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PubMed2002

Assessment of quality of life in the treatment of patients with neuropathic fecal incontinence.

INTRODUCTION: Development of quality-of-life measures has been the focus of research in colorectal disorders in recent years. The assessment of quality of life for fecal incontinence should be more important than quantitative measurement of soiling. PURPOSE: This study assesses specific patient quality-of-life objectives, categorizes objectives, and correlates these objectives with continence scores. METHODS: One hundred eighteen patients entered into a randomized, controlled trial of biofeedback were assessed using the Direct Questioning of Objectives quality-of-life measure. All objectives were documented, categorized, and correlated with continence scores and analog scales. RESULTS: In patients with neuropathic fecal incontinence, the most frequent quality-of-life group concerned the ability to get out of home, to socialize outside of home, to go shopping, and not to have to worry about the location of the nearest toilet while out of home (34 percent; 123/364). At least one of these four objectives was stated by 72 percent of patients (85/118). Only 31 percent of patients (37/118) nominated an objective related to the physical act of soiling. The ability to travel (29 percent), exercise including walking (25 percent), perform home duties (19 percent), family and relationships (22 percent), and job (13 percent) were less frequently cited by patients. CONCLUSION: Continence scores focus heavily on the physical aspects of incontinence such as soiling and hygiene, aspects which seem to be less important to the patients themselves. It is important, therefore, that assessments of fecal incontinence should include reference to quality of life, and in particular to its impact on activities relating to "getting out of the house."

Activities of Daily Living↗
PubMed1991

Anorectal manometry and defecography in the diagnosis of fecal incontinence.

We carried out anorectal manometry and defecography prospectively in 43 consecutive patients with fecal incontinence. A subgroup of 17 patients with severe incontinence was identified radiologically by a short and incompletely closed anal canal. In these patients, the anal resting pressure was significantly lower than in the rest of the group (34.9 +/- 11.4 mm Hg versus 60.0 +/- 25.7 mm Hg, respectively; p less than 0.01). The anorectal angle did not change in 24 patients during squeezing, indicating a dysfunction of the puborectalis muscle. Manometric data did not differ between this subgroup and patients with a more acute anorectal angle during voluntary sphincter contraction. This indicates that the anal pressures recorded manometrically do not reflect the function of a muscular component that is important in the maintenance of fecal continence. We conclude that anorectal manometry and defecography are complementary diagnostic tools in the investigation of patients with fecal incontinence.

Adult↗
PubMed2005

Outcomes of continent catheterizable stomas for urinary and fecal incontinence: comparison among different tissue options.

OBJECTIVE: To retrospectively review the outcome of appendix, transverse tubularized intestine segments, caecal flap, gastric tube and others tissue options used as a continent stoma for urinary and fecal incontinence. PATIENTS AND METHODS: Between January 1993 and January 2003 we created 179 continent stomas to treat urinary and fecal incontinence in 135 patients (81 females and 54 males; mean age at surgery 13 years, 118, 87%, aged <17 years). We used either appendix (112), a short segment of bowel following the Yang-Monti technique (49), gastric augment single pedicle tube (eight), caecal flap (seven), Casale continent vesicostomy (two) and Meckel's diverticulum (one). Thirty-six patients had both urinary and fecal continent stomas created. RESULTS: The mean follow-up for the appendix group was 46 months for the urinary stoma and 23 months for the Malone antegrade continent enema (MACE) stoma. Stoma-related complications occurred in 24 of 112 (21%) patients; there was complete channel fibrosis in five (4%). The mean follow-up for the Yang-Monti group was 38 months for the urinary and 59.2 months for the MACE stoma. There were stoma-related problems in 11 of 49 (22%) patients, with complete channel fibrosis in three (6%). Overall, in the long-term follow-up, there were stoma-related complications in 42 of 179 (23.5%) procedures. CONCLUSIONS: Continent catheterizable stomas are a feasible and reliable method for treating urinary and fecal incontinence. Long-term success can be accomplished with appendix, transverse tubularized intestinal segments and caecal flaps, with similar complication rates in all groups. Surgeon preference and individual patient status should determine the surgical technique to be used.

Adolescent↗
PubMed1999

Measurement of the anorectal angle by defecography for the diagnosis of fecal incontinence.

We assessed the reliability of anorectal angle (ARA) measurement as an index of fecal incontinence. The "posterior" ARA was measured at rest, squeezing, and straining in 69 continent and 82 incontinent subjects all complaining of various evacuation dysfunctions. The two groups were homogeneous with regard to sex distribution (48.6% vs. 51.4% men and 44.7% vs. 55.3% women, n.s.) and age (56.5 +/- 10.2 vs. 59.3 +/- 9.7 years, n.s.). The incidence of rectal prolapse was the same in the two groups (40 each). The intraobserver agreement index from two independent measurements (Pearson's correlation coefficient), age, and gender interaction [T2 Hotelling test in multivariate analysis of variance (ANOVA)] and the most discriminating category of ARA measurement (Fisher's F test in ANOVA) were calculated. In addition, the relationship between ARA and severity of incontinence was assessed by the eta coefficient. Pearson's correlation coefficient was between 0.78 and 0.98 (P < 0.01). The mean ARA differed significantly between the continent and incontinent subjects (104.5 +/- 10.3 degrees vs. 116.2 +/- 23.6 degrees at rest, 84.5 +/- 14.2 degrees vs. 95.1 +/- 20.1 degrees on squeezing, and 133.7 +/- 21.7 degrees vs. 141.7 +/- 25.9 degrees on straining; T2 0.066, P < 0.05 in multivariate ANOVA). No interaction was noted between groups and gender (T2 = 0.023; F = 1.11, n.s.). Resting ARA was shown by ANOVA to be the most discriminating index (F = 9.4 P < 0.01) between the two groups. Overall, ARA measurement was correlated with the severity of fecal incontinence (eta coefficient: 0.894 at rest; 0.811 on squeezing; 0.695 on straining); its accuracy was 79%, the false-positive rate was 15.3% and the false-negative rate 26.5%. Irrespective of the underlying abnormality, namely rectal prolapse, ARA measurement by defecography can: (a) be reinterpreted reliably by the same observer and (b) differentiate continent from incontinent subjects.

Adolescent↗
PubMed1998

[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.

Adult↗
PubMed2002

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

UNLABELLED: 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.

Clinical Competence↗
PubMed1981

Biofeedback therapy for fecal incontinence.

Twenty-five patients (ages 10 to 79 years; average, 48 years) with fecal incontinence underwent anorectal manometry with a three-balloon system connected to a physiograph. On a basis of manometric criteria showing the presence of rectal sensation, 17 patients underwent biofeedback conditioning. Underlying disorders included irritable bowel syndrome, diabetes mellitus, anal sphincter damage from surgery or disease, and neurogenic anal dysfunction. Twelve of the 17 patients who received biofeedback training had significant improvement in bowel soiling. Follow-up periods ranged from 2 to 38 months (mean, 15 months). There were no significant differences in threshold of rectal sensation, relaxation of the internal anal sphincter, and pre- and postbiofeedback thresholds of external anal sphincter contraction between responders and nonresponders. Minimal criteria for successful treatment appeared to be ability to sense rectal distension, good motivation, and absence of significant psychological dysfunction. Biofeedback conditioning is a simple and effective technique in the treatment of selected patients with fecal incontinence.

Adolescent↗
PubMed1999

Stimulated graciloplasty for treatment of intractable fecal incontinence: critical influence of the method of stimulation.

INTRODUCTION: Patients with end-stage fecal incontinence, in whom all standard medical and surgical treatment has failed or is not expected to be effective, can be treated by stimulated graciloplasty. The aim of the present study was to assess the efficacy of stimulated graciloplasty by both direct nerve and intramuscular perineural stimulation techniques and to evaluate various parameters relative to outcome. METHODS: A prospective analysis of all patients who underwent this procedure was undertaken. All patients were preoperatively investigated by anal manometry, electromyography, pudendal nerve terminal motor latency assessment, endoanal ultrasound, and an enema retention test. They were further assessed with an incontinence scoring system and a Quality of Life Questionnaire. Postoperative evaluation included anorectal manometry, incontinence score registry, and a Quality of Life Questionnaire. In our initial experience the stimulation system electrodes were fixed directly to the nerve (direct nerve stimulation graciloplasty); later in the study the stimulation system electrodes were fixed intramuscularly close to the nerve branches (intramuscular perineural stimulation graciloplasty). RESULTS: From May 1993 to February 1998, 27 patients underwent 33 gracilis transpositions for fecal incontinence, 30 of which were stimulated. Six of the patients with direct nerve stimulation graciloplasty eventually had the direct nerve stimulator removed and replaced with an intramuscular electrode stimulator. After an mean follow-up (until the time of exit from study) of 12.5 (range, 1-23) months for direct nerve stimulation graciloplasty and 21 (range, 8-27) months for intramuscular perineural stimulation graciloplasty, 13 graciloplasties (43 percent) were successful. There was no correlation between outcome of surgery and age, duration or cause of symptoms, body habitus, manometric or electromyographic parameters, prior sphincter repair, the presence of a pre-existing stoma, or any immediate postoperative complications. However, the number of patients with intramuscular perineural stimulation graciloplasty who had a successful outcome (continent, 69 percent; improved but not fully continent, 23 percent; incontinent, 8 percent) was significantly higher than patients with direct nerve stimulation graciloplasty (improved but not fully continent, 10 percent; incontinent, 90 percent). CONCLUSION: The success of stimulated graciloplasty is dependent on the method of nerve stimulation, whereas surprisingly, none of the many other factors assessed influenced outcome.

Adult↗
PubMed1999

[Surgical management of urinary and fecal incontinence in neurological sphincter disorders of children and adolescents].

The management of urinary and fecal incontinence in children and adolescents with neurogenic disorders related to congenital or acquired conditions was frequently considered to be of secondary importance compared with orthopaedic complications. The improvement of artificial urinary sphincter and continent urinary diversion techniques allowed to establish for each case an individual plan considering overall, abilities and voiding dysfunction as well as renal complications. Antegrade colonic enema has greatly improved the quality of life of children with fecal incontinence or intractable constipation. Surgical management requires a large contribution by the patients and their closest relatives and complete information about goals, advantages and obligations of surgical management. Surgical principles for bladder augmentation, bladder neck reconstruction and continent urinary diversion are presented and discussed according to data in the recent literature and the author's clinical experience.

Adolescent↗
PubMed1989

Impaired internal anal sphincter in a subgroup of patients with idiopathic fecal incontinence.

During multiport manometric recordings of the anorectum, 35 of 140 patients with idiopathic fecal incontinence had abnormally weak sphincters that did not relax during rectal distention, suggesting impaired function of the internal anal sphincter. This study documents this finding and compares anorectal function in these 35 patients with 25 matched normal subjects and the remaining 105 incontinent patients. Basal and squeeze pressures were significantly lower in the incontinent study group than in the other two groups. During rectal distention, 25 of 35 patients showed no anal relaxation at any volume, whereas 10 patients showed some relaxation after 60-ml distention because of the postinflation rebound in internal anal sphincter tone. The electrical responses of the external anal sphincter to rectal distention and to increases in intraabdominal pressure were greater in patients than in normal subjects, but the anal pressures were lower and anal leakage was common. Rectal sensations were not significantly different from normal subjects. These results indicate that 25% of patients with idiopathic fecal incontinence have markedly impaired function of the internal anal sphincter, but these patients also have extremely weak external sphincters.

Adult↗
PubMed2002

Recent innovations in the management of fecal incontinence.

The importance of having a reproducible scoring system to objectively assess the severity of fecal incontinence and its response to treatment is stressed, and a number of methods are described. The approach to conservative treatment and investigation is outlined. Recent advances in the surgical management of fecal incontinence including the electrically stimulated gracilis neosphincter, sacral nerve stimulation, the artificial anal sphincter, internal anal sphincter augmentation, rectal augmentation, and antegrade colonic irrigation are described in detail.

Anal Canal↗
PubMed2002

Fecal incontinence in females with a past history of vaginal delivery: significance of anal sphincter defects detected by ultrasound.

PURPOSE: The aim of this study was to determine the significance of anal sphincter defects detected by ultrasonography, in a population of fecal incontinent parous females without previous anoperineal surgery. METHODS: From 100 consecutive incontinent patients, 61 females with at least one previous vaginal delivery and no past anoperineal surgery were studied. The severity of fecal incontinence was assessed by the Cleveland Clinic questionnaire score. Lesions of the internal or external anal sphincters, and the radial size of these defects were assessed by ultrasonography. Anal vector manometry was performed to measure anal pressures at rest and during voluntary squeeze, and the anal asymmetry index. RESULTS: Twenty-three had a normal sphincter (38 percent), and 38 (62 percent) had a defect detected by ultrasonography: 20 isolated defects of the external sphincter and 18 combined defects of the internal and external sphincters. Combined defects were significantly larger. The radial size of the defects was positively correlated with the severity of clinical symptoms. Anal pressure asymmetry index was significantly increased in the group with combined defects compared with the two other groups. An index of 25 percent or greater had a very high (100 percent) negative predictive value for the presence of a defect larger than 90 degrees. CONCLUSIONS: This study confirms the high prevalence of anal sphincter defects detected by ultrasonography in a population of incontinent parous females without previous proctologic surgery. The clinical symptoms are related to the size of these defects. Anal vector manometry may be a useful tool to confirm the relation between echographic anal sphincter lesions and fecal incontinence.

Adult↗
PubMed2006

Is an anal plug useful in the treatment of fecal incontinence in children with spina bifida or anal atresia?

PURPOSE: We evaluated the efficacy and tolerance of the Conveen anal plug in children with spina bifida or anal atresia with persistent fecal incontinence necessitating diapers despite bowel management. MATERIALS AND METHODS: Seven 4 to 12-year-old patients with high congenital imperforate anus and 9 who were 6 to 13 years old with spina bifida, no mental retardation and no involuntary urine loss on clean intermittent catheterization were included in the study. During a prospective, 6-week crossover descriptive study after a test period to find the most comfortable plug with a diameter of 37 or 45 mm patients and parents completed a diary with the number of soiling episodes, stool frequency, stool consistency and the number of diapers used during 3 weeks without and with the plug, respectively. They provided a final assessment of the device. RESULTS: Two of the 7 patients with congenital imperforate anus discontinued use because of pain and discomfort, 1 had a decrease in soiling episodes and 4 achieved full continence and needed no diapers while using 2 plugs daily (range 1 to 4). All patients preferred the smaller plug. Two of the 9 patients with spina bifida always lost the plug within 1 hour after introduction, 5 had a decrease in soiling episodes but continued to need diapers and 2 achieved full continence using 2 plugs daily (range 1 to 4). All patients preferred the larger plug. CONCLUSIONS: The Conveen anal plug is an adjuvant treatment option for fecal incontinence in children with congenital imperforate anus or spina bifida, enabling a minority to stop using diapers. The Conveen anal plug is not a universal solution for fecal incontinence problems in these patients.

Anus, Imperforate↗
PubMed2006

Diagnosis of celiac disease in a patient with fecal incontinence.

BACKGROUND: A 69-year-old white woman presented to our gastroenterology department with loose stools, daily fecal incontinence and weight loss. She had a 3-year history of fecal incontinence, which had increased in frequency and severity in the year before her most recent presentation. Prior diagnostic workup included anorectal manometry, revealing global sphincter dysfunction, which improved slightly with biofeedback therapy, and colonoscopy, which proved unremarkable. At the time of referral, the patient was taking loperamide 2mg once daily. INVESTIGATIONS: Physical examination, fecal fat stain, abdominal CT scan, therapeutic trial of pancreatic enzymes, celiac disease serologic tests, and upper endoscopy with small-bowel biopsy. DIAGNOSIS: Celiac disease. MANAGEMENT: Gluten-free diet.

Aged↗
PubMed1996

Long-term results of anterior levatorplasty for fecal incontinence. A retrospective study.

PURPOSE: To review the long-term results of anterior levatorplasty for fecal incontinence. METHODS: Fifty-four women with obstetric trauma and 31 with idiopathic incontinence responded to a questionnaire 1.5 to 18.5 (median, 8.5) years after anterior levatorplasty. Results were classified as excellent, good, fair, or poor. RESULTS: An excellent or good result was reported in 40 of 54 (74 percent) patients with an obstetric injury and in 14 of 31 (45 percent) patients in the idiopathic group (P < 0.01). The presence of a cloaca (P < 0.05) and a young age (P < 0.05) were associated with a favorable outcome in the obstetric and idiopathic group, respectively. Length of follow-up and preoperative severity of incontinence were not significantly related to outcome. CONCLUSIONS: This study suggests that every second patient undergoing anterior levatorplasty for fecal incontinence has a successful result that is sustained in the long term. Obstetric trauma, presence of a cloaca, and young age are associated with a successful outcome.

Adult↗
PubMed2006

Fecal incontinence associated with epidural spinal hematoma and intervertebral disk extrusion in a dog.

CASE DESCRIPTION: A 7-year-old castrated male Great Dane was evaluated because of a 2-month history of fecal incontinence. CLINICAL FINDINGS: On the basis of the presence of paraparesis and apparently normal spinal reflexes, the neurologic signs were localized in the region of the third thoracic to the third lumbar spinal cord segments. On the basis of the findings of magnetic resonance imaging, a presumptive diagnosis of a compressive intervertebral disk extrusion with secondary hemorrhage and epidural hematoma formation was made. TREATMENT AND OUTCOME: A right-sided hemil-aminectomy was performed (centered at the T13-L1 intervertebral space) to further characterize the lesion and decompress the spinal cord. The histopathologic diagnosis was extruded intervertebral disk material with chronic hemorrhage and inflammation. Three weeks after surgery, there was complete resolution of the dog's fecal incontinence and moderate improvements in its hind limb function. CLINICAL RELEVANCE: Thoracolumbar spinal cord injuries can result in upper motor neuron fecal incontinence in ambulatory dogs. Epidural spinal hematomas may develop secondary to intervertebral disk herniations and cause spinal cord compression resulting in neurologic deficits.

Animals↗
PubMed1997

[Fecal incontinence due to hemiplegia].

This article outlines a program which, if correctly applied, solves the problem of fecal incontinence in hemiplegic ictus patients in a simple, practical way by weighing the factors which provoke fecal incontinence in these patients and applying the objectives of our local training program. Nursing programs of this type serve not only to improve our patients' quality of life but also increase the role of our profession.

Fecal Incontinence↗
PubMed2001

What is the impact of fecal incontinence on quality of life?

PURPOSE: The objective of this study was to determine at what point fecal incontinence affects quality of life. METHODS: In 35 patients who had anterior sphincter repair for fecal incontinence as a result of obstetric injury, continence evaluated by the Wexner score was compared with validated quality of life tests (Gastrointestinal Quality of Life Index and Medical Outcomes Study Short-Form General Health Survey). The questionnaires were sent by mail. Thirty-two patients responded. The Wexner score (0-20) was correlated with the Gastrointestinal Quality of Life Index and the Medical Outcomes Study Short-Form General Health Survey and matched with those of reference groups. RESULTS: The mean Wexner score was 8.8, corresponding with losing stools between once a week and once a month. The mean Gastrointestinal Quality of Life Index score was 105 (range, 48-136), which is significantly lower than the score found in a reference group of normal individuals. Medical Outcomes Study Short-Form General Health Survey scores were significantly lower in all six dimensions compared with the reference group. A Wexner score of 9 or higher was associated with a Gastrointestinal Quality of Life Index score of less than 105, which implies that patients were less mobile in the community and were confined to their homes. A similar correlation was found between a Wexner score higher than 9 and the Medical Outcomes Study Short-Form General Health Survey. CONCLUSIONS: A Wexner score of 9 or higher indicates a significant impairment of quality of life and can therefore be used in decision making.

Adult↗