A prospective evaluation of the value of anorectal physiology in the management of fecal incontinence

PURPOSE: This study was designed to determine whether anorectal physiology testing significantly altered patient management in the setting of fecal incontinence. METHODS: Patients referred to the anorectal physiology laboratory for evaluation of fecal incontinence were prospectively interviewed and examined by a colon and rectal surgeon. A decision to treat either medically or surgically was reached. The patients underwent physiologic testing with transanal ultrasound, pudendal nerve terminal motor latency, and anorectal manometry. A panel of board-certified colon and rectal surgeons then reviewed the history and physical examination, as well as the anorectal physiology tests, of each patient and reached a consensus on management. Management plans before and after physiologic evaluation were compared. RESULTS: Ninety patients (6 males) were entered into the study. The patients were divided in two groups: those with pretest medical management plans (n=45) and those with pretest surgical management plans (n=45). A change in management was noted in nine patients (10 percent). In the medical management group, the management changed from medical to surgical therapy in five patients. Transanal ultrasound detected anal sphincter defects in all patients who changed from medical to surgical management but in only 10 percent of those who remained under medical management (P=0.0001). In the surgical management group, three patients (7 percent) changed from surgical to medical therapy and one patient (2 percent) changed from sphincteroplasty to neosphincter. Transanal ultrasound detected a limited anal sphincter defect in one patient (33 percent) who changed from surgical to medical management and a significant defect in all 41 patients (100 percent) who remained under surgical management (P=0.003). CONCLUSIONS: Anorectal physiology testing is useful in the evaluation of patients with fecal incontinence. Without the information obtained from physiologic testing, 11 percent of patients who may have benefited from surgery would not have been given this option, and 7 percent of patients could have potentially undergone unnecessary surgery. Transanal ultrasound is the study most likely to change a patient's management plan.Presented at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.Winner of the Pittsburgh Society of Colon & Rectal Surgeons Karl A. Zimmerman, M.D., Award.     

The use of unilateral gluteus maximus muscle for the management of fecal incontinence following anorectal surgery

A dynamic unilateral gluteoplasty sutured as a U-shaped sling around the anal canal was carried out in 9 patients with fecal incontinence, including 8 males and one female ranging in age from 6 to 46 years (mean, 13.9 years). All had previous anorectal surgery: in four cases a Swenson's operation for congenital megacolon, in 2 cases a pull-through procedure for high anorectal anomalies, in 2 cases for a failed sphincteric repair, and in one case to correct rectal prolapse. Morbidity was limited to minor wound infection and postoperative dermatitis (4 cases). Seven patients achieved an improvement in their continence score. Overall continence score was 5–6 (mean, 4.0; SD = 1.4) preoperatively and 2–6 (mean, 4.0; SD = 1.4) postoperatively, a difference which was statistically significant (p = 0.006). Maximum resting pressure and maximum squeeze pressure were improved. None of the patients could retain 200 ml saline in their rectum preoperatively, while 6 patients could do so postoperatively. Rectoanal inhibitory reflex was positive in 2 patients preoperatively and in 6 postoperatively. In conclusion, unilateral dynamic gluteoplasty is an effective option for improving continence with no mortality and minimal morbidity in patients who previously had anorectal surgery, reserving the other gluteus muscle for use in a second attempt if first operation fails. Received: 22 September 1999 / Accepted in revised form: 10 October 1999     

Long-term results of electromyographic biofeedback training for fecal incontinence

PURPOSE: The aim of this study was to examine the long-term results of electromyographic biofeedback training in fecal incontinence. METHODS: Thirty-seven patients (1 male) received a customised program of 2 to 11 (median, 3) biofeedback training sessions with an anal plug electromyometer. Nine patients had persistent incontinence after anal sphincter repair, a further 8 patients had postsurgical or partial obstetric damage of the sphincter but no sphincter repair, 9 patients had neurogenic sphincter damage, and 11 patients were classified as having idiopathic fecal incontinence. Duration of voluntary sphincter contraction was measured by anal electromyography (endurance score) before and after treatment. A postal questionnaire was used to investigate the following variables: 1) subjective rating on a four-grade Likert-scale of the overall result of the biofeedback training; 2) incontinence score (maximum score is 18, and 0 indicates no incontinence); and 3) rating of bowel dissatisfaction using a visual analog scale (0 to 10). RESULTS: Twenty-two patients (60 percent) rated the result as very good (n=8) or good (n=14) immediately after the treatment period. Median endurance score improved from 1 to 2 minutes (P<0.0001). Median incontinence score improved from 11 to 7, and bowel dissatisfaction rating improved from 5 to 2.8 (bothP<0.0001). After a median follow-up of 44 (range, 12–59) months, 15 patients (41 percent) still rated the overall result as very good (n=3) or good (n=12). The incontinence score did not change during follow-up. Median bowel dissatisfaction rating deteriorated from 2.8 to 4.2 but remained better than before treatment. Poor early subjective rating and the need for more than three biofeedback sessions were predictive of worsening during follow-up. CONCLUSION: We think it is encouraging that in this study biofeedback treatment for fecal incontinence with an intra-anal plug electrode resulted in a long-term success rate in nearly one-half of the patients.     

生物反馈治疗大便失禁的疗效评价

目的　评价生物反馈方法治疗大便失禁患者的疗效。方法　对 2 6例大便失禁患者进行生物反馈治疗 ,治疗前后分别做肛肠测压和肌电图检查 ,评价患者的肛门功能。结果　 2 6例患者肛管最大收缩压、收缩肌电振幅、持续收缩时间、直肠感觉阈值和感觉收缩时间治疗前、后均有显著差异 (P <0 .0 1)。结论　生物反馈治疗大便失禁有效     

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 patients 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 patients cooperative and learning attitude, and the patients 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.     

Treatment strategies in obstructed defecation and fecal incontinence

Obstructed defecation (OD) and fecal incontinence (FI) are challenging clinical problems, which are commonly encountered in the practice of colorectal surgeons and gastroenterologists. These disorders socially and psychologically distress patients and greatly impair their quality of life. The underlying anatomical and pathophysiological changes are complex, often incompletely understood and cannot always be determined. As a consequence, many medical, surgical, and behavioral approaches have been described, with no panacea. Over the past decade, advances in an understanding of these disorders together with rational and similar methods of evaluation in anorectal physiology laboratories (ARP), radiology studies, and new surgical techniques have led to promising results. In this brief review, we discuss treatment strategies and recent updates on clinical and therapeutic aspects of obstructed defecation and fecal incontinence.     

Electrostimulation in fecal incontinence

PURPOSE: Continence scores and anal manometry are commonly used to assess the effect of electrostimulation in fecal incontinence. This study determined the increase of muscular compound potentials in electroneurography of the pudendal nerve after three months of electrostimulation treatment. PATIENTS AND METHODS: Thirty women were tested; their average age was 46.8 (standard deviation, 9.82) years. Electrostimulation was applied twice daily for 15 minutes in each case. RESULTS: Before treatment, amplitudes were, on average, 0.54 mV (standard deviation, 0.2). After three months of electrostimulation, the amplitudes had increased to 0.84 mV (standard deviation, 0.2). The continence score was improved from 8.73 to 7.1 points. CONCLUSION: We believe that by electrostimulation the atrophic muscle can be trained to stabilize the pelvic floor, thus increasing anal pressure and, thereby, creating a basis for adequate voluntary contraction. Electrostimulation is, therefore, especially suitable for functional deficits of the external anal sphincter (insufficient voluntary contractions because of atrophic muscle) without identifiable muscular lesion.     

Stimulated graciloplasty for treatment of intractable fecal incontinence

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.Supported in part by educational grants from NICE Technology, Inc. of Ft. Lauderdale, Florida and Medtronic, Inc. of Minneapolis, Minnesota. Dr. Mavrantonis was supported in part by a grant from the Onassis Educational Foundation.Read at the meeting of the American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Sphincteroplasty for fecal incontinence in the era of sacral nerve modulation

The role of sphincteroplasty in the treatment of patients with fecal incontinence due to anal sphincter defects has been questioned because the success rate declines in the long-term.A new emerging treatment for fecal incontinence,sacral nerve stimulation,has been shown to be effective in these patients.However,the success rate of sphincteroplasty may depend of several patient-related and surgical-related factors and the outcome from sphincteroplasty has been evaluated differently(with qualitative data) fro...     

Double-blind crossover study of sacral nerve stimulation for fecal incontinence

PURPOSE: Patients with fecal incontinence not amenable to simple repair may have to undergo major reconstructive surgery or resort to a stoma. Sacral nerve stimulation is an alternative approach that may diminish incontinence by altering sphincter and rectal motor function. This study is the first double-blind trial examining the effectiveness of this therapy. METHODS: Two patients with passive fecal incontinence who had been implanted for nine months with a permanent sacral nerve stimulator and electrode were studied using fecal incontinence diaries, anorectal physiological tests, and quality-of-life assessments (SF-36 health survey). The trial period consisted of two two-week periods, with the stimulator turned on for two weeks and off for two weeks. The main investigator and the patients were blinded to the status of the stimulator. RESULTS: There was a dramatic difference between the number and severity of episodes of incontinence when the stimulator was turned onvs. turned off (Patient 1, 20vs. 2 episodes; Patient 2, 4vs. 0 episodes; offvs. on). There was an increase in squeeze pressure (Patient 1, 70vs. 100 cm H₂O; Patient 2, 60vs. 90 cm H₂O; offvs. on), with moderate increases in resting pressure and rectal threshold and urge volumes. Quality-of-life measurements showed a marked improvement prestimulationvs. nine months after permanent stimulation. CONCLUSIONS: There is a marked, unequivocal improvement in symptoms of fecal incontinence with sacral nerve stimulation shown in this double-blind crossover trial. Sacral nerve stimulation improves the quality of life in selected patients with fecal incontinence.A grant and all the equipment used in this study were supplied by Medtronic INTERSTIM, Maastricht, the Netherlands.     

Preliminary experience in management of fecal incontinence caused by internal anal sphincter injury

PURPOSE: Isolated injuries of the internal anal sphincter can cause fecal incontinence. With the advent of ultrasound, which accurately delineates the anatomy of the anal sphincters, internal sphincter injuries can be diagnosed more precisely. The purpose of this study was to evaluate the outcome of direct repair of isolated internal anal sphincter defects. METHODS: Eight patients (6 males; median age, 37 years) with clinically and sonographically proved internal anal sphincter defects were the subject of this study. Patients had different degrees of incontinence that failed to respond to medical treatment. All patients had their sphincters repaired by direct apposition using coated Vicryl® 2-0 stitches. A strict postoperative regime that avoided stretch of the sphincter for one month was adopted. RESULTS: At a median follow-up period of 15 months, continence improved in all patients, and two achieved full continence. None of the patients wore pads. Mean continence score improved significantly from 4 to 12 and 11 at 6 and 12 postoperative months, respectively (P<0.0001, pairedt-test). CONCLUSION: Despite the limited number of patients and the short follow-up, the preliminary results of repair of isolated internal sphincter defects are satisfactory.     

Results of neurophysiologic evaluation in fecal incontinence

PURPOSE: Several methods of neurophysiologic assessment exist in the investigation of patients with fecal incontinence. However, the clinical significance of the information gained is uncertain. The aim of this prospective study was to evaluate the results of pudendal nerve terminal motor latency and fiber density in relation to clinical variables and manometric measurements. METHODS: Seventy-two patients with fecal incontinence (63 women; mean age, 62; range, 24–81 years) responded to a bowel questionnaire and underwent anorectal manovolumetry, anal ultrasonography, defecography, and electromyography, including pudendal nerve terminal motor latency and fiber density. RESULTS: Pudendal neuropathy (pudendal nerve terminal motor latency >2.5 ms) was found in 46 percent and increased fiber density (>1.7) in 82 percent. Pudendal neuropathy and increased fiber density were most common in patients with rectal prolapse or intra-anal intussusception. No difference was seen concerning anal resting and incremental pressures, rectal compliance, rectal sensibility or severity of incontinence in patients with unilateral, bilateral, or marked (>4 ms) pudendal neuropathyvs. patients with normal pudendal nerve terminal motor latency. In contrast, patients with increased fiber density had lower incremental pressures (P<0.05) and stated decreased rectal sensibility (P<0.05) compared with those with normal fiber density. These differences were most pronounced in patients with neurogenic or idiopathic incontinence. CONCLUSIONS: Pudendal neuropathy and increased fiber density are common in patients with fecal incontinence. Fiber density but not pudendal nerve terminal motor latency was correlated with clinical and manometric variables. The severity of nerve injury correlated with anal motor and sensory function in patients with neurogenic or idiopathic incontinence. The routine use of pudendal nerve terminal motor latency in the assessment of patients with fecal incontinence can be questioned.Read at The American Society of Colon and Rectal Surgeons' 100th Anniversary and Tripartite Meeting, Washington, D.C., May 1 to 6, 1999.     

Sacral nerve stimulation for treatment of fecal incontinence

PURPOSE: Many patients with fecal incontinence demonstrate a functional deficit of the internal anal sphincter or the external sphincter muscles without any apparent structural defects. Few patients are amenable to repair or substitution of the sphincter. However, sacral nerve stimulation appears to offer a valid treatment option for fecal incontinence. The objectives of this study were: to evaluate the efficacy of temporary stimulation of the sacral nerve roots (percutaneous nerve evaluation) in patients with functional fecal incontinence; to determine the mechanisms of possible improvement; and to evaluate if temporary stimulation could be reproduced and maintained by implanting a permanent neurostimulation system. METHODS: Twenty-three patients with fecal incontinence, 18 females and 5 males, median age of 54.9 years (range 28–71), underwent a percutaneous nerve evaluation test. Eleven patients (47.8 percent) also had urinary disorders: urge incontinence (4), stress incontinence (3), and retention (4). Associated disorders included perineal and rectal pain (1), spastic paraparesis (1), and syringomyelia (1). All patients underwent a preliminary evaluation using stationary anal manovolumetry, pudendal nerve terminal motor latency measurements, and anal ultrasound. A percutaneous electrode for the stimulation of the sacral nerve roots was positioned at the level of the third sacral foramen (S3) in 20 patients and S2 in 2 patients (1 patient missing). Stimulation parameters used were: pulse width 210µsec, frequency 25 Hz, and average amplitude of 2.8 V (range 1–6). The electrode was left in place for a minimum of 7 days. Five patients were successively implanted with a permanent sacral electrode with a stimulation frequency of 16 to 18 Hz and amplitude of 1.1–4.9 V. RESULTS: Seventeen of the 19 patients (89.4 percent) who completed the minimum percutaneous nerve evaluation period of 7 days (median 10.7 (range 7–30)), had a reduction of liquid or solid stool incontinence by more than 50 percent, and fourteen (73.6 percent) were completely continent for stool. The most important changes revealed by manovolumetry were an increase in resting pressure (P<0.001) and voluntary contraction (P=0.041), reduction of initial pressure for first sensation (P=0.049) and urge to defecate (P=0.002), and a reduction of the rectal volume for urge sensation (P=0.006). The percutaneous nerve evaluation results were reproduced at a median follow-up of 19.2 months (range 5 to 37) in the 5 patients who received a permanent implant. CONCLUSIONS: Temporary stimulation of the sacral roots (percutaneous nerve evaluation) can be of help in those patients with fecal incontinence, and the results are reproduced with permanent implantation. The positive effect on continence seems to be derived from not only the direct efferent stimulation on the pelvic floor and the striated sphincter muscle, but also from modulating afferent stimulation of the autonomous neural system, inhibition of the rectal detrusor, activation of the internal anal sphincter, and modulation of sacral reflexes that regulate rectal sensitivity and motility.     

Cost-effectiveness of dynamic graciloplasty in patients with fecal incontinence

PURPOSE: This study evaluates the cost-effectiveness of dynamic graciloplasty for intractable fecal incontinence. PATIENTS AND METHODS: The costs and effects of dynamic graciloplasty were measured in a prospective, longitudinal study and in a clinical trial. Forty-three patients with intractable fecal incontinence were evaluated before and after dynamic graciloplasty. Costs were obtained from the hospital information system and from patient-oriented questionnaires. We compared the costs of a dynamic graciloplasty with the costs of a colostomy. Colostomy costs were evaluated using a group of seven patients who had a stoma in place for incontinence for several years. Sensitivity analyses were included. RESULTS: Total direct costs of lifelong dynamic graciloplasty were $31,733 (United States dollars), costs of lifelong conventional treatment were $12,180 (United States), and costs of colostomy, including lifelong stoma care, were $71,576 (United States). The clinical success rate of dynamic graciloplasty was 74 percent. Quality of life after successful dynamic graciloplasty was better than with conventional treatment. CONCLUSION: We found that dynamic graciloplasty was more expensive than conventional treatment but resulted in a significantly higher quality of life. Stoma treatment was the least attractive alternative regarding both costs and effects. The Dutch Health Insurance Executive Board recommended reimbursement for the dynamic graciloplasty procedure.the Board of DirectorsResearch was performed at the University Hospital Maastricht and was supported by the National Fund for Investigational Medicine of the Dutch Health Insurance Executive Board.     

Functional changes after physiotherapy in fecal incontinence

Background Physiotherapy is a common treatment option in patients with fecal incontinence. Although physiotherapy may result in relief of symptoms, to what extent improvement is associated with changes in anorectal function is still unclear.Aim The aim of the present study was to investigate prospectively how anorectal function changes with physiotherapy and whether these changes are related to changes in fecal incontinence score.Methods Consenting consecutive patients (n=266) with fecal incontinence (91% women; mean age, 59 years) underwent anorectal manometry, anal and rectal mucosal sensitivity measurements, and rectal capacity measurement at baseline and after nine sessions of standardized pelvic floor physiotherapy. These findings were compared with changes in Vaizey incontinence score.Results On follow-up 3 months after physiotherapy, squeeze pressure (p=0.028), as well as urge sensation threshold (p=0.046) and maximum tolerable volume (p=0.018), had increased significantly. The extent of improvement was not related to age, duration of fecal incontinence, menopause, and endosonography findings. All other anorectal functions did not change. An improvement in the Vaizey score was moderately correlated with an increase in incremental squeeze pressure (r=0.14, p=0.04) and a decrease in anal mucosal sensitivity threshold (r=0.20, p=0.01).Conclusions Physiotherapy improves squeeze pressure, urge sensation, and maximum tolerable volume. However, improved anorectal function does not always result in a decrease in fecal incontinence complaints.     

Clinical, manometric, and EMG characteristics of patients with fecal incontinence

Fecal incontinence occurs frequently in both men and women. Yet, few studies on fecal incontinence have separated the evaluation and interpretation of data by gender. This study was designed to identify differences in the clinical, anorectal manometry, and electromyography (EMG) characteristics between male and female patients with fecal incontinence. We compared 53 incontinent males (mean age, 64 years) with 72 incontinent females (mean age, 61 years). Each patient underwent computerized anorectal manometry, and invasive (pudendal nerve conduction studies and concentric needle EMG) and noninvasive EMG (anal sensor surface electrode). An anal incontinence score (AIS) ranging from 0 to 6 was used to categorize patients. Male patients had higher incontinence scores at presentation (AIS greater than 4, 70% vs. 54%). Female patiens had significantly lower resting pressure (40 vs. 53 mmHg, p < 0.05) and more women had sphincter asymmetry (36% vs. 25%, p < 0.05). Both groups had similar PNTMLs (2.41 vs. 2.47 ms). Difference was seen in the net strength of the sphincter (women 4.0 μV vs. men 8.0 μV, p < 0.05), as measured by noninvasive EMG. In conclusion, it is well known that there are differences in anorectal physiologic function between male and female patients with normal continence. Comparing male and female patients with fecal incontinence suggests that female patients tend to have worse sphincter function that men. Both groups had similar EMG alterations, suggesting a common neurogenic injury as etiology. Future studies are needed to address the sexes separately. Received: 18 July 2000 / Accepted in revised form: 6 October 2001     

The prevalence of fecal incontinence in community-dwelling adults: a systematic review of the literature

PURPOSE: Reported prevalence estimates for fecal incontinence among community-dwelling adults vary widely. A systematic review was undertaken to investigate the studied prevalence of fecal incontinence in the community and explore the heterogeneity of study designs and sources of bias that may explain variability in estimates.METHODS: A predetermined search strategy was used to locate all studies published that reported the prevalence of fecal incontinence in a community-based sample of adults. Data were extracted onto a proforma for sampling frame and method, sample size, response rate, definition of fecal incontinence used, data-collection method, and prevalence rates. Included studies were critically appraised for possible sources of selection bias, information bias, and imprecision.RESULTS: A total of 16 studies met the inclusion criteria. These could be grouped into definitions of incontinence that included or excluded incontinence of flatus. The estimated prevalence of anal incontinence (including flatus incontinence) varied from 2 to 24 percent, and the estimated prevalence of fecal incontinence (excluding flatus incontinence) varied from 0.4 to 18 percent. Only three studies were found to have a study design that minimized significant sources of bias, and only one of these used a validated instrument for data collection. The prevalence estimate of fecal incontinence from these studies was 11 to 15 percent. No pooling of estimates was undertaken because there was wide variation in study design.CONCLUSIONS: A consensus definition of fecal incontinence is needed that accounts for alterations in quality of life. Further cross-sectional studies are required that minimize bias in their design and use validated self-administered questionnaires.Reprints are not available.Poster presentation at the Scientific Congress of the Royal Australasian College of Surgeons, Brisbane, Australia, May 5 to 9, 2003.     

Combined biofeedback, physiotherapy and electrostimulation for fecal incontinence

Different outcomes are reported in the literature following pelvic floor rehabilitation for fecal incontinence, possibly due to the type of procedure employed, whether biofeedback or physiotherapy or electrostimulation. The aim of the present study is to analyze the results achieved in a group of patients treated with a combination of the three procedures. Thirty-two patients (24 females) affected by fecal incontinence underwent a course of combined rehabilitation (CR); 23 of them had anal surgery prior to CR, for rectal mucosal prolapse and hemorrhoids in most cases. Eighteen had anal manometry before and after CR. Sixteen underwent anal ultrasound prior to treatment. Patients were taught perineal exercises, biofeedback was either sensory or electromyographic, and electrostimulation was performed with a 10–20 MHz endoanal probe. Twenty-seven patients were available for follow-up. The mean incontinence score improved from 4.0±0.8 to 2.1±1.7 (mean±sd) (p<0.001); 19 patients (70%) were satisfied after CR, and 11 (44%) were fully continent. Post-treatment manometry showed an increased amplitude of squeeze pressure in 50% of the cases, whereas 61% had an increase in duration, but only 27% of them had a positive clinical outcome. Rectal evacuation thresholds improved in 55% of the cases and 86% of them had a corresponding positive clinical outcome. At ultrasound, 6 patients showed intact anal sphincters and had a positive outcome following CR. Pelvic floor rehabilitation seems to be effective for the management of fecal incontinence when carried out combining different types of procedures. No significant correlation was found between manometric and clinical response to the treatment. An increase of rectal sensation may be responsible for the clinical improvement. Received: 25 August 2000 / Accepted in revised form: 20 October 2000     

Delorme's operation and sphincteroplasty for rectal prolapse and fecal incontinence

Clinical and manometric results of Delorme's operation and sphincteroplasty were assessed retrospectively in patients undergoing this procedure for fecal incontinence and rectal prolapse. A series of 33 patients (11 males, 22 females; aged 18–83 years, mean 59) with external rectal prolapse were treated by Delorme's operation between 1989 and 1996. Mean follow-up was 39 months (range 7–84). Sphincteroplasty was associated in 12 cases with severe fecal incontinence due to striated muscle defects. Good results were achieved in 27 patients (79%); prolapse recurrence was observed in 6 (21%), the mean recurrence time being 9 months (range 1–24 months). There were no postoperative deaths. Minor complications occurred in 15 patients. Changes in preoperative and postoperative manometric patterns were as follows (mean±SEM): voluntary contraction from 59±6.9 to 66±7.1 mmHg (P=0.05), resting tone from 33±5 to 32±4.3 mmHg, rectal sensation from 59±5 to 61±5.2 ml of air (n.s.). A solitary rectal ulcer syndrome was detected in five patients. The histological pattern demonstrated pathological changes in 40% of cases. Fecal incontinence was resolved in 6 of 20 cases (30%) and chronic constipation in 4 of 9 (44%). Failure (n=3) was related primarily to postoperative sepsis. The incontinence score showed a mean improvement of 35% decreasing, from 4.5±0.39 to 2.9±0.44 after surgery (P<0.01). In conclusion, Delorme's procedure did not lead to constipation and improved anal continence when associated with sphincteroplasty. Accepted: 20 January 1998