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.      

Electromyographic biofeedback can improve subjective and objective measures of fecal incontinence in the short term

Electromyographic biofeedback therapy has demonstrated subjective improvement in patients with fecal incontinence that is comparable to surgery. We assessed the efficacy of biofeedback therapy in a consecutive heterogeneous group of patients using both subjective and objective assessment criteria. These 28 patients with fecal incontinence were studied retrospectively. Patients were assessed using a qualityof-life questionnaire (QOL), the Vaizey and Wexner incontinence scoring systems, and anorectal manometry for efficacy of treatment, before and after biofeedback therapy. Eighty-six percent of patients completed the study. Median follow-up was 18 months. Eighty percent of patients demonstrated significant improvements in their Vaizey and Wexner scores (P < 0.001 and P < 0.001, respectively). The mean QOL score improved from 62 to 77 (P < 0.01). Significant improvements were also demonstrated in the mean resting pressure (P < 0.01), peak amplitude of squeeze (P < 0.01), and the duration of squeeze pressure (P < 0.05). The deferred 15-minute evacuation time also significantly increased (P < 0.001). This study reported significant short-term improvement in fecal incontinence with electromyographic biofeedback therapy using validated subjective and objective scoring systems. Similarly, this treatment also significantly improved anorectal manometric findings. Our data confirm the role of biofeedback therapy in the multimodality approach to patients with fecal incontinence. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 19–21, 2003 (oral presentation).     

Clinical,urodynamic, and manometric findings in women with combined fecal and urinary incontinence

AIMS: To determine the prevalence of fecal incontinence in patients with urinary incontinence, who were referred for urodynamic evaluation, and to compare clinical and manometric findings between double incontinence and isolated fecal incontinence. METHODS: Nine hundred women with urinary and/or fecal incontinence were prospectively investigated. Patients with double incontinence (group 1) were compared with 38 women with isolated fecal incontinence (group 2). Clinical data regarding obstetric and urogynecologic history, bowel habit, and type of fecal incontinence were collected. Urodynamics and anal manometry were performed. RESULTS: Seventy-eight patients (8.7%) presented double incontinence. A history of vaginal delivery and chronic straining was more frequent in patients with double incontinence (P=0.043). No differences were found in the severity of fecal incontinence. Physical examination showed a greater prevalence of rectocele (54% vs. 12%) in group 1. On urodynamics, 80% of women with double incontinence had stress urinary incontinence. Rectal sensation testing revealed a significantly higher rate of hyposensitivity in group 2 (22% vs. 43%). CONCLUSIONS: This study supports a close association between combined stress urinary and fecal incontinence, history of vaginal delivery, and chronic straining.     

Prevalence of urinary,fecal and double incontinence in the elderly living at home

The aim of this study was to evaluate the prevalence of urinary, fecal and double incontinence in the elderly, through a population-based cross-sectional survey. The study included all patients aged 60 and over of nine general practices in the Nijmegen Monitoring Project. Patients living in a home for the elderly were excluded, as well as patients with dementia, patients who were too ill to participate and patients with a catheter. There were 5278 selected patients who received a postal questionnaire. Of these, 88% returned it. Nineteen percent of the respondents had involuntary loss of urine twice a month or more, 6% loss of feces and 3% both. The prevalence of urinary, fecal and double incontinence increased with age in both men and women, and especially in men in the oldest age group. Urinary incontinence was more prevalent in women than in men. The prevalence of fecal incontinence showed no sex differences, but the type of fecal incontinence did differ between men and women. In men loss of mucus was twice as common as in women. Double incontinence was also equally prevalent in men and women, except in the age group 65–74 years. In conclusion, urinary, fecal and double incontinence are common conditions in the community-dwelling population. The prevalence rates increase with age. Urinary incontinence is more prevalent in women. There were no sex differences in the prevalence of fecal incontinence but the type of fecal incontinence was different in men and women.Abbreviations FI Fecal incontinence - UI Urinary incontinence Editorial Comment: This large population-based survey looked at the prevalence of urinary, fecal, and double incontinence in women and men in the Netherlands. The fact that the authors were able to get an 88% return on their questionnaire demonstrates the utility of having primary care physicians involved in gaining pertinent information from patients. The response rate for specialists attempting such surveys on their own is grossly inferior to what these authors were able to accomplish. Although there was a higher prevalence of urinary incontinence in women, there was no difference between men and women in the prevalence of fecal incontinence. More studies like this are needed to establish prevalence data for pelvic floor dysfunction in general.An erratum to this article can be found at     

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。     

肛门病变术后肛门失禁相关因素分析

目的探讨肛门病变术后肛门失禁的相关因素。方法回顾性分析沈阳市肛肠医院2009年1—5月间1074例肛门病变术后患者临床资料及其与术后肛门失禁的关系。结果1074例患者术后出现轻度失禁144例（13．4％）,中度失禁57例（5．3％）,无完全失禁病例;总失禁率为18．7％,其中肛瘘术后失禁率为41．8％（107／256）,明显高于混合痔（12．4％,73／591）和肛裂（9．2％,21／227）．差异有统计学意义（P〈O．01）。行内痔注射术490例混合痔中注射消痔灵大于或等于10ml者术后轻度和中度失禁率分别为10．4％（27／259）和2．3％（6／259）：注射消痔灵小于10Inl者分别为9．5％（22／231）和4．3％（10／231）：差异无统计学意义（P〉O．05）。行内痔结扎术的354例混合痔中结扎痔核数大于或等于3枚者术后轻度和中度失禁率均为14．1％（10／71）：小于3枚者分别为3．9％（11／283）和2．1％（6／283）;差异有统计学意义（P〈O．01）。肛瘘和肛裂的手术方式对术后肛门失禁并无显著影响（P〉O．05）。结论肛瘘手术后肛门失禁发生率较高。对于混合痔,结扎痔核的数目不应超过3枚,注射疗法值得临床推广。     

Laparoscopic Burch colposuspension and overlapping sphincteroplasty for double incontinence.

OBJECTIVES: 1. To assess the effectiveness of laparoscopic Burch and overlapping sphincteroplasty in treating urinary and fecal incontinence. 2. To determine the importance of unilateral pudendal neuropathy in fecal incontinence. METHOD: Forty-six women with proven genuine stress incontinence and anal sphincter tears were treated with a laparoscopic Burch colposuspension. Patients with detrusor instability, intrinsic sphincter dysfunction, idiopathic fecal incontinence, and prior anal surgery were excluded. Objective postoperative testing for urinary continence included a cough stress test and bladder neck ultrasound, with repeat urodynamic studies if either test was positive. Fecal incontinence was graded with a clinical scoring index. The anal evaluation included sonography, sigmoidoscopy, manometry, and pudendal nerve terminal motor latency. Patients were divided into 2 groups. Group I (n = 34) had no neuropathy, and Group II (n = 12) had unilateral neuropathy. RESULTS: At 1-year follow-up, 40 patients (89%) were objectively dry, but 3 (7%) had recurrent genuine stress incontinence, and 2 (4%) had detrusor instability. Fecal incontinence cure rate was 82% in Group I and 58% in Group II. Group I had greater improvement in anal physiology studies than did Group II. Sphincter breakdown was the most common cause of recurrent fecal incontinence in Group I, but 4 of 5 patients with persistent incontinence in Group II had intact sphincters. DISCUSSION: Burch colposuspension is effective in treating genuine stress incontinence. Anal sphincteroplasty is effective in treating fecal incontinence due to obstetrical tears in the absence of pudendal neuropathy. Even unilateral neuropathy can significantly impair surgical outcomes.     

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.     

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.     

Prevalence and correlations of anal incontinence and constipation in Taiwanese women

Anal incontinence and constipation are not only physically and psychologically disabling symptoms but also a significant social and public health problem. The epidemiology of anal incontinence and constipation from community-bases remains largely unknown, especially in Asian women. This study is a continuation of a previous survey taken on the epidemiology of urinary incontinence and overactive bladder in Taiwanese women by using a second questionnaire (correlation coefficient for symptoms, r=0.87; P<0.05). We evaluated the prevalence and potential risk factors associated with anal incontinence and constipation in the general population. Of the 1,584 (2.92%) women sampled, 1,253 (79.1%) were successfully interviewed at home. The prevalence of fecal incontinence and flatus incontinence was 35 (2.8%) and 107 (8.6%), respectively. There were 306 (24.5%) participants who reported constipation. However, according to the current medical criteria for constipation, the prevalence of constipation was only 2.7%. The prevalence of anal incontinence did not increase after the age of 65 years (9.7%, including 3.5% of elderly women with fecal incontinence and 6.2% of elderly women with flatus incontinence). The prevalence of constipation significantly increased in the women aged 65 years and over (self-reported prevalence: 32.4%, fitted in medical criteria for constipation: 8.3%). Our results demonstrated that constipation shares some of the same risk factors, namely, symptoms of uterovaginal prolapse, prior gynecologic surgery, and overactive bladder that predispose women to the occurrence of anal incontinence. The questionnaire needs a higher discriminatory capacity, and a longitudinal study should be conducted to clarify this conflict further.     

Left-colon antegrade continence enema (LACE) procedure for fecal incontinence

Purpose: Antegrade continence enemas (ACE) are an efficacious therapeutic option for patients with fecal incontinence. The authors review their institution’s experience with a variation of the Monti-Malone ACE procedure using the left colon as a source of an intestinal conduit and enema reservoir.Methods: From 2000 to 2002, 18 patients with fecal incontinence or intractable constipation underwent left-colon ACE (LACE) procedure. Concomitant Mitrofanoff appendicovesicostomy was performed in 15 patients and bladder augmentation in 9. The majority of patients had neural tube defects. A segment of left colon was tubularized, tunneled into the muscular wall of the distal colon, and exteriorized through the left upper quadrant or midabdomen. Stomal catherization and enema installation were started one month postoperatively.Results: Fifteen patients (83%) achieved fecal continence, 2 remain incontinent of stool, and 1 experienced stomal closure (mean follow-up was 24 ± 9 months). Two patients had stomal stenosis that required revision. The mean enema volume in patient’s achieving continence was 360 ± 216 mL, and the mean transit time was 18 ± 12 minutes.Conclusions: LACE is an efficacious procedure for fecal incontinence that can be performed safely at the time of major urologic reconstruction. Administration of enemas into the left colon has several physiologic advantages that result in predictable bowel evacuation.     

Extracorporeal magnetic innervation treatment for urinary incontinence

BACKGROUND: Extracorporeal magnetic innervation (ExMI) is a new technology used for pelvic muscle strengthening for the treatment of stress urinary incontinence. We explored whether this new technology is effective for patients with urge incontinence, as well as those with stress urinary incontinence. METHODS: We studied 20 patients with urge incontinence and 17 patients with stress urinary incontinence. The Neocontrol system (Neotonus Inc., Marietta, GA) was used. Treatment sessions were for 20 min, twice a week for 8 weeks. Evaluations were performed by bladder diaries, one-hour pad weight testing, quality-of-life surveys and urodynamic studies. RESULTS: Of the urge incontinence cases, five patients were cured (25.0%), 12 patients improved (60.0%) and three patients did not show any improvement (15.0%). Leak episodes per day reduced from 5.6 times to 1.9 times at 8 weeks (P < 0.05). Eight patients with urge incontinence recurred within 24 weeks after the last treatment (47.1%). Of the stress incontinence cases, nine patients were cured (52.9%), seven patients improved (41.1%) and one patient did not show any improvement (6%). In one-hour pad weight testing, the mean pad weight reduced from 7.9 g to 1.9 g at 8 weeks (P < 0.05). Three patients returned to the baseline values within 24 weeks after the last treatment (17.6%). No side-effects were experienced by any of the patients. CONCLUSION: Although the results for urge incontinence were less effective than for stress urinary incontinence, ExMI therapy offers a new option for urge incontinence as well as stress urinary incontinence.     

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.     

Fecal incontinence,anal skin irritation,and metabolic concerns associated with pelvic pouches

Mechanical and inflammatory complications of pelvic pouch surgery have been well described but there has been limited recognition of problems such as fecal incontinence, anal skin irritation and metabolic changes that may develop after surgery. Reported rates of daytime and nighttime fecal incontinence rates are 29% and 47% respectively. We discuss strategies for managing fecal incontinence and associated anal skin irritation that can develop. Metabolic consequences of pelvic pouch surgery are also increasingly being recognized. Patients with IPAA who are doing well with no evidence of pouch inflammation have low rates of nutrient deficiencies but should be monitored for vitamin B12, vitamin D and zinc deficiencies. In contrast, patients with IPAA who develop pouchitis, diarrhea, and/or rectal bleeding are more susceptible to nutrient deficiencies and should have a broader assessment of nutrient status. In additions, there appears to be an increased risk of bone loss among patients with IPAA and thus these patients should undergo appropriate risk screening and testing. Finally, patients with IPAA have physiologic changes that predispose to formation of calcium oxalate and uric acid renal stones.     

Urinary incontinence in adults

Urinary incontinence is both a common and sometimes debilitating condition in adults. The reversible and chronic causes of urinary incontinence can be elicited from a good history and targeted examination. Voiding diaries and questionnaires can be helpful to quantify symptoms. The type of incontinence needs to be defined as well as the degree of bother that it causes the patient. In mixed types of urinary incontinence the most bothersome aspect is managed first. Once established, the management starts with conservative strategies such as caffeine avoidance and fluid management or pelvic floor exercise. Medical therapy can help for urgency incontinence and both urgency and stress urinary incontinence can be managed with surgery for refractory cases.     

Urinary incontinence detection in elderly inpatient men

Urinary incontinence is a serious medical and social problem affecting approximately 40% of elderly inpatients. Evaluating the extent of the illness and response to therapy requires an accurate method for quantitative measurement of urinary incontinence. Quantitative parameters of urinary loss include the frequency and volume of urinary incontinence. A telemetric incontinence detection instrument designed to measure incontinence frequency is described and the instrument is compared with a standard ?wet check”? incontinence detection technique. The electronic instrument appears to be an accurate method for detection of urine loss and is nonobtrusive to the patients.     

A longitudinal assessment of bowel related symptoms and fecal incontinence following radical perineal prostatectomy

PURPOSE: Recent studies have suggested an increased incidence of fecal incontinence following radical perineal prostatectomy. We provide a prospective and longitudinal assessment of bowel related symptoms of patients undergoing radical perineal prostatectomy. MATERIALS AND METHODS: A total of 78 patients who underwent radical perineal prostatectomy between January 1 and December 31, 2001 and had a minimal followup of 6 months were included in the analysis. Patient information was obtained from the chart and the bowel domain specific questions of a validated quality of life questionnaire, the Expanded Prostate Cancer Index Composite. The questionnaire was administered to the candidates preoperatively, at 4 weeks following surgery and subsequently at 3-months intervals. A mean bowel function, bother and summary health related quality of life score was calculated at each interval. The duration of new or worsened symptoms with respect to baseline was evaluated using Kaplan-Meier analysis. RESULTS: Symptoms of involuntary stool leakage and rectal urgency were reported by 11.5% (9 of 78) and 19.2% (15) of patients preoperatively. While all bowel related symptoms transiently increased following surgery, rectal urgency was the most persistent symptom, yet normalized in more than 90% of patients within 9 1/2 months. Compared to individual baseline 15.4%, 7.7%, 5.1% and 3.9% of patients reported worsened symptoms of fecal incontinence after 3, 6, 9 and 12 months, respectively. In the subset of 69 patients who denied preoperative fecal incontinence the incidence of involuntary stool leakage was 2.9% by 12 months following radical perineal prostatectomy. Of 10 patients 9 recovered individual health related quality of life score by 6 months after prostatectomy. CONCLUSIONS: Longitudinal assessment of self-reported questionnaire data suggests that fecal incontinence and bowel related symptoms are more prevalent following radical perineal prostatectomy compared to baseline, yet resolve in the majority of patients with time in the early postoperative period.     

骶神经刺激疗法在治疗排粪失禁中的应用

排粪失禁是严重影响人们生活质量和心理健康的重要疾病之一。1995年德国外科医生首次对排粪失禁患者进行了骶神经刺激治疗。骶神经刺激治疗的根本目的是通过刺激支配肛门括约肌、盆底肌肉的神经,动员它们的残余控便能力。标准的骶神经刺激治疗分为两个阶段．即骶神经刺激效果评估阶段和永久刺激器植入阶段。术前评估颇为重要是确保骶神经刺激治疗成功的前提。骶神经刺激是严重排粪失禁的首选治疗方法。骶神经刺激常见的并发症包括：疼痛、电极移位、伤口裂开,肠功能异常和感染等。     

Time to and predictors of dual incontinence in older nursing home admissions

Aims

There are few studies of nursing home residents that have investigated the development of dual incontinence, perhaps the most severe type of incontinence as both urinary and fecal incontinence occur. To determine the time to and predictors of dual incontinence in older nursing home residents.

Methods

Using a cohort design, records of older nursing home admissions who were continent or had only urinary or only fecal incontinence (n = 39,181) were followed forward for report of dual incontinence. Four national US datasets containing potential predictors at multiple levels describing characteristics of nursing home residents, nursing homes (n = 445), and socioeconomic and sociodemographic status of the community surrounding nursing homes were analyzed. A Cox proportional hazard regression with nursing home‐specific random effect was used.

Results

At 6 months after admission, 28% of nursing home residents developed dual incontinence, at 1 year 42% did so, and at 2 years, 61% had dual incontinence. Significant predictors for time to developing dual incontinence were having urinary incontinence, greater functional or cognitive deficits, more comorbidities, older age, and lesser quality of nursing home care.

Conclusions

The development of dual incontinence is a major problem among nursing home residents. Predictors in this study offer guidance in developing interventions to prevent and reduce the time to developing this problem which may improve the quality of life of nursing residents.