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PubMed2006

Electrical stimulation and pelvic floor muscle training with biofeedback in patients with fecal incontinence: a cohort study of 281 patients.

PURPOSE: Pelvic floor rehabilitation is an appealing treatment for patients with fecal incontinence but reported results vary. This study was designed to assess the outcome of pelvic floor rehabilitation in a large series of consecutive patients with fecal incontinence caused by different etiologies. METHODS: A total of 281 patients (252 females) were included. Data about medical history, anal manometry, rectal capacity measurement, and endoanal sonography were collected. Subgroups of patients were defined by anal sphincter complex integrity, and nature and possible underlying causes of fecal incontinence. Subsequently patients were referred for pelvic floor rehabilitation, comprising nine sessions of electric stimulation and pelvic floor muscle training with biofeedback. Pelvic floor rehabilitation outcome was documented with Vaizey score, anal manometry, and rectal capacity measurement findings. RESULTS: Vaizey score improved from baseline in 143 of 239 patients (60 percent), remained unchanged in 56 patients (23 percent), and deteriorated in 40 patients (17 percent). Mean Vaizey score reduced with 3.2 points (P < 0.001). A Vaizey score reduction of >or= 50 percent was observed in 32 patients (13 percent). Mean squeeze pressure (+5.1 mmHg; P = 0.04) and maximal tolerated volume (+11 ml; P = 0.01) improved from baseline. Resting pressure (P = 0.22), sensory threshold (P = 0.52), and urge sensation (P = 0.06) remained unchanged. Subgroup analyses did not show substantial differences in effects of pelvic floor rehabilitation between subgroups. CONCLUSIONS: Pelvic floor rehabilitation leads overall to a modest improvement in severity of fecal incontinence, squeeze pressure, and maximal tolerated volume. Only in a few patients, a substantial improvement of the baseline Vaizey score was observed. Further studies are needed to identify patients who most likely will benefit from pelvic floor rehabilitation.

Biofeedback, Psychology↗
PubMed1997

Prospective trial of pelvic floor retraining in patients with fecal incontinence.

PURPOSE: Our aim was to prospectively evaluate pelvic floor retraining (PFR) in improving symptomatic fecal incontinence. METHODS: PFR was used to treat 30 patients with fecal incontinence (28 women; age range, 29-85 (median, 68) years). PFR was performed by a physiotherapist in the outpatient department according to a strict protocol and included biofeedback using an anal plug electromyometer. Manometry (24 patients), pudendal nerve terminal motor latency (PNTML, 16 patients), and anal ultrasound (14 patients) were done before commencing therapy. Independent assessment of symptoms was done at the commencement of therapy, at 6 weeks, and at 6 and 12 months posttherapy. RESULTS: Twenty patients (67 percent) had improved incontinence scores, with eight patients (27 percent) being completely or nearly free of symptoms. Of 28 patients followed up longer than six months, 14 achieved a 25 percent or greater improvement at six weeks, which was sustained in all cases. Fourteen had an initial improvement of less than 25 percent, with only four (29 percent) showing later improvement (P < 0.0001). There was no relationship between results of the therapy and patient age, initial severity of symptoms, etiology of incontinence, and results of anal manometry, PNTML, and anal ultrasound. CONCLUSIONS: PFR is a physical therapy that should be considered as the initial treatment in patients with fecal incontinence. An improvement can be expected in up to 67 percent of patients. Initial good results can predict overall outcome.

Adult↗
PubMed1997

Long-term results of suture rectopexy in patients with fecal incontinence associated with incomplete rectal prolapse.

UNLABELLED: Suture rectopexy is the recommended therapy for complete rectal prolapse that is associated with fecal incontinence. It has been suggested that correction of an incomplete rectal prolapse is also worthwhile for patients with fecal incontinence. PURPOSE: Aims of this study were 1) to evaluate the clinical outcome of suture rectopexy in a consecutive series of patients with incomplete rectal prolapse associated with fecal incontinence, and 2) to compare these results with those obtained from patients with complete rectal prolapse. METHODS: Between 1979 and 1994, suture rectopexy was performed in 13 incontinent patients (3 males; median age, 65 (range, 45-77) years) with incomplete rectal prolapse (Group I) and in 24 incontinent patients (21 females; median age, 71 (range, 24-86) years) with complete rectal prolapse (Group II). RESULTS: After a median follow-up of 67 months, continence was restored in 5 of 13 (38 percent) patients with incomplete rectal prolapse and in 16 of 24 (67 percent) patients with complete rectal prolapse. In both groups, all male patients became continent. CONCLUSIONS: For the majority of incontinent patients with incomplete rectal prolapse, a suture rectopexy is not beneficial. The clinical outcome of this procedure is only good in incontinent patients with complete rectal prolapse. Based on these data, it is questionable whether incomplete rectal prolapse plays a causative role in fecal incontinence.

Adult↗
PubMed1998

Fecal incontinence in scleroderma: assessment of the anal sphincter with thin-section endoanal MR imaging.

PURPOSE: To compare the magnetic resonance (MR) imaging appearance of the anal sphincter in patients with fecal incontinence and scleroderma with that in patients with fecal incontinence alone, scleroderma alone, or neither. MATERIALS AND METHODS: The study population comprised 14 patients with fecal incontinence and scleroderma, four with scleroderma alone, 13 with incontinence alone, and six with neither. T1- and T2-weighted spin-echo, magnetization transfer contrast-weighted, and dynamic gadolinium-enhanced images were obtained and analyzed for the integrity, thickness, and length of sphincter components. Magnetization transfer contrast ratios and T2 were calculated to assess fibrosis of the internal sphincter. The percentage enhancement above baseline was calculated at 30-second intervals for the internal and the external sphincter. RESULTS: Eleven patients with incontinence and scleroderma showed descent of rectal air and feces into the anterior anal canal, with forward deviation of the significantly (P < .05) atrophied internal sphincter, which showed a slower gadolinium-enhancement pattern compared with that in other groups. Patients with incontinence alone showed no evidence of internal sphincter deviation or altered vascularity but had a significant reduction (P < .05) in deep external sphincter bulk. CONCLUSION: In patients with fecal incontinence and scleroderma, endoanal MR imaging helps delineate the anterior sphincter deformity and shows the slower gadolinium-enhancement pattern on dynamic studies of the internal sphincter.

Adult↗
PubMed1996

Biofeedback treatment is ineffective in neurogenic fecal incontinence.

PURPOSE: This study was undertaken to assess biofeedback treatment (active sphincter exercises under direct electromyography vision) in neurogenic fecal incontinence. METHODS: Twelve patients with neurogenic fecal incontinence have been studied prospectively. External sphincter contractions were exercised under direct electromyographic vision twice per day for 30 minutes during 12 weeks. Manometry was done at the beginning and after 12 weeks of training to evaluate objectively changes in sphincter functions. RESULTS: No patient experienced any improvement in fecal control. Mean resting pressure increased from 7 to 9 kPa and mean squeeze pressure from 3.9 to 4.9 kPA, which was of no statistical significance (P = 0.20 and P = 0.46, respectively). CONCLUSIONS: External sphincter contraction exercises under direct electromyographic vision are not effective in neurogenic fecal incontinence. Degree of continence does not improve, and external sphincter function is not increased significantly.

Adult↗
PubMed1997

Electromyographic assessment of biofeedback training for fecal incontinence and chronic constipation.

INTRODUCTION: Biofeedback training is an effective modality for the treatment of chronic constipation and fecal incontinence. In general, patients express satisfaction and perceive functional improvement following biofeedback therapy; however, quantifying these observations has been difficult. AIM: This study was undertaken to evaluate the physiologic benefits of biofeedback therapy as reflected by noninvasive electromyography parameters. METHODS: Fifty-five patients who underwent computerized electromyography-based biofeedback treatment at our institution between July 1993 and July 1995 were identified. Noninvasive electromyographic testing was performed before, during (weekly), and at completion of training. Mean number of weekly sessions was seven (range, 5-11). Short-term and ten-second contractions (amplitude/microV), sustained contractions (endurance, in seconds), and net strength (microV) of the external anal sphincter before and after biofeedback were compared for differences. RESULTS: There were 30 patients with chronic constipation, mean age, 65.3 (range, 33-86) years, composed of 24 women, and 25 patients with fecal incontinence, mean age 66 (range, 34-85) years, composed of 12 males. Statistically significant improvement in endurance and net strength following biofeedback training was noted in both the constipated and the fecal incontinence groups. Fifty-three of 55 (96.4 percent) patients expressed 50 to 100 percent subjective satisfaction after biofeedback therapy. Forty-six of 55 (83.6 percent) patients demonstrated individually improved endurance. CONCLUSIONS: Sphincter endurance and net strength, as measured by noninvasive electromyography, significantly improve following biofeedback therapy in both constipated and fecal incontinence patients. These data suggest that endurance and net strength may be useful tools in assessing a benefit from biofeedback training in these patients.

Adult↗
PubMed2006

Risk factors for fecal incontinence: a population-based study in women.

BACKGROUND: In women with "idiopathic" fecal incontinence (FI), consensus guidelines recommend anal sphincter imaging and surgical repair, when feasible, of anal sphincter defects believed to cause FI. However, the relative contributions of obstetric trauma and bowel symptoms to FI in the community are unknown. METHODS: To assess risk factors for FI during the past year, a previously validated questionnaire was mailed to an age-stratified random sample of 5,300 women residing in Olmsted County, Minnesota. RESULTS: Altogether, 2,800 women (53%) responded. The risk of fecal incontinence increased with age (odds ratio [OR] per decade 1.3, 95% CI 1.2-1.4). The risk of fecal incontinence was higher among women with rectal urgency (OR 8.3, 95% CI 4.8-14.3) whether or not they also had other bowel disturbances (i.e., constipation, diarrhea, or abdominal pain) or had a vaginal delivery with forceps or stitches (OR 9.0, 95% CI 5.6-14.4). Among women with FI, rectal urgency and age were also risk factors for symptom severity. In contrast, obstetric risk factors for anorectal trauma did not increase the risk for FI. The risk for FI was not significantly different among women with cesarean section, vaginal delivery with or without forceps or stitches, or anorectal surgery, compared with nulliparous women without any of these risk factors. CONCLUSIONS: Rectal urgency rather than obstetric injury is the main risk factor for FI in women. These observations reinforce the importance of behavioral, dietary, and pharmacological measures to ameliorate bowel disturbances before anal imaging in women with "idiopathic" FI.

Adult↗
PubMed2003

Customized biofeedback therapy improves results in fecal incontinence.

BACKGROUND AND AIMS: Biofeedback therapy has been extensively used and accepted in fecal incontinence, but reports of its efficiency vary. We evaluated feedback therapy efficiency when (a) selecting the patient's subject of the therapy, and (b) customizing the therapy protocol used for each patient. PATIENTS AND METHODS: Fifty-three patients with fecal incontinence were selected for biofeedback training. The treatment program was customized for each patient depending on the underlying dysfunction, the patient's cooperative and learning attitude, and the patient's progress. Biofeedback efficiency was measured using clinical scores, subjective satisfaction of the patient, and manometry. RESULTS: Incontinent scores showed improvement in 66% of patients and good improvement in 11% and 15%, respectively, indicating an overall excellent effect of the therapy. Subjective satisfaction was strongly correlated with the previous incontinent scores. Comparison of manometry parameters before and after biofeedback therapy, including maximum anal resting, maximum anal squeeze pressure, and maximum duration of the squeeze, all showed significant differences. In addition, the sensory threshold significantly decreased after biofeedback therapy. Clinical improvements were maintained during the following 12 months. CONCLUSION: Biofeedback improves objective and subjective parameters of anorectal function. Selection of patients and customization of the therapy program increased biofeedback efficiency for the treatment of fecal incontinence.

Adult↗
PubMed1997

Is a new biofeedback therapy effective for fecal incontinence in patients who have anorectal malformations?

PURPOSE: The authors devised computerized equipment for use in the biofeedback therapy in the management of fecal continence after surgery for anorectal malformations. METHODS: The therapy was used for two to eight sessions in 14 children (11 who had high-type anomalies and three who had intermediate-type anomalies). The ages ranged 5 to 14 years. A control group of 17 children, aged 5 to 11 years, who had encopresis, was also treated with the same biofeedback therapy. RESULTS: Clinical improvement was noted in 5 of the 14 (36%) children who had fecal incontinence, and in 15 of the 17 children (88%) who had encopresis. Both in patients who had fecal incontinence and in those who had encopresis, anal resting pressures were not affected by biofeedback therapy. Furthermore, the anal resting pressure in children who had fecal incontinence was significantly lower than that in children who had encopresis. However, anorectal manometry showed that the biofeedback therapy improved voluntary sphincter function and rectal sensation in both groups. CONCLUSION: Biofeedback therapy appears to be effective in most children who have encopresis whose sphincter function is intact, and in some children who have fecal incontinence after surgery for anorectal malformations.

Adolescent↗
PubMedDate not supplied

Supplementation with dietary fiber improves fecal incontinence.

BACKGROUND: Human studies have shown that dietary fiber affects stool composition and consistency. Because fecal incontinence has been shown to be exacerbated by liquid stools or diarrhea, management strategies that make stool consistency less loose or liquid may be useful. OBJECTIVE: To compare the effects of a fiber supplement containing psyllium, gum arabic, or a placebo in community-living adults who were incontinent of loose or liquid stools. Mechanisms underlying these effects (e.g., fermentation of the fibers and water-holding capacity of stools) were examined. METHODS: Thirty-nine persons with fecal incontinence of loose or liquid stools prospectively recorded diet intake and stool characteristics and collected their stools for 8 days prior to and at the end of a 31-day fiber supplementation period. During the fiber supplementation period, they ingested psyllium, gum arabic, or a placebo by random assignment. RESULTS: In the baseline period, the groups were comparable on all variables measured. In the fiber supplementation period, (a) the proportion of incontinent stools of the groups ingesting the fiber supplements was less than half that of the group ingesting the placebo, (b) the placebo group had the greatest percentage of stools that were loose/unformed or liquid, and (c) the psyllium group had the highest water-holding capacity of water-insoluble solids and total water-holding capacity. The supplements of dietary fiber appeared to be completely fermented by the subjects as indicated by nonsignificant differences in total fiber, short chain fatty acids and pH in stools among the groups in the baseline or fiber supplementation periods. CONCLUSIONS: Supplementation with dietary fiber from psyllium or gum arabic was associated with a decrease in the percentage of incontinent stools and an improvement of stool consistency. Improvements in fecal incontinence or stool consistency did not appear to be related to unfermented dietary fiber.

Adult↗
PubMed2003

Long-term follow-up of dynamic graciloplasty for fecal incontinence.

PURPOSE: Graciloplasty has been used as a treatment for end-stage fecal incontinence since 1946. Electric stimulation with an implantable pulse generator has existed for 15 years. The gracilis muscle is wrapped around the anal canal and stimulated by intramuscular electrodes connected with an implantable pulse generator. Initial reports have been promising, but long-term results have not been presented to date. METHODS: Data of 200 consecutive patients with a follow-up of at least two years were analyzed in a prospective manner from 1986 until 1999. RESULTS: The overall success rate was 72 percent. In patients with fecal incontinence caused by trauma, the rate was 82 percent. Once continent, patients remained continent after a median follow-up of 261 (standard deviation, 132) weeks. Median survival of the implantable pulse generator until battery expiration was 405 weeks. Disturbed evacuation remained a problem in 16 percent of all patients. Complications were frequent but treatable. CONCLUSION: Dynamic graciloplasty is a good, cost-effective treatment for fecal incontinence with results lasting for a median of more than five years.

Adolescent↗
PubMed2005

Efficacy of sacral nerve stimulation for fecal incontinence: results of a multicenter double-blind crossover study.

BACKGROUND AND AIMS: This is the first double-blind multicenter study examining the effectiveness of sacral nerve stimulation in a significant number of fecally incontinent patients. METHODS: A total of 34 consecutive patients (31 women), median age 57 years (range, 33-73 years), underwent sacral nerve stimulation for fecal incontinence. After implantation, 27 of 34 patients were randomized in a double-blind crossover design to stimulation ON or OFF for 1-month periods. While still blinded, the patients chose the period of stimulation (ON or OFF) that they had preferred. The mode of stimulation corresponding to the selected period was continued for 3 months (final period). Outcome measures were frequency of fecal incontinence and urgency episodes, delay in postponing defecation, score severity, feeling of improvement, preference for ON or OFF, quality of life, and manometric measurements. RESULTS: In the crossover portion of the study, the self-reported frequency of fecal incontinence episodes was significantly reduced during the ON versus the OFF period (P = 0.03), and this symptomatic improvement was consistent: 1) with the patients feeling of greater improvement during the ON versus OFF period (P = 0.02); 2) with the significant preference of patients (P = 0.02) for the ON versus OFF period. In the final period of the study, the frequency of fecal incontinence episodes decreased significantly (P = 0.005) in patients with the stimulator ON. The ability to postpone defecation (P = 0.01), the score for symptom severity (P = 0.0004), and the quality of life (P < 0.05) as well as anal sphincter function significantly improved. CONCLUSIONS: The significant improvement in FI during the ON versus OFF period indicated that the clinical benefit of sacral nerve stimulation was not due to placebo.

Adult↗
PubMed2003

Patterns of abnormal pudendal nerve function that are associated with postpartum fecal incontinence.

OBJECTIVE: The purpose of this study was to assess patterns of abnormal pudendal nerve function in women who complain of postpartum fecal incontinence. STUDY DESIGN: During a 12-month period, a cohort of 83 women underwent neurophysiologic assessment as part of an evaluation of fecal incontinence after vaginal delivery. Pudendal nerve assessment consisted of the measurement of the clitoral-anal reflex and quantitative electromyography of the external anal sphincter. Endoanal ultrasound examination and anal manometry were also performed in each patient. RESULTS: Thirty of 83 women (38%) with fecal incontinence were found to have abnormal neurophysiologic condition, among whom four identifiable patterns of abnormality emerged. Five women (17%) had evidence of pudendal nerve demylenation with a prolonged sensory threshold of the clitoral-anal reflex (>5.2 mA), although electromyography studies were normal. Eight women (27%) had abnormal electromyography results that were consistent with axonal neuropathy with or without reinervation, in whom the clitoral-anal reflex was normal. Thirteen women (43%) demonstrated a mixed demyelinating and axonal pudendal neuropathy, with evidence of reinervation. Four women (13%) had abnormal patterns of neurophysiologic condition that was not attributable directly to past obstetric trauma but to coincident medical problems. CONCLUSION: Four abnormal patterns of pudendal nerve function may be identified, three of which (demyelinating, axonal, and mixed demyelinating/axonal) can be attributed to specific past obstetric events, although a fourth radicular pattern is due to coincident medical or orthopedic problems. Assessment of pudendal nerve function is important in women with postpartum fecal incontinence because particular patterns of abnormality correlate with different symptoms and can influence treatment options.

Anal Canal↗
PubMed1995

Relationship between manometric anal waves and fecal incontinence.

PURPOSE: The significance of manometric anal waves is uncertain, and their fate and diagnostic importance are unknown. It is conceivable that in neurogenic fecal incontinence (NFI) the frequency and amplitude of these waves may be altered into specific, recognizable patterns. Evaluation of this unexplored relationship between fecal incontinence and anal manometric waves has potential diagnostic use. METHODS: Anal motility was studied in 20 patients, each with NFI and traumatic fecal incontinence (TFI), and results were compared with findings in 20 control subjects to determine changes in frequency and amplitude of anal waves in fecal incontinence. RESULTS: Frequency of slow waves when present (NFI = 9.5/minute; TFI = 9.5/minute; control subjects = 9.1/minute) was identical in the three groups (P > 0.05). Amplitude of slow waves (NFI = mean, 4.3 mmHg; TFI = mean, 3.9 mmHg; control subjects = mean, 6.6 mmHg) was reduced in patients who were incontinent compared with control subjects but failed to reach statistical significance (P > 0.05). Frequency of ultraslow waves when present (NFI = mean, 0.75/minute; TFI = mean, 0.6/minute; control subjects = mean, 1.2/minute) was not statistically different between the three groups (P > 0.05). Amplitude of ultraslow waves (NFI = mean, 10.5 mmHg; TFI = mean, 23.4 mmHg; control subjects = mean, 29.6 mmHg) was significantly reduced in NFI vs. control subjects (P < 0.01) and between TFI vs. control subjects (P < 0.05). CONCLUSIONS: Manometric slow and ultraslow waves, when present, retain their frequency characteristics, irrespective of underlying disease. Amplitude of slow waves was not statistically different from control subjects, but the amplitude of ultraslow waves was significantly decreased in patients who were incontinent.

Adult↗
PubMed2005

Fecal incontinence: an up-to-date critical overview of surgical treatment options.

BACKGROUND: Surgery is the last resort for patients suffering from severe fecal incontinence. The armamentarium of surgical options for this condition has increased impressively during the last decade. Nevertheless, this fact seems to make neither patients nor surgeons feel more comfortable. Treatment of fecal incontinence still remains a challenge to modern medicine due to many specific sides of this problem. AIMS: This article gives an up-to-date overview of existing operative treatment options. METHODS: An unbiased review of relevant literature was performed to assess the role of all methods of surgical treatment for fecal incontinence available nowadays. RESULTS: Recent studies have shown poor late results after primary sphincter repair and low predictive value for most preoperative diagnostic tests. New surgical options such as artificial devices and electrically stimulated muscle transpositions are doomed by low success rates and unacceptably frequent complications. That is why current attention has focused on non- or minimally invasive therapies such as sacral nerve stimulation and temperature-controlled radio-frequency energy delivery to the anal canal. However, all these innovative techniques remain experimental till enough high-evidence data are gathered for their objective evaluation. CONCLUSION: Careful and detailed preoperative assessment to exactly determine the etiology of incontinence and individual approach remain the cornerstones of surgical treatment of fecal incontinence nowadays.

Anastomosis, Surgical↗
PubMed1997

Fecal incontinence in children.

Functional constipation is the cause of fecal incontinence in 95 percent of affected children, and anatomic or neurologic causes account for up to 5 percent of cases. The history and the physical examination (with emphasis on abdominal, rectal and neurologic examinations) are most helpful in identifying organic disease. In some children, anorectal manometry, a barium enema radiographic examination and a rectal biopsy are necessary to determine the etiology. Most children with fecal incontinence benefit from a strict treatment plan that includes defecation trials, a fiber-rich diet and laxative medications. Surgery followed by medical treatment is required in patients with Hirschsprung's disease and in some patients with anal stenosis or a history of surgical repair of an anorectal malformation.

Child↗
PubMed2001

Urinary incontinence in Wisconsin skilled nursing facilities: prevalence and associations in common with fecal incontinence.

OBJECTIVES: This article reports the characteristics associated with fecal incontinence (FI) in a nursing home population that are also associated with urinary incontinence (UI). METHOD: A cross-sectional survey composed of data from the Wisconsin Center for Health Statistics' Annual Nursing Home Survey in 1992 and 1993. Demographic characteristics, functional status, and disease histories were correlated with UI. RESULTS: Data were available for 18,170 and 17,117 residents respectively, 56% of who were to varying degrees incontinent of urine in each year. Significant positive associations with UI included, in order of adjusted odds ratios: FI, truncal restraints, dementia, female gender, impaired vision, stroke, and constipation. Inverse associations were age, body mass index, tube feedings, and pressure ulcers. Diabetes, heart disease, arthritis, fecal impaction, and race were not associated with UI. CONCLUSIONS: UI frequently coexists with FI in nursing home residents. FI and UI differ in their association with age, body mass, and gender.

Aged↗
PubMed2005

Bio-feedback treatment of fecal incontinence: where are we, and where are we going?

Fecal incontinence is a disabling disease, often observed in young subjects, that may have devastating psycho-social consequences. In the last years, numerous evidences have been reported on the efficacy of bio-feedback techniques for the treatment of this disorder. Overall, the literature data claim a success rate in more than 70% of cases in the short term. However, recent controlled trials have not confirmed this optimistic view, thus emphasizing the role of standard care. Nonetheless, many authors believe that this should be the first therapeutic approach for fecal incontinence due to the efficacy, lack of side-effects, and scarce invasiveness. Well-designed randomized, controlled trial are eagerly awaited to solve this therapeutic dilemma.

Biofeedback, Psychology↗