排粪失禁的治疗现状

排粪失禁较为常见,严重影响患者生活质量。在过去的二十年中,以治疗和减少并发症为目的的新疗法得到了一定发展。目前常用的非手术疗法包括饮食调节、药物治疗、生物反馈治疗,手术疗法包括修补术（括约肌成形术）、神经刺激疗法（骶前神经刺激等）、人工肛门括约肌替代或者自体肌肉转移术,以及排粪转流造口术。尚属起步阶段,仍存有争议的治疗手段包括射频能量疗法和注射疗法,因其创伤更小,可作为某些轻症排粪失禁患者的非手术治疗选择。医生应综合考虑肛门功能、生活质量及潜在并发症,制定个体化的治疗方案。对于重症排粪失禁患者应谨慎选择创伤较大的手术疗法。本文重点就目前排粪失禁各种治疗方法的选择策略及疗效进行系统回顾和总结。     

骶神经刺激疗法在下尿路功能障碍中的应用

下尿路功能障碍是临床上常见又较难处理的问题，传统的药物治疗等方法常不能取得满意的效果。各种手术治疗效果有限，骶神经刺激疗法（SNS）安全，有效，术后并发症少而轻，长期的随访证实其疗效确定切，因此，对于难治性下尿路梗阻，这种方法具有良好的前景。     

神经电刺激疗法治疗粪失禁现状与展望

1前言一般认为,粪失禁（fecal incontinence,FI）是指不能随意控制排大便和排气。2001年美国粪失禁治疗共识会议报告定义为"年龄至少4岁且反复出现的不能控制排大便至少1个月",并提出不带有粪质的气体溢出不构成失禁^[1]。粪失禁是一个在普通人群中被隐瞒的常见问题,国外文献报告人群中发病率差异较大,为1.4%¹8%,在养老院人群中发病率可高达50%^[24]。粪失禁可能严重影响患者的日     

骶神经刺激疗法在下尿路功能障碍中的应用

下尿路功能障碍是临床上常见又较难处理的问题 ,传统的药物治疗等方法常不能取得满意的效果。各种手术治疗效果有限。骶神经刺激疗法 (SNS)安全 ,有效 ,术后并发症少而轻。长期的随访证实其疗效确切。因此 ,对于难治性下尿路梗阻 ,这种方法具有良好的前景     

骶神经刺激和神经调节治疗排尿功能障碍

排尿功能障碍是一种常见的下尿路疾病 ,可以有明确病因 ,也可为特发性。临床实践中体会到 ,当保守治疗对急迫性尿失禁及尿急尿频等症状无效时 ,进一步处理极为困难 ;同样 ,对非梗阻性尿潴留患者 ,除间断导尿外几乎没有其他有效方法。神经调节 (ｎｅｕｒｏｍｏｄｕｌａｔｉｏｎ)     

骶神经刺激治疗便秘的研究进展

骶神经刺激(sacral nerve stimulation ,SNS)是指利用介入手段,将一种短脉冲刺激电流连续施加于特定的骶神经,以此剥夺神经细胞本身的电生理特性,人为激活兴奋或抑制神经通路,干扰异常的骶神经反射弧,进而影响骶神经支配的效应器官,起到神经调控的作用.可用于治疗尿失禁、大便失禁和慢性盆腔疼痛等.Gan...     

骶神经刺激治疗膀胱排尿功能障碍

目的：观察骶神经刺激治疗膀胱排尿功能障碍的疗效。方法：采用经皮穿刺刺激骶3神经治疗4例排尿功能障碍患者,其中1例接受永久性神经刺激器植入治疗。通过排尿日记及患者症状评价疗效。结果：3例难治性尿频尿急综合征的患者症状有显著改善,且排尿次数显著减少,平均排尿量增加,尿急程度减轻;另1例膀胱收缩无力患者无效。结论：骶神经刺激可以显著地改善部分患者膀胱排尿功能障碍。     

骶神经刺激/调节在下尿路功能障碍的应用

慢性排尿功能障碍临床十分常见,主要包括急迫性尿失禁、尿频尿急综合征、慢性尿潴留和慢性盆腔疼痛综合征.目前临床中,药物和其他保守治疗方法效果不确切,外科手术因创伤大,患者不易接受,因此此类排尿障碍成为当前泌尿外科临床实践的难题之一.20世纪90年代以来,排尿反射的神经调节概念越来越被人们重视,功能性神经电刺激治疗慢性排尿功能障碍得到应用.近年来出现并不断应用于临床的骶神经刺激(sacral nerve stimulation,SNS)和骶神经调节(sacral neuromodulation)为治疗排尿功能障碍患者提供了一种新途径.本文就有关骶神经调控技术(Interstim)的原理、适应证、临床操作技术及相关进展作一简介.     

骶神经电刺激在治疗肛门直肠疾病中的作用

肛门直肠疾病严重影响患者生活质量,而治疗难度大,仍是临床上较为棘手的问题。近年来,骶神经电刺激,包括短期间断骶神经电刺激和长期持续骶神经电刺激,在肛门直肠疾病治疗领域备受关注,大量研究报道了良好的治疗效果,为突破肛门直肠疾病当前的治疗瓶颈带来了新的希望。本文将就骶神经刺激在排粪失禁、便秘和功能性肛门直肠痛等肛门直肠疾病治疗中的应用现状进行综述。     

肠道管理系统对小儿排粪失禁的治疗作用

目的 评价肠道管理系统治疗小儿排粪失禁的疗效.方法 回顾性分析2012年1月至2013年1月间,广州市妇女儿童医疗中心小儿外科通过肠道管理系统（即利用粪便可在结肠内停留24～48 h的原理,采用灌肠方法,一次性清除结肠内的所有粪便,从而保持患儿肛周24 h清洁,改善临床症状）治疗19例排粪失禁患儿的临床资料.结果 19例患儿中,15例真性排粪失禁,4例假性排粪失禁.经肠道管理系统治疗后,真性排粪失禁患儿,粪污及便秘情况改善;假性失禁患儿中2例可通过口服药物自主控制排粪,另2例失禁症状完全缓解.结论 肠道管理系统可有效治疗小儿排粪失禁,其成功的关键在于反复调整灌肠液,找到最佳配比和用量,并保证患儿24 h肛周洁净.     

Treatment of fecal incontinence by temporary sacral nerve stimulation

Summary BACKGROUND: Sacral nerve stimulation (SNS) is an option for the treatment of fecal incontinence in patients with morphologically intact, but weak external anal sphincter. METHODS: In ten patients a percutaneous test-SNS was performed. Two patients suffered from fecal incontinence after surgery, one patient after incomplete leg palsy after traumatic spine injury and seven patients from idiopathic incontinence. Incontinence score, anorectal manometry and patient diary were performed before and after test-SNS. RESULTS: Intraoperative response (Bellows action) could be achieved in 90% of patients. Test-SNS was successful in 50% of patients. In these patients, resting pressure was increased by 100.1% and squeeze pressure by 84.5%. CONCLUSIONS: SNS is an effective therapy in a subset of patients with fecal incontinence. Fifty percent of patients tested are eligible for implantation of a permanent stimulation device.      

A review of sacral nerve stimulation for the treatment of faecal incontinence

Sacral nerve stimulation is an emerging surgical technique that uses chronic low-level electrical stimulation, applied to the nerves of the sacral plexus, to produce a clinically beneficial physiological effect on the lower bowel, pelvic floor and anal canal. Faecal incontinence is common, maximal conservative therapy may improve some patients but many require surgery. Results are variable and often unsatisfactory and further options are limited, the traditional end-point being the formation of a colostomy. Sacral nerve stimulation appears to be an alternative treatment that is successful, has low morbidity, is maintained in the medium term and associated with an improved quality of life. The technique has the advantage of a minimally invasive test procedure with high predictive value and the surgery is minor. The underlying mechanism of action although predominately neurological in nature remains to be determined. Precise patient selection is currently unclear however, results are superior to other techniques.     

Functional results and patient satisfaction with sacral nerve stimulation for idiopathic faecal incontinence

Aim Sacral nerve stimulation (SNS) is an established treatment for faecal incontinence (FI) when conservative modalities have failed to restore continence. This two‐centre study aimed to document functional outcome and its relationship to patient satisfaction. Method Patients treated with SNS for idiopathic FI in Aarhus (Denmark) and Maastricht (The Netherlands) were included. At the most recent follow‐up appointment, 127 patients (80%) were identified as receiving active SNS therapy. A questionnaire considering bowel habits, quality of life, and self‐reported satisfaction and a 3‐week bowel‐habit diary were mailed to these patients, and 85% responded. Results Patient satisfaction was clearly related to the number of FI episodes. Patients experiencing full continence were all satisfied, and although the satisfaction rate decreased as the number of FI episodes increased, 46% of the patients with more FI episodes at follow‐up than at baseline were still satisfied. Per‐protocol analysis resulted in a satisfaction rate of 57.3%. In total, 74.7% of the patients receiving active SNS therapy reported a reduction of ≥ 50% in FI episodes, 10.3% of whom were dissatisfied after a median of 46 months of follow‐up. Conclusion There is a clear relationship between patient satisfaction and improved continence. A total of 57.3% of the patients offered SNS therapy were satisfied at follow‐up. However, 46% of the patients with more FI episodes at follow‐up than at baseline were also satisfied. Therefore, functional outcome of SNS therapy cannot be based only on bowel‐habit diaries and bowel scores.     

Outcomes associated with Interstim therapy for medically refractory fecal incontinence

Background

Fecal incontinence is a common, socially debilitating disorder. Initial management involves dietary manipulation with bulking agents or antidiarrheal medications and pelvic floor biofeedback. For patients failing these modalities, traditional surgical approaches are morbid and of variable efficacy. Sacral nerve neuromodulation (Interstim, sacral nerve stimulation) was approved in May 2011 for management of medically refractory fecal incontinence. This report summarizes our experience with this treatment modality.

Methods

A prospectively maintained database from a colorectal specialty practice was reviewed from December 2011 to June 2013. Patient demographics, incontinence etiology, and medical treatment regimens were reviewed. Outcomes for Interstim placement and surgical morbidity were reviewed.

Results

A total of 330 patients were evaluated in the clinic for fecal incontinence during the study period. A total of 33 patients (10%) were offered Interstim therapy. The mean age was 63 (39 to 91) years, and 91% (30 of 33) were female. The etiology of the incontinence was obstetric (81%), rectal prolapse (11%), neurogenic (5%), and iatrogenic (3%). The entire group failed either supplemental fiber or antidiarrheal medications and 73% (24 of 33) failed pelvic floor biofeedback. The mean number of bowel accidents/2-week bowel diary before implant was 19 (9 to 52). After phase I implant, 88% (29 of 33) experienced a successful test phase and proceeded to phase II permanent implant. The mean number of bowel accidents/2-week diary postimplant was 3 (0 to 12). A trend toward less severe episodes of incontinence postimplant was observed. There were no complications associated with either the phase I or phase II implant. There were no phase II failures although 1 patient underwent device explant 9 months after phase II implant for chronic pain.

Conclusions

Sacral nerve neuromodulation (Interstim, sacral nerve stimulation) is an effective and efficacious tool for management of medically refractory fecal incontinence that offers a less morbid surgical approach to this problem. Interstim should be considered the first-line surgical approach for medically refractory fecal incontinence.     

Turning off sacral nerve stimulation does not affect gastric and small intestinal motility in patients treated for faecal incontinence

Aim Sacral nerve stimulation (SNS) reduces symptoms in up to 80% of patients with faecal incontinence (FI). Its effects are not limited to the distal colon and the pelvic floor. Accordingly, spinal or supraspinal neuromodulation have been suggested as part of the mode of action. The effect of SNS on gastric and small‐intestinal motility was studied. Method Using the magnet tracking system, MTS‐1, a small magnetic pill was tracked twice through the upper gastrointestinal tract of eight patients with FI successfully treated with SNS. Following a randomized double‐blind crossover design, the stimulator was either left active or was turned off for 1 week before investigations with MTS‐1. Results The median (range) frequency of gastric con‐tractions was 3.05 (2.83–3.40) per min during SNS and 3.04 (2.79?–3.76) per min without (P = NS). The median (range) frequency of contractions in the small intestine during the first 2 h after pyloric passage was 10.005 (9.68–10.70) per min during SNS and 10.09 (9.79–10.29) per min without SNS (P = NS). The median (range) velocity of the magnetic pill during the first 2 h in the small intestine was 1.6 (1.2–2.8) cm/min during SNS and 1.7 (0.8–3.7) cm/min without SNS (P = NS). Small‐intestinal propagation mainly occurred during very fast movements (> 15 cm/min), accounting for 51% (42–60%) of the distance 3% (2–4%) of the time during SNS and for 53% (18–73%) of the distance 3% (1–8%) of the time without SNS (P = NS). Conclusion Turning off SNS for 1 week did not affect gastric or small‐intestinal motility patterns.     

Permanent sacral nerve stimulation for fecal incontinence

OBJECTIVE: To characterize the longer-term therapeutic response of permanent sacral nerve stimulation for fecal incontinence and to delineate suitable indications and the mode of action. SUMMARY BACKGROUND DATA: A single report of permanent sacral nerve stimulation in three patients followed up for 6 months showed marked improvement in fecal continence. Acute evaluation has shown that the effect may be mediated by altered rectal and anal smooth muscle activity, and facilitation of external sphincter contraction. METHODS: Five women (age 41-68 years) with fecal incontinence for solid or liquid stool at least once per week were followed up for a median of 16 months after permanent implantation. All had passive incontinence, and three had urge incontinence. The cause was scleroderma in two, primary internal sphincter degeneration in one, diffuse weakness of both sphincters in one, and disruption of both sphincters in one. RESULTS: All patients had marked improvement. Urgency resolved in all three patients with this symptom. Passive soiling resolved completely in three and was reduced to minor episodes in two. Continence scores (scale 0-20) improved from a median of 16 before surgery to 2 after surgery. There were no early complications, and there have been no side effects. One patient required wound exploration at 6 months for local pain, and a lead replacement at 12 months for electrode displacement. The quality of life assessment improved in all patients. The resting pressure increased in four patients, but there was no consistent measured physiologic change that could account for the symptomatic improvement. CONCLUSIONS: In patients with sphincter degeneration and weakness, and possibly in those with sphincter disruption, sacral nerve stimulation markedly improves fecal incontinence.     

Implantable neuromodulation for urinary urge incontinence and fecal incontinence: a urogynecology perspective

Implantable sacral nerve stimulation is a minimally invasive, durable, and reversible procedure for patients with urinary urge and fecal incontinence who are refractory to conservative therapy. The therapy is safe compared with other surgical options. An intact external or internal rectal sphincter is not a prerequisite for success in patients with fecal incontinence.