 vaginal delivery was 1.30 (0.77-3.95). Odds ratio (95% CI) calculated for the prevalence of fecal incontinence by pregnancy and mode of delivery were: any term pregnancy vs no term pregnancy was 2.26 (1.22-4.19), any term pregnancy but no vaginal deliveries (cesarean section only) vs no term pregnancy was 1.13 (0.43-2.96), any term pregnancy and at least 1 vaginal delivery vs no term pregnancy was 2.41 (1.30-4.49), and any term pregnancy but no vaginal deliveries (cesarean section only) vs any term pregnancy, and at least 1 vaginal delivery was 2.15 (0.97-4.77). BMI and age did not impact these results. CONCLUSION: Pregnancy increases the risk of urinary and fecal incontinence. Cesarean section does not decrease the risk of urinary or fecal incontinence compared to pregnancy with a vaginal delivery.

Body Mass Index↗
PubMed2003

Fecal incontinence after high-risk delivery.

OBJECTIVE: To investigate the prevalence of and factors associated with fecal incontinence and its precursors among high-risk women at 12 months postpartum. METHODS: A survey of women in the immediate and later postpartum was conducted. Participants were 568 women at higher risk of anal sphincter damage, namely those who had an instrumental delivery and/or delivered a high birth weight infant (4000 g or more) at tertiary teaching hospitals in Australia. Women participated in a baseline hospital-based interview and a 12-month follow-up telephone interview. The main outcome measures were frank fecal incontinence (solid and/or liquid stool) and precursor symptoms (flatal incontinence, soiling, and/or fecal urgency) at 12 months postpartum. RESULTS: Prevalence rates were 2.6% for solid stool incontinence and 4.9% for liquid stool incontinence. Overall, 6.9% women had either one or both of these symptoms of frank fecal incontinence. Prevalence rates were 24.4% for flatal incontinence, 10.9% for soiling, and 14.8% for fecal urgency. Overall, 32.4% women had at least one of these precurser symptoms. Concurrent urinary incontinence and postpartum constipation were significantly associated with both frank fecal incontinence and precursor symptoms. In addition, joint hypermobility and older maternal age were associated with frank fecal incontinence, whereas inability to stop the urine flow and multiparity was associated with precursor symptoms. CONCLUSION: The present findings suggest that older and multiparous women, and women with joint hypermobility are at increased risk of postpartum anal incontinence symptoms after a high-risk delivery. Concurrent urinary incontinence, flow-stopping inability, and constipation are also associated with postpartum anal incontinence symptoms after high-risk deliveries.

Adolescent↗
PubMed2006

Fecal Incontinence: a woman's view.

Fecal incontinence (FI) has a prevalence of 2-7% in the general community and increases substantially in hospitalized patients and nursing home residents. Incontinent patients often isolate themselves from society for fear of having an incontinent episode in public. Few of these patients ever discuss this ailment with their doctor, despite a significant increase in depression and anxiety. Women have gender-specific medical and surgical conditions that predispose them to FI such as pregnancy, scleroderma, MS, IBS, childbirth, and pelvic surgeries. This article will address multiple facets of FI, but will focus specifically on issues related to women.

Fecal Incontinence↗
PubMedDate not supplied

Pathophysiology and management of fecal incontinence.

The successful management of fecal incontinence requires an understanding of anorectal function, careful delineation of the disorder by a detailed history and physical examination, and specialized studies of anorectal and pelvic floor function in selected patients. These studies include anorectal manometry, dynamic radiographic studies of the anorectum, pelvic floor neurophysiologic tests and anal endosonography. Therapeutic options include dietary modifications, behavioral programs, pharmacologic agents and surgery. Currently available diagnostic tests should result in optimal management of these patients.

Aged↗
PubMed2004

Injectable silicone biomaterial for fecal incontinence caused by internal anal sphincter dysfunction is effective.

PURPOSE: Fecal incontinence caused by a weak or disrupted internal anal sphincter is common but there has been no effective treatment. This prospective study evaluates the medium-term clinical effects of an injectable silicone biomaterial, PTP (Bioplastique), used to augment the internal anal sphincter. METHOD: Eighty-two patients (64 females; median age, 66 years) with severe fecal incontinence and a low anal resting pressure caused by internal anal sphincter dysfunction (defect, n = 11; intact, n = 71) were randomized to PTP injection into intersphincteric space and internal anal sphincter with (Group A, n = 42) or without (Group B, n = 40) guidance by endoanal ultrasound. Both groups were similar in terms of age, gender, past anorectal surgery, duration of follow-up (median, 6 months; range, 1-12 months), and baseline continence score. Sixty-two percent of Group A and 55 percent of Group B had prolonged pudendal nerve terminal motor latency. RESULTS: There was no significant complication. Two patients in Group A and four patients in Group B noted minor discomfort at injection sites. At one month postprocedure, endoanal ultrasound confirmed retention of silicone biomaterial without migration. In both groups, fecal continence was significantly improved by PTP implants 1 month after injection, but continued to improve significantly for up to 12 months in Group A and 6 months in Group B (P < 0.001). Improvement in fecal continence and maximum anal resting pressure was significantly greater in Group A, in whom injection was guided by endoanal ultrasound, than in Group B. At three months after injection, significantly more Group A patients than Group B patients achieved >50 percent improvement in Wexner's continence score (69 percent vs. 40 percent; P = 0.014). Ninety-three percent of Group A and 92 percent of Group B had >50 percent improvement in global quality of life scores (visual analog scale). At a median follow-up of 6 months, all domains of the fecal incontinence quality of life scale improved significantly in both groups; however, the physical function and mental health scores of Short Form-12 only improved in Group A. A prolonged pudendal nerve terminal motor latency had no effect on functional outcome in either group. CONCLUSION: Injection of silicone biomaterial provided a marked improvement in fecal continence and quality of life in patients with internal sphincter dysfunction, despite the presence of pudendal neuropathy.

Activities of Daily Living↗
PubMedDate not supplied

[Surgical treatment of fecal incontinence secondary to obstetric trauma].

Fecal incontinence (FI) is associated to elevated costs related to diagnostic work-up, surgical treatment and instrumental follow-up. The real incidence is unknown and prevalence is higher after 45 years with a ratio F:M ratio of 8:1. Frequently FI is due to pelvic damage secondary to obstetric trauma. The Authors analyze surgical treatment results of FI secondary to obstetric trauma evaluating pathogenesis and instrumental diagnostic preoperative work-up. In case of muscular injury, "overlapping" of external sphincter represents the treatment of choice allowing a good medium long term results. In the treatment of patients with more complex injures or after overlapping failures, direct sphincteroplasty are indicated. After multiple surgical failures, or in case of pure neural damage, sacral nerve stimulation, graciloplasty or artificial anal sphincter may be offered by referral centers.

Fecal Incontinence↗
PubMed2003

Randomized controlled trial of biofeedback for fecal incontinence.

BACKGROUND & AIMS: Behavioral treatment (biofeedback) has been reported to improve fecal incontinence but has not been compared with standard care. METHODS: A total of 171 patients with fecal incontinence were randomized to 1 of 4 groups: (1) standard care (advice); (2) advice plus instruction on sphincter exercises; (3) hospital-based computer-assisted sphincter pressure biofeedback; and (4) hospital biofeedback plus the use of a home electromyelogram biofeedback device. Outcome measures included diary, symptom questionnaire, continence score, patient's rating of change, quality of life (short-form 36 and disease specific), psychologic status (Hospital Anxiety and Depression scale), and anal manometry. RESULTS: Biofeedback yielded no greater benefit than standard care with advice (53% improved in group 3 vs. 54% in group 1). There was no difference between the groups on any of the following measures: episodes of incontinence decreased from a median of 2 to 0 per week (P < 0.001). Continence score (worst = 20) decreased from a median of 11 to 8 (P < 0.001). Disease-specific quality of life, short-form 36 (vitality, social functioning, and mental health), and Hospital Anxiety and Depression scale all significantly improved. Patients improved resting, squeeze, and sustained squeeze pressures (all P < 0.002). These improvements were largely maintained 1 year after finishing treatment. CONCLUSIONS: Conservative therapy for fecal incontinence improves continence, quality of life, psychologic well-being, and anal sphincter function. Benefit is maintained in the medium term. Neither pelvic floor exercises nor biofeedback was superior to standard care supplemented by advice and education.

Adult↗
PubMed1993

[Therapy of fecal incontinence from the internal medicine viewpoint].

Despite a general belief is fecal incontinence a symptom rather than a diagnosis, usually occurring as a consequence of an underlying disease. Treatment of fecal incontinence, thus, is primarily treatment of this underlying disorder. If this causal treatment is not possible or effective, symptomatic treatment may become the goal. Furthermore, conservative management has to utilize all its possibilities before surgery may become a therapeutic option. This, however, is restricted by the limited number of conservative options available: Only a very few drugs act directly on the anal sphincter mechanism to increase the tone, all other medication may be contra-indicated. Laxatives are no treatment option at all in fecal incontinence, and the efficacy of electric stimulation of pelvic floor muscles has not been proven so far. Therefore, pelvic floor exercises have become treatment of choice, most effective with biofeedback support. This is supported by a variety of studies published in the past years.

Biofeedback, Psychology↗
PubMed1996

Constipation and fecal incontinence in the elderly population.

OBJECTIVE: To describe the assessment and management of constipation and fecal incontinence in elderly patients. DESIGN: We reviewed pertinent publications in the recent medical literature and outlined effective management strategies for constipation and fecal incontinence in the geriatric population. RESULTS: Constipation can be classified into two syndromes--functional constipation and rectosigmoid outlet delay. Evaluation consists of elicitation of a detailed history, directed physical examination, and selected laboratory tests. Management involves nonpharmacologic (such as exercise and fiber) and pharmacologic measures. Fecal incontinence in elderly patients can be due to stool impaction, medications, dementia, or neuromuscular dysfunction. Management options include modification of contributing disorders, pharmacologic therapy, and behavioral techniques. CONCLUSION: Constipation and fecal incontinence are common and often debilitating conditions in elderly patients. Management should be highly individualized and dependent on cause, coexisting morbidities, and cognitive status.

Aged↗
PubMed2003

A longitudinal assessment of bowel related symptoms and fecal incontinence following radical perineal prostatectomy.

PURPOSE: Recent studies have suggested an increased incidence of fecal incontinence following radical perineal prostatectomy. We provide a prospective and longitudinal assessment of bowel related symptoms of patients undergoing radical perineal prostatectomy. MATERIALS AND METHODS: A total of 78 patients who underwent radical perineal prostatectomy between January 1 and December 31, 2001 and had a minimal followup of 6 months were included in the analysis. Patient information was obtained from the chart and the bowel domain specific questions of a validated quality of life questionnaire, the Expanded Prostate Cancer Index Composite. The questionnaire was administered to the candidates preoperatively, at 4 weeks following surgery and subsequently at 3-months intervals. A mean bowel function, bother and summary health related quality of life score was calculated at each interval. The duration of new or worsened symptoms with respect to baseline was evaluated using Kaplan-Meier analysis. RESULTS: Symptoms of involuntary stool leakage and rectal urgency were reported by 11.5% (9 of 78) and 19.2% (15) of patients preoperatively. While all bowel related symptoms transiently increased following surgery, rectal urgency was the most persistent symptom, yet normalized in more than 90% of patients within 9 1/2 months. Compared to individual baseline 15.4%, 7.7%, 5.1% and 3.9% of patients reported worsened symptoms of fecal incontinence after 3, 6, 9 and 12 months, respectively. In the subset of 69 patients who denied preoperative fecal incontinence the incidence of involuntary stool leakage was 2.9% by 12 months following radical perineal prostatectomy. Of 10 patients 9 recovered individual health related quality of life score by 6 months after prostatectomy. CONCLUSIONS: Longitudinal assessment of self-reported questionnaire data suggests that fecal incontinence and bowel related symptoms are more prevalent following radical perineal prostatectomy compared to baseline, yet resolve in the majority of patients with time in the early postoperative period.

Adult↗
PubMed1998

Anorectal manometric characteristics in men and women with idiopathic fecal incontinence.

To characterize and compare the anorectal manometric findings of men and women with idiopathic fecal incontinence referred to a tertiary care center for pelvic floor disorders, we reviewed 86 consecutive patients who underwent anorectal manometry during a 13-month period. We determined the etiologies of all patients and analyzed men and women with no obvious cause (idiopathic). The manometric parameters included resting and squeeze anal canal pressures, duration of squeeze pressures, threshold of external anal sphincter contraction, threshold of rectal sensation, and rectal compliance. Thirty-one of 86 patients were classified as having idiopathic fecal incontinence. The mean age of the 7 male patients with idiopathic fecal incontinence was 65 years, (range, 45-78 years) and 63 years (range, 38-83 years) in the 24 women. Compared with male patients, female patients had lower sphincteric pressures and shorter squeeze durations. Both men and women frequently exhibited poor phasic response of the external anal sphincter to rectal distention. We conclude that, compared with men, women with idiopathic fecal incontinence more often exhibit abnormalities of anal sphincteric motor function. The sex-related differences in muscle mass and past traumatic events related to childbirth may partly account for these findings.

Adult↗
PubMed1997

Management of neurogenic fecal incontinence in myelodysplastic children by a modified continent appendiceal stoma and antegrade colonic enema.

OBJECTIVES: Antegrade colonic enemas for neurogenic fecal incontinence via reverse reimplanted appendices (Mitrofanoff principle) have been primarily reported by Malone and coworkers in 1990. We used a modification of the described surgical technique and treated the first 10 patients with neurogenic fecal incontinence due to spina bifida. The surgical procedure and the results are reported. METHODS: Since November 1991, we have used a surgical procedure similar to the appendiceal continence mechanism in urinary diversion to establish a continent colonic cutaneous stoma for antegrade enemas in 10 myelodysplastic patients (4 females, 6 males; median age 13.2 years [range 6 to 26]) with severe neurogenic fecal incontinence. The average follow-up is now 26.4 months (range 12.5 to 50). All patients had neurogenic bladder dysfunction successfully managed by clean intermittent catheterization, anticholinergic drugs, or artificial sphincter implantation. The surgical technique for fecal incontinence included the partial orthotopic submucosal imbedding of the appendix into a cecal tenia and the fixation of the ileocecal region at the inner side of the abdominal wall after creation of an appendicocutaneous catheterizable stoma. RESULTS: All patients reached fecal continence for at least 38 hours (median 45.3) by using antegrade colonic enemas with 1.5% saline solution (n = 9) or GoLYTELY solution (n = 1), 0.5 to 1.5 L every 2 to 3 days. All other therapies (diet, oral medication, rectal purgative, or enema) to reach fecal continence had previously failed. There were only two complications seen at the follow-up. One boy with an artificial urinary sphincter presented with infection of the sphincter system, which led to explantation. Another boy presented 15 months after creation of the colonic appendiceal stoma with saline intoxication possibly due to a homemade saline solution. CONCLUSIONS: We conclude that the antegrade colonic enema via an orthotopic continent appendiceal stoma is a safe and highly effective treatment modality for fecal incontinence in patients with neurogenic bowel dysfunction if nonsurgical management has failed.

Adolescent↗
PubMed2004

Electromyographic biofeedback can improve subjective and objective measures of fecal incontinence in the short term.

Electromyographic biofeedback therapy has demonstrated subjective improvement in patients with fecal incontinence that is comparable to surgery. We assessed the efficacy of biofeedback therapy in a consecutive heterogeneous group of patients using both subjective and objective assessment criteria. These 28 patients with fecal incontinence were studied retrospectively. Patients were assessed using a quality-of-life questionnaire (QOL), the Vaizey and Wexner incontinence scoring systems, and anorectal manometry for efficacy of treatment, before and after biofeedback therapy. Eighty-six percent of patients completed the study. Median follow-up was 18 months. Eighty percent of patients demonstrated significant improvements in their Vaizey and Wexner scores (P<0.001 and P<0.001, respectively). The mean QOL score improved from 62 to 77 (P<0.01). Significant improvements were also demonstrated in the mean resting pressure (P<0.01), peak amplitude of squeeze (P<0.01), and the duration of squeeze pressure (P<0.05). The deferred 15-minute evacuation time also significantly increased (P<0.001). This study reported significant short-term improvement in fecal incontinence with electromyographic biofeedback therapy using validated subjective and objective scoring systems. Similarly, this treatment also significantly improved anorectal manometric findings. Our data confirm the role of biofeedback therapy in the multimodality approach to patients with fecal incontinence.

Adult↗
PubMed2002

Fecal incontinence in anorectal malformations, neuropathy, and miscellaneous conditions.

In the majority cases, fecal soiling in children is functional and usually associated with severe constipation. Fortunately, functional soiling is a self-limiting problem and usually disappears at puberty. Organic fecal incontinence is a consequence of congenital malformations affecting the anorectum, anal sphincters, or the spinal cord. Inability to control bowel function may be permanent, as in patients with myelodysplasia; self-limiting, as in patients who have fecal soiling after a pull-through operation for Hirschsprung's disease; or partial, as in many patients who have undergone repair of an anorectal malformation. The purpose of this report is to review the etiology, long-term outcome, and evolution of the management of different types of organic fecal incontinence in children. Knowledge of the pathophysiology of fecal incontinence has accumulated during recent decades, and this provides the basis of modern treatment modalities that have revolutionized treatment so that today most patients can be provided total or at least social continence from early childhood.

Anal Canal↗
PubMed2005

Patients' views of a colostomy for fecal incontinence.

INTRODUCTION: Formation of a permanent stoma often is seen as a last resort when all other interventions for fecal incontinence have failed. However, no previous study has examined patients' views of a colostomy to manage fecal incontinence. METHODS: People who had a colostomy to manage fecal incontinence were recruited via an advertisement in the magazine of the British Colostomy Association or from those operated at a specialist colorectal hospital. Four questionnaires were sent, asking about the stoma, previous incontinence, anxiety and depression, and quality of life. RESULTS: A total of 69 replies were received. Respondents were 11 males and 58 females with a median age of 64 years and a median of 59 months since the operation. Rating their ability to live with their stoma now on a scale of 0 to 10, the median response was 8 (range, 0-10). The majority (83 percent) felt that the stoma restricted their life "a little" or "not at all" (a significant improvement from perceived restriction from former incontinence, P = 0.008). Satisfaction with the stoma was a median of 9 on a scale of 0 to 10 (range, 0-10). Eighty-four percent would "probably" or "definitely" choose to have the stoma again. Quality of life (SF-36) was poor, but neither depression nor anxiety was a prominent feature. CONCLUSIONS: The majority of previously incontinent people were positive about the stoma and the difference it had made to their life. However, a few had not adapted and disliked the stoma intensely. Health care professionals should discuss a stoma as an option with patients whose lives are restricted by fecal incontinence.

Adult↗
PubMed2004

Protocol- and therapist-related variables affecting outcomes of behavioral interventions for urinary and fecal incontinence.

Biofeedback techniques used to treat urinary and fecal incontinence lack standardization. Most early protocols used a pressure device placed within the vagina or anal canal, or electromyographic (EMG) sensors in the same locations, to measure the external anal sphincter (EAS) or pelvic floor muscle (PFM) contractile function, and most early studies provided feedback from a single physiological transducer. The goal was to improve bowel and bladder control by improving EAS or PFM contractile function. Protocols that have resulted in the most consistent reductions in urinary incontinent episodes used 2 or more channels of physiological information to reinforce stable abdominal and bladder pressures concurrently with PFM contraction. For fecal incontinence, more significant treatment results were derived when protocols measured (1) patient perception of sensory cues associated with rectal distention and potential loss of stool, (2) short-latency EAS contraction when perceiving rectal distention, (3) inhibition of (extraneous muscle) activity that would increase intra-abdominal pressure during EAS contraction, and (4) reinforcement of sustained (up to 30 seconds) contractions rather than only brief 1- to 2-second contractions. Limited data support the use of surface abdominal EMG measures as indices of extraneous muscle activity associated with increased intra-abdominal pressure and anal or vaginal EMG probes to obtain measures of PFM function. Better results may also be obtained when there are at least 4 training sessions, when daily home exercises are prescribed, and when the therapist is well trained and experienced. These inferences are based for the most part on indirect evidence, and more studies are needed that compare different treatment protocols.

Behavior Therapy↗