炎症性肠病患者大便失禁现状及管理的研究进展

大便失禁是炎症性肠病患者常见的症状之一,常导致患者日常人际交往和活动受限,严重影响患者的心理状态、生活及工作质量。该文概述了炎症性肠病患者大便失禁的概念、发生现状、不良影响、评估工具以及干预措施,旨在为该类患者大便失禁的管理及相关临床研究的开展提供参考依据。     

Transurethral collagen injection for female stress incontinence

Periurethral collagen injections have been used to treat female urinary incontinence secondary to intrinsic sphincteric deficiency (ISD). As an alternative, a transurethral submucosal collagen injection was used in 33 consecutive women suffering from stress incontinence secondary to ISD at Tulane University Medical Center. Prior to the procedure, careful clinical examination with a videofluorourodynamic study was performed for each case. The procedure was carried out under local anesthesia assisted with monitored anesthesia care (MAC). The collagen was injected transurethrally by the long collagen needle (C. R. Bard). In the first 11 cases the average cumulative collagen injected per patient was 6.1 ml, whereas in the last 22 cases the average was 3.5 ml. As a result of the injection 16 patients were dry (48.5%) and 11 were improved (33.3%), with an overall success rate of 81.8%. The injection failed in 6 patients (18.1%). The mean follow-up was 18.8 months, with a range of 2–33 months. In the successful group there was a significant decrease in pretreatment frequency, from an average of 8 to 4.9 (P=0.005) and in nocturia from an average of 2.14 to 0.76 (P=0.001). Also, there was a significant decrease in the number of pads, from an average of 3.7 to 1.1 (P=0.001). The stress leak-point pressure showed a significant increase, from an average of 68.1 to 93.5 cmH₂O (P=0.03). There was no relation between grade of incontinence and the success of the injection. Two cases suffered from temporary urinary retention. This study revealed that the transurethral submucosal collagen injection is an effective method for treating cases of intrinsic sphincteric deficiency. The volume of collagen required to produce the seal effect is small and it may decrease the reinjection rate. As experience is gained, the procedure time is typically 15 minutes. This makes it a reliable, cost-effective and well-controlled method. However, it has a learning curve and the cystoscope instruments require minor adaptation for its use.Presented at the 17th Annual Scientific Meeting of the American Urogynecologic Society, New Oreleans, LA, 4–7 October 1996.Editorial Comment: The authors present the results of 33 patients who underwent transurethral submucosal collagen injection for the treatment of intrinsic sphincter deficiency. All injections were performed using a 5-Fr long needle-tipped catheter introduced through the cystoscope channel. The collagen was placed just under the urethral mucosa, between the lamina propria and muscularis layers. This approach alleviated the risk of injury to blood vessels and periurethral abscess, present with the periurethral route. The authors noted a significantly reduced amount of collagen required, with an 81.8% cure/improvement rate. The amount of anesthetic time was reduced, along with hospital stay and complication rate, which lowers the overall cost of this treatment. They point out that minor modifications are needed for routine cystoscopic equipment to be utilized for this technique, and that a commercially available unit can be purchased. Transurethral injection offers a relatively safe and easy alternative to the use of urethral bulking agents in the treatment of intrinsic sphincter deficiency.     

Videocystourethrography with a ring pessary in situ. A clinically useful preoperative investigation for continent women with urogenital prolapse?

The aim of the study was to evaluate the use of a vaginal pessary in the detection of genuine stress incontinence (GSI) in women with urogenital prolapse undergoing urodynamic investigation. Continent women with urogenital prolapse, with or without associated urinary symptoms, were studied. All underwent video-cystourethrography using a standarized protocol. None had evidence of incontinence on provocative testing in the upright position. A well-fitting vaginal ring pessary was inserted to reduce the prolapse and mimic a vaginal repair. The provocative tests were then repeated while the bladder was screened. Seventy women with a mean age 59.0 years (range 34–83) were recruited over a 21-month period: 15 women complained of prolapse alone and 55 had concurrent urinary symptoms; 19 women (27%) developed GSI only following the insertion of a vaginal pessary. The women who became incontinent were significantly older (mean age 63.9 years) than those who remained continent (mean age 56.8 years) (P<0.020). The use of a vaginal pessary increases the detection rate of GSI in continent women with urogenital prolapse undergoing videocystourethrography. These findings are important becasuse women with prolapse and coexisting incontinence should be offered a continence procedure rather than a simple vaginal repair.Editorial Comment: All patients with significant uterovaginal prolapse require preoperative evaluation to rule out the presence of potential stress incontinence. The simplest and best way to perform this preoperatively has yet to be determined, although several methods have been described. These include a cough stress test or cough urethral profile performed with a full bladder with the prolapse reduced with a Sims' speculum, a pessary or vaginal packing. A pad test with the prolapse reduced in a similar fashion has also been used clinically to identify patients at risk for postoperactive potential stress incontinence following correction of pelvic prolapse. The authors present their experience using a ring pessary to reduce the prolapse during videourodynamic evaluation of lower urinary tract function, finding this technique to be effective in identifying patients who leak only with the pessary in place, and therefore, require an incontinence procedure. The pickup rate for this cohort of patients is similar to previous studies using alternative methods of detection. Perhaps the only question yet to be answered is the percentage of patients with negative testing preoperatively, yet who develop urinary incontinence immediately following surgical correction of pelvic relaxation. Only this determination will truly assess the clinical utility of the preoperative methods used to identify potential stress incontinence.     

Adapting Incontinent Patients Incontinence Aids to their Leakage Volumes

The importance of adapting incontinence aids according to the patients leakage volume and comfort was investigated in 28 urinary incontinent 85-year-old men and women who were living at home. The patients incontinence was quantified by a 48-hour pad test and was graded as slight (max. leakage per pad < 5 g; total leakage/48 h <30 g), moderate (max. leakage per pad 5–15 g; total leakage/48 h 30–70 g) or severe (max. leakage per pad > 15 g; total leakage/48 h >70g). Four women had slight urinary incontinence, eight were moderately incontinent and nine were severely incontinent. The corresponding figures for the seven men were as follows: slight, one; moderate, one; severe, five. After the primary assessment, incontinence aids were prescribed based on the measured leakage volumes. The correctly selected and adapted incontinence aid brought the patient better comfort and security. The importance of careful information and instructions how to apply the pad is emphasised. There is also a need to see the patient again at intervals as leakage volumes may vary. Thus, smaller packages of pads should be supplied as the choice of pad may need to be modified. The latter is also important from a financial point of view as the expense of otherwise wasted pads would unnecessarily increase costs.     

A retrospective evaluation of rectal irrigation in the treatment of disorders of faecal continence

Objectives The aim of this study was, firstly, to evaluate the efficacy and acceptability of rectal irrigation in the treatment of patients with disorders of faecal continence that have not responded to other treatment modalities. Secondly, to see if standard anorectal physiology measures can identify patients who might have successful treatment with rectal irrigation. Patients and methods All patients who had been treated with rectal irrigation, between 1998 and 2000, were sent a postal questionnaire. Patients were asked to quantify their symptoms (before and after rectal irrigation) using a visual analogue scale to determine the efficacy of rectal irrigation. An increase of 10 (10 mm) in this score was regarded as successful treatment and incontinence scores obtained. The acceptability of rectal irrigation was determined using a Quality of Life questionnaire. Data regarding presenting symptoms, previous therapies, pretreatment anorectal physiology measurements were obtained from a retrospective case note and database review. Results Completed questionnaires were obtained from 48 (52%) of 92 patients, 39 patients had had previous medical and/or surgical treatment before trying rectal irrigation. At the time of the questionnaire 44 of 48 patients were still using rectal irrigation. Using the linear analogue scores 24 of 48 (50%) reported an improvement in their symptoms using rectal irrigation. Most patients found the treatment acceptable. Incontinence scores and anorectal physiology measures did not predict those patients who responded successfully to rectal irrigation. Conclusion Rectal irrigation can offer symptomatic improvement to patients with faecal evacuatory disorders where other therapies have failed. Most patients find the treatment acceptable. Standard anorectal physiology measures and incontinence scores do not predict those patients likely to have successful treatment.     

Self-Injury and Incontinence in Psychogenic Seizures

Summary: Two patients who incurred significant injuries during psychogenic seizures prompted us to do a telephone survey of self-injury and incontinence in 102 consecutive patients diagnosed with psychogenic seizures by EEG-closed-circuit TV (EEG-CCTV) monitoring. Seventy-three patients (or a close family member or friend) were reached by telephone and responded to our survey. During typical attacks of psychogenic seizures, 40% reported injuries, 44% reporting tongue biting, and 44% reported urinary incontinence. Suicide attempts were reported by 32% and were more common in those with self-injury and urinary incontinence. We compared the results of patients with psychogenic seizures with those of 30 patients with refractory epilepsy documented by ictal recordings, using a similar telephone survey. Injuries of all types were more commonly reported by epilepsy patients. Burn injuries were reported only by patients with epilepsy. Suicide attempts were more commonly reported by the psychogenic seizure group. Self-injury and incontinence are commonly reported by psychogenic seizure patients. In view of their significant association with suicide attempts, they may indicate an underlying depression.     

The Larsson frequency/volume chart is not a substitute for cystometry in the investigation of women with urinary incontinence

The aim of the study was to assess the ability of the Larsson chart nomogram to predict the presence of detrusor instability or genuine stress incontinence without recourse to cystometry. The Larsson chart provides a probability of detrusor instability by plotting 24-hour urinary frequency against the range of void volumes. Frequency/volume chart data were obtained from the records of 216 patients who had undergone subtraction cystometry. The Larsson chart was assessed by comparing the probability of detrusor instability or of genuine stress incontinence obtained with the cystometric diagnosis. The maximum sensitivity of the Larsson chart was 52%, with a specificity of 70% for detrusor instability. For genuine stress incontinence these figures were 66% and 65% respectively. The Larsson chart provides no diagnostic information and does not remove the need for formal cystometric evaluation of patients with urinary incontinence.Editorial Comment: The authors critically assess the Larsson frequency/volume chart as a diagnostic aid in evaluating female incontinence, hoping to validate its use as a decisive test that could preclude the need for multichannel urodynamics. In a unselected cohort of females with incontinence the investigators compare the diagnosis made based on the Larsson chart to that arrived at by multichannel cystometrography. Although the Larsson chart is found to have low specificity and sensitivity in detecting DI or GSI, the voiding diary remains an important diagnostic aid in the evaluation of urinary incontinence, imparting much information regarding functional bladder capacity, urinary frequency, nocturia and daily fluid intake. This information is critical in understanding the overall function of the patient's lower urinary tract, suggests the presence of specific entities such as diabetes insipidus, contracted bladder, interstitial cystitis etc., and allows the physician to make simple adjustments in fluid intake that can minimize incontinence, nocturia and diuria. It is rather simplistic to believe that a voiding record alone could reliably distinguish between categories of incontinence, without any other evaluation.     

Impact of stapled haemorrhoidopexy on stool continence and anorectal function—long-term follow-up of 242 patients

Background and aims Several studies have proved the feasibility and safety of stapled anopexy for treating haemorrhoidal prolapse. However, stool urgency and faecal incontinence as possible side effects are still debated. Therefore, the present study was designed to assess the impact of Longo’s procedure on stool continence and anorectal function. Materials and methods From 1999 to 2005, 300 patients underwent stapled haemorrhoidopexy for symptomatic haemorrhoidal prolapse. Two hundred forty-two patients (100 women, 142 men) were available for follow-up and were retrospectively reviewed. All operations were performed by one single surgeon. To evaluate anorectal function, the results of a validated incontinence score (total incontinence score [IS]: 0 = best, 20 = worst) and evacuation score (total evacuation score [ES]: 0 = worst, 28 = best) were compared pre- and postoperatively. Results The total IS showed no difference in means before and after operation (p = 0.875, CI 95%) retrospectively. Concerning the ES, paired sample t-test showed a weak positive correlation, indicating a significant difference in score means (p = 0.041, CI 95%). The group means changed from 26.24 before operation to 26.60 after the follow-up period. Conclusion The present data revealed no significant negative impact of Longo’s technique on anorectal function. In contrast, according to the evacuation score, the results showed a significant improvement of evacuation.