The Malone antegrade continence enema combined with urinary diversion in adult neurogenic patients: early results

Objectives. Patients with neurogenic voiding dysfunction often have coexisting neurogenic bowel problems. Impaired bowel evacuation is a cause of major morbidity and impaired lifestyle for these patients. The Malone antegrade continence enema (ACE) performed synchronously with a urinary continence procedure has been successful in pediatric patients. We report early experience combining the ACE with a urinary continence procedure in adult neurogenic patients.Methods. Adult patients with neurogenic voiding dysfunction and impaired bowel evacuation refractory to conservative management underwent a urinary continence procedure synchronously with an ACE.Results. Two patients have undergone the procedure. One patient chose a continent catheterizable supravesical bladder augmentation, whereas the other patient chose an ileal conduit. Both patients had a separate appendiceal stoma for their ACE. Both patients are continent of stool at their appendiceal stoma and per rectum. Both patients have stabilized their urinary tracts. Complications were minimal.Conclusions. The ACE may benefit adult patients with impaired bowel evacuation and may be combined with a urinary continence procedure. Further study of the ACE is warranted.     

Development of hydronephrosis secondary to poorly managed neurogenic bowel requiring surgical disimpaction in a patient with spinal cord injury: A case report

Context

Case of an adult patient with paraplegia managing neurogenic bladder with intermittent catheterization who was not performing a standard bowel program for management of neurogenic bowel.

Findings

Patient presented with increasing spasticity, fecal incontinence, and abdominal pain and ultimately was hospitalized for management. Imaging revealed massive fecal impaction, resulting in ureteral obstruction and hydronephrosis. Despite repeated aggressive bowel regimens, serial abdominal X-rays showed continued large stool burden. Ultimately surgical intervention was required to evacuate the colon and subsequently the hydronephrosis resolved.

Conclusion/Clinical relevance

This case illustrates the importance of proper management of neurogenic bowel, as significant medical complications, such as hydronephrosis can occur with poorly managed neurogenic bowel.     

EAU Guidelines on Surgical Treatment of Urinary Incontinence

Context

The European Association of Urology (EAU) guidelines on urinary incontinence published in March 2012 have been rewritten based on an independent systematic review carried out by the EAU guidelines panel using a sustainable methodology.

Objective

We present a short version here of the full guidelines on the surgical treatment of patients with urinary incontinence, with the aim of dissemination to a wider audience.

Evidence acquisition

Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches based on Population, Intervention, Comparator, Outcome (PICO) questions. The appraisal of papers was carried out by an international panel of experts, who also collaborated in a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.

Evidence summary

The full version of the guidance is available online (www.uroweb.org/guidelines/online-guidelines/). The guidance includes algorithms that refer the reader back to the supporting evidence and have greater accessibility in daily clinical practice. Two original meta-analyses were carried out specifically for these guidelines and are included in this report.

Conclusions

These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where high-level evidence is lacking, they present a consensus of expert panel opinion.     

EAU Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence

Context

The previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology.

Objective

We present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination.

Evidence acquisition

Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.

Evidence summary

The full version of the guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice.

Conclusions

These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where such evidence does not exist, they present a consensus of expert opinion.     

The effect of posterior colporrhaphy on anorectal function

Introduction and hypothesis

The objective of this study is to determine the effect of posterior colporrhaphy on bowel symptoms.

Methods

Comprehensive pelvic floor data were collected prospectively for 60 women undergoing posterior colporrhaphy. The electronic Personal Assessment Questionnaire-Pelvic Floor (ePAQ-PF) was completed at initial assessment and 3–6?months post-operatively. The bowel dimension of ePAQ-PF computes domain scores for IBS, constipation, evacuation, continence and QoL on a scale of 0–100. Preoperative bowel domain scores were compared with post-operative scores (Student t test).

Results

Significant improvement was seen in bowel evacuation (42%), continence (37%) and bowel-related QoL (61%) scores. IBS score improved by 28%, but this did not reach significance. There was no significant change noted in constipation (0.5%). All individual symptoms relating to bowel evacuation and continence improved significantly other than painful evacuation and incontinence to solid stool.

Conclusions

Bowel evacuation and continence improve significantly 3–6?months following posterior colporrhaphy and are associated with parallel improvement in QoL.     

EAU Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence

Context

The European Association of Urology guidelines on urinary incontinence (UI) have been updated in cyclical fashion with successive major chapters being revised each year. The sections on assessment, diagnosis, and nonsurgical treatment have been updated as of mid-2016.

脊髓损伤伴神经源性肠功能障碍患者肠道管理最佳证据总结

目的 总结脊髓损伤伴神经源性肠功能障碍患者肠道管理的最佳证据,为改善患者肠道功能提供依据。方法 检索国内外相关循证资源网站及数据库中关于脊髓损伤肠道功能障碍患者肠道管理证据。对纳入文献进行方法学质量评价和证据提取。结果 共纳入17篇文献,其中指南7篇、专家共识5篇、系统评价3篇、随机对照试验2篇。总结了关于肠道功能评估方法、评估量表、健康教育、饮食干预、药物干预、行为干预及手术干预7个方面的26条证据。结论 脊髓损伤伴神经源性肠功能障碍患者最佳证据可为临床医护人员评估患者肠道功能及采取干预措施提供依据,实际应用中应结合临床实际情况和患者需求选择证据。     

Transrectal Electrostimulation Therapy for Neuropathic Bowel Dysfunction in Children With Myelomeningocele

Purpose

We attempted to evaluate the efficacy of transrectal bowel stimulation for neurogenic bowel dysfunction in children with myelodysplasia.

Materials and Methods

Daily sessions of transrectal electrostimulation were performed on an outpatient basis for 2 to 3 weeks on children with myelodysplasia and stool incontinence. If benefits were noted, 5 to 10 additional daily sessions were performed. Complete success was defined as improvement in all parameters of interest, including decrease in the frequency of daily bowel movements, increased sensation, increased ability to hold stool and a significant subjective change in bowel habits. Moderate success implied improvement in 1 to 3 parameters and treatment failure was defined as lack of improvement in any parameter.

Results

A total of 55 children 2 to 14 years old (mean age 6.7) completed a mean of 18 daily sessions per patient of bowel electrostimulation. Followup ranged from 1 to 6 years. Diapers are no longer required due to defecation problems in 14 children older than 3 years. Complete success was achieved in 20 cases (36.3%) and moderate success in an additional 30 (54.5%, overall success rate 90.8%). Specifically, 89% of the patients reported elimination of stooling accidents, 82% reported increased sensation and 71% were able to hold the bowel movement. Overall 68% of the patients noticed significantly improved bowel function. Completely/moderate success of transrectal electrostimulation was statistically significant for all 4 parameters (p <0.05), and complete success was significant for increased sensation, ability to hold and episodes of accidents. Therapy failed in 5 children (9%). There were no untoward effects.

Conclusions

Transrectal electrostimulation is a well tolerated and minimally invasive modality that provides sustainable improvement in stool continence in children with myelomeningocele and neuropathic bowel dysfunction.     

EAU Guidelines on Chronic Pelvic Pain

Context

These guidelines were prepared on behalf of the European Association of Urology (EAU) to help urologists assess the evidence-based management of chronic pelvic pain (CPP) and to incorporate the recommendations into their clinical practice.

Objective

To revise guidelines for the diagnosis, therapy, and follow-up of CPP patients.

Evidence acquisition

Guidelines were compiled by a working group and based on a systematic review of current literature using the PubMed database, with important papers reviewed for the 2003 EAU guidelines as a background. A panel of experts weighted the references.

Evidence synthesis

The full text of the guidelines is available through the EAU Central Office and the EAU Web site (www.uroweb.org). This article is a short version of the full guidelines text and summarises the main conclusions from the guidelines on the management of CPP.

Conclusions

A guidelines text is presented including chapters on chronic prostate pain and bladder pain syndromes, urethral pain, scrotal pain, pelvic pain in gynaecologic practice, neurogenic dysfunctions, the role of the pelvic floor and pudendal nerve, psychological factors, general treatment of CPP, nerve blocks, and neuromodulation. These guidelines have been drawn up to provide support in the management of the large and difficult group of patients suffering from CPP.     

EAU Guidelines on Neurogenic Lower Urinary Tract Dysfunction

Context

Most patients with neurogenic lower urinary tract dysfunction (NLUTD) require life-long care to maintain their quality of life (QoL) and to maximise life expectancy.

Objective

To provide a summary of the 2008 version of the European Association of Urology (EAU) guidelines on NLUTD and to assess the effectiveness of currently available diagnostic tools, particularly ultrasound imaging and urodynamics.

Evidence acquisition

The recommendations provided in the 2008 EAU guidelines on NLUTD are based on a review of the literature, using online searches of Medline and other source documents published between 2004 and 2007. A level of evidence and/or a grade of recommendation have been assigned to the guidelines where possible.

Evidence synthesis

NLUTD encompasses a wide spectrum of pathologies, and patients often require life-long, intensive medical care to maximise their life-expectancy and to maintain their QoL. Treatment must be tailored to the needs of the individual patient and, in many cases, involves a multidisciplinary team of experts. Timely diagnosis and treatment are essential if irreversible deterioration of both the upper and lower urinary tracts are to be avoided. Therapeutic decisions are made on the basis of a comprehensive medical assessment, including urodynamics to identify the type of dysfunction. Advances in investigative technologies have facilitated the noninvasive and conservative management of patients who have NLUTD.

Conclusions

The diagnosis and treatment of NLUTD, which is a highly specialised and complex field involving both urology and medicine, requires up-to-date expert advice to be readily available. The current guidelines are designed to fulfil this need.     

Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

Purpose

In 2009, the European Hernia Society published the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. The guidelines expired January 1, 2012. To keep them updated, a revision of the guidelines was planned including new level 1 evidence.

Methods

The original Oxford Centre for Evidence-Based Medicine ranking was used. All relevant level 1A and level 1B literature from May 2008 to June 2010 was searched (Medline and Cochrane) by the Working Group members. All chapters were attributed to the two responsible authors in the initial guidelines document. One new chapter on fixation techniques was added. The quality was assessed by the Working Group members during a 2-day meeting and the data were analysed, especially with respect to any change in the level and/or text of any of the conclusions or recommendations of the initial guidelines. In the end, all relevant references published until January 1, 2013 were included. The final text was approved by all Working Group members.

Results

For the following topics, the conclusions and/or recommendations have been changed: indications for treatment, treatment of inguinal hernia, day surgery, antibiotic prophylaxis, training, postoperative pain control and chronic pain. The addendum contains all current level 1 conclusions, Grade A recommendations and new Grade B recommendations based on new level 1 evidence (with the changes in bold).

Conclusions

Despite the fact that the Working Group responsible for it tried to represent most kinds of surgeons treating inguinal hernias, such general guidelines inevitably must be fitted to the daily practice of every individual surgeon treating his/her patients. There is no doubt that the future of guideline implementation will strongly depend on the development of easy to use decision support algorithms tailored to the individual patient and on evaluating the effect of guideline implementation on surgical outcome. At the 35th International Congress of the EHS in Gdansk, Poland (May 12–15, 2013), it was decided that the EHS, IEHS and EAES will collaborate from now on with the final goal to publish new joint guidelines, most likely in 2015.     

An overview of clinical guidelines for the management of vertebral compression fracture: a systematic review

Background Context

Vertebral compression fractures (VCFs) are the most common type of osteoporotic fracture comprising approximately 1.4 million cases worldwide. Clinical practice guidelines can be powerful tools for promoting evidence-based practice as they integrate research findings to support decision making. However, currently available clinical guidelines and recommendations, established by different medical societies, are sometimes contradictory.

Fundamentals and clinical perspective of urethral sphincter instability as a contributing factor in patients with lower urinary tract dysfunction—ICI‐RS 2014

Aims

Urethral pathophysiology is often neglected in discussions of bladder dysfunction. It has been debated whether “urethral sphincter instability,” referred to based on observed “urethral pressure variations,” is an important aspect of overactive bladder syndrome (OAB). The purpose of this report is to summarize current urethral pathophysiology evidence and outline directions for future research based on a literature review and discussions during the ICI‐RS meeting in Bristol in 2014.

Methods

Urethral pathophysiology with a focus on urethral pressure variation (UPV) was presented and discussed in a multidisciplinary think tank session at the ICI_R meeting in Bristol 2014. This think tank session was based on collaboration between physicians and basic science researchers.

Results

Experimental animal studies or studies performed in clinical series (predominantly symptomatic women) provided insights into UPV, but the findings were inconsistent and incomplete. However, UPV is certainly associated with lower urinary tract symptoms (likely OAB), and thus, future research on this topic is relevant.

Conclusions

Future research based on adequately defined clinical (and urodynamic) parameters with precisely defined patient groups might shed better light on the cause of OAB symptoms. Further fundamental investigation of urethral epithelial–neural interactions via the release of mediators should enhance our knowledge and improve the management of patients with OAB. Neurourol. Urodynam. 35:318–323, 2016. © 2016 The Authors. Neurourology and Urodynamics published by Wiley Periodicals, Inc.     

MALONE ANTEGRADE CONTINENCE ENEMA FOR ADULTS WITH NEUROGENIC BOWEL DISEASE

Purpose

We describe the outcomes of adults with neurogenic bowel disease who underwent a Malone antegrade continence enema procedure with or without concomitant urinary diversion.

Materials and Methods

Consecutive adult patients with neurogenic bowel disease who underwent an antegrade continence enema procedure (continent catheterizable appendicocecostomy for fecal impaction) were retrospectively reviewed.

Results

Of the 7 patients who underwent an antegrade continence enema synchronous urinary procedure (ileal conduit, augmentation ileocystoplasty with continent catheterizable abdominal stoma or augmentation ileocystoplasty) was also performed in 6. Mean patient age was 32 years and mean followup was 11 months. Of the 7 patients 6 who self-administered antegrade continence enemas regularly were continent of stool per rectum and appendicocecostomy, using the appendicocecostomy as the portal for antegrade enemas. All 6 compliant patients reported decreased toileting time and improved quality of life. Preoperative autonomic dysreflexia resolved postoperatively in 3 patients. All urinary tracts were stable. In 4 patients 5 complications occurred, including antegrade continence enema stomal stenosis requiring appendicocutaneous revision (1), antegrade continence enema stomal stenosis requiring dilation (1), superficial wound infection (1), small bowel obstruction requiring lysis of adhesions (1) and urinary incontinence (1 who underwent continent urinary diversion).

Conclusions

Patients with neurogenic bladder and bowel disease may benefit from antegrade continence enema performed synchronously with a urinary procedure. Antegrade continence enema may be indicated alone for neurogenic bowel. Patient selection is important.     

Development of hydronephrosis secondary to poorly managed neurogenic bowel requiring surgical disimpaction in a patient with spinal cord injury: A case report

Abstract

Context

Case of an adult patient with paraplegia managing neurogenic bladder with intermittent catheterization who was not performing a standard bowel program for management of neurogenic bowel.

Findings

Patient presented with increasing spasticity, fecal incontinence, and abdominal pain and ultimately was hospitalized for management. Imaging revealed massive fecal impaction, resulting in ureteral obstruction and hydronephrosis. Despite repeated aggressive bowel regimens, serial abdominal X-rays showed continued large stool burden. Ultimately surgical intervention was required to evacuate the colon and subsequently the hydronephrosis resolved.

Conclusion/Clinical relevance

This case illustrates the importance of proper management of neurogenic bowel, as significant medical complications, such as hydronephrosis can occur with poorly managed neurogenic bowel.     

Social And Personal Consequences Of Acquired Bowel Dysfunction For Persons With Spinal Cord Injury

Abstract

Background: Traditional literature regarding acquired bowel dysfunction for persons with spinal cord injury (SCI) has focused on clinical assessments of bowel dysfunction and bowel management programs. These studies make reference to the effects of bowel dysfunction on quality of life (QOL), but none systematically study the relationship. This study develops 4 scales that measure impediment to community integration (ICI) due to bowel dysfunction and then examines the relationship between bowel dysfunction, ICI, and QOL.

Methods: A structured telephone survey was conducted with a convenience sample of 103 SCI consumers. Survey questions documented bowel dysfunction (ie, severity and number of accidents), bowel management (ie, how often bowels are evacuated), ICI , and satisfaction with 4 life domains.

Results: Correlation analyses showed that subjective bowel dysfunction severity and number of days per month a respondent had to stay home because of lack of bowel control were associated with barriers to personal relationships, feelings about self, and home life. Also, the number of bowel accidents per month was associated with feelings about self. ICI scales were shown to be related to lower levels of satisfaction with free time, friendships. family life, and life in general. No statistically significant relationships were found between bowel dysfunction and satisfaction with life.

Conclusion: Bowel dysfunction is a barrier to community integration and is related to low leve ls of life satisfaction. Also , it is possible to quantify ICI related to bowel dysfunction. Educational programs can reduce the stigma associated with bowel dysfunction. Further research into the intricate relationships between bowel problems, barriers to participation in the community, and life satisfaction is needed.     

Descending perineum syndrome: a review of the presentation,diagnosis, and management

Introduction and hypothesis

Defecatory dysfunction is a relatively common and challenging problem among women and one that practicing pelvic reconstructive surgeons and gynecologists deal with frequently. A subset of defecatory dysfunction includes obstructed defecation, which can have multiple causes, one of which is descending perineum syndrome (DPS).

Methods

A literature search was performed to identify the pathophysiology, diagnosis, and management of DPS.

Results

Although DPS has been described in the literature for many decades, it is still uncommonly diagnosed and difficult to manage. A high index of suspicion combined with physical examination consistent with excess perineal descent, patient symptom assessment, and imaging in the form of defecography are required for the diagnosis to be accurately made. Primary management options of DPS include conservative measures consisting of bowel regimens and biofeedback. Although various surgical approaches have been described in limited case series, no compelling evidence can be demonstrated at this point to support surgical intervention.

Conclusions

Knowledge of DPS is essential for the practicing pelvic reconstructive surgeon to make a timely diagnosis, avoid harmful treatments, and initiate therapy early on.

     

Incontinence and voiding difficulties associated with prolapse

Purpose

Prolapse is the protrusion of a pelvic organ beyond its normal anatomical confines. It represents the failure of fibromuscular supports.

Materials and Methods

A MEDLINE search was done using the keywords cystocele, uterine prolapse, vault prolapse, enterocele or rectocele in combination with urinary incontinence. We reviewed 97 articles. From this material the definition, classification, incidence, symptoms and evaluation are described.

Results

Prolapse and urinary incontinence often occur concomitantly and cystocele, rectocele, enterocele, uterine descent or vaginal vault prolapse may also be present. The pathophysiology of prolapse encompasses direct and indirect injury, metabolic abnormalities and chronic high intra-abdominal pressure. Anterior vaginal wall prolapse may present as stress incontinence. A large cystocele may cause urethral kinking and overflow incontinence. Uterine descent can cause lower back and sacral pain. Enterocele may cause only vague symptoms of vaginal discomfort. A rectocele can lead to incomplete evacuation of stool. A thorough history and physical examination are the most important means of assessment. A voiding diary helps determine functional bladder capacity. Uroflow examination determines the average and maximum flow rates, and the shape of the curve can help identify Valsalva augmented voiding. Multichannel urodynamics or videourodynamics with prolapse reduced can be important. The advantages of dynamic magnetic resonance imaging include excellent depiction of the soft tissues and pelvic organs, and their fluid content during various degrees of pelvic strain. To our knowledge whether it is cost-effective in this manner has not been determined.

Conclusions

Correction of prolapse must aim to restore vaginal function and any concomitant urinary incontinence.     

PROSPECT: a practical method for formulating evidence-based expert recommendations for the management of postoperative pain

Background

Many patients still suffer severe acute pain in the postoperative period. Although guidelines for treating acute pain are widely published and promoted, most do not consider procedure-specific differences in pain experienced or in techniques that may be most effective and appropriate for different surgical settings. The procedure-specific postoperative pain management (PROSPECT) Working Group provides procedure-specific recommendations for postoperative pain management together with supporting evidence from systematic literature reviews and related procedures at http://www.postoppain.org

Methods

The methodology for PROSPECT reviews was developed and refined by discussion of the Working Group, and it adapts existing methods for formulation of consensus recommendations to the specific requirements of PROSPECT.

Results

To formulate PROSPECT recommendations, we use a methodology that takes into account study quality and source and level of evidence, and we use recognized methods for achieving group consensus, thus reducing potential bias. The new methodology is first applied in full for the 2006 update of the PROSPECT review of postoperative pain management for laparoscopic cholecystectomy.

Conclusions

Transparency in PROSPECT processes allows the users to be fully aware of any limitations of the evidence and recommendations, thereby allowing for appropriate decisions in their own practice setting.