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PubMed2000

A nursing assessment tool for adults with fecal incontinence.

Fecal incontinence affects slightly more than 1% of community-dwelling adults. This article describes an assessment format, with a research basis when available, that has been developed in a specialist nursing clinic in the United Kingdom. The focus is on how to obtain the most useful information from the patient to plan appropriate nursing interventions. A subsequent article will describe the biofeedback program developed as part of a package of care to meet individual needs of persons with fecal incontinence.

Activities of Daily Living↗

PubMed1984

A components analysis of biofeedback in the treatment of fecal incontinence.

Fecal incontinence is a socially disabling symptom for which rectosphincteric biofeedback has been reported to be dramatically effective. The most commonly employed biofeedback procedure incorporates three separate and potentially effective components: exercise of the external sphincter muscle, training in discrimination of rectal sensations, and training synchrony of the internal and external sphincter responses. This paper reports the results of single case experiments employed with eight incontinent patients to examine the contributions of each of these components. All eight patients improved, but only one required the biofeedback procedure as it was originally described. Three responded to sensory discrimination training, one to exercise training, and one to the training of synchronous sphincteric responses; three recovered independently of the effects of biofeedback. Despite the achievement of continence, the rectosphincteric reflexes following treatment continued to be abnormal in every case. These findings suggest that the character of the external sphincter response to rectal distension is an unreliable index of sphincter function and that exercise and sensory discrimination training procedures are effective for some cases of fecal incontinence.

Adolescent↗

PubMed2001

Fecal Incontinence.

Fecal incontinence is a socially devastating clinical condition. Initial symptomatic treatment includes exclusion of foods that precipitate the problem, increased use of fiber, and drug therapy with loperamide. Persistence of incontinence after these lifestyle modifications requires the physician to evaluate the internal and external anal sphincters. Anal endosonography and manometry provide an evaluation of sphincter structure and function. If an isolated muscle defect is seen, sphincteroplasty can be tried. If this surgical procedure is not indicated, biofeedback may be an option. Biofeedback should be considered for patients with neurogenic fecal incontinence, a weak but structurally intact external sphincter, or a decreased ability to perceive rectal distention. Muscle transposition to create a neosphincter should be offered only by surgeons with extensive experience performing this surgery. Because of the cosmetic sequela of colostomy, this surgery is often considered as a last-step procedure, despite being safe and effective.

Journal Article↗

PubMed2001

Surgical treatment of constipation and fecal incontinence.

Fecal incontinence is a disabling and distressing condition. Many patients are reluctant to discuss the condition with a physician. A thorough history, good physical examination, and detailed anorectal physiologic investigations can help in the therapeutic decision-making algorithm. Patients with isolated anterior sphincter defects are candidates for overlapping repair. In the presence of unilateral or bilateral pudendal neuropathy, the patient should be counseled preoperatively regarding a [table: see text] lower anticipation of success. If the injury occurred shortly before the planned surgery and neuropathy is present, it may be prudent to wait because neuropathy sometimes can resolve within 6 to 24 months of the injury. Pudendal nerve study may help determine surgical timing. An anterior sphincter defect combined with a rectovaginal fistula can be approached by overlapping sphincter repair and a concomitant transanal advancement flap. Patients who had undergone multiple such procedures may benefit from concomitant fecal diversion at the time of repeat sphincter repair. Patients with global or multifocal sphincter injury may be candidates for a neosphincter procedure. The stimulated graciloplasty and artificial bowel sphincter are reasonable options. In the absence of the availability of these techniques or because of financial constraints, consideration could be given to bilateral gluteoplasty or unilateral or bilateral nonstimulated graciloplasty. The postanal repair still serves a role in patients with isolated decreased resting pressures with or without neuropathy or external sphincter injury with minimal degrees of incontinence. Biofeedback and the Procon device may play a role in these patients. Lastly, fecal diversion must be considered as a means of improving the quality of life because the patient can participate in the activities of daily living without the fear of fecal incontinence.

Constipation↗

PubMed2005

The etiology, assessment, and treatment of fecal incontinence.

Fecal incontinence is a common symptom that often impairs quality of life. It is generally caused by a variety of conditions that are associated with anorectal sensorimotor dysfunction and/or diarrhea. Assessment should be tailored to age and symptom severity. Modulation of disordered bowel habits is the key to management; biofeedback and surgery might also be beneficial.

Antidiarrheals↗

PubMed2001

Recent concepts in fecal incontinence.

Fecal incontinence is an inability to defer release of gas or stool from the anus and rectum by mechanisms of voluntary control. It is an important medical disorder affecting the quality of life of more than 2% of the US population. The most common contributing factors include previous vaginal deliveries, pelvic or perineal trauma, previous anorectal surgery, and rectal prolapse. Many physicians lack experience and knowledge related to pelvic floor incontinence disorders, but advancing technology has improved this knowledge. Increased experience with endoanal ultrasound and endoanal magnetic resonance imaging have given us better understanding of the anatomy of the anal canal, and new techniques with muscle translocation and artificial neosphincters and neuromodulation have expanded our armamentarium of options for restoring continence.

Aged↗

PubMed1996

[Conservative therapy of fecal incontinence].

Fecal incontinence is not diagnosis, but a symptom which can result from multiple causes. Therefore, therapy should attempt to treat the underlying disorder whenever possible. If this is not possible, therapy becomes symptom oriented. Besides drug treatment anal biofeedback training is the most important basis of medical therapy. Except for special situations surgery is indicated only if medical therapy has failed.

Biofeedback, Psychology↗

PubMed1994

Fecal incontinence.

Fecal incontinence is a common but infrequently reported, imperfectly understood, multifactorial disease with far-reaching socioeconomic and psychological implications. Limited success with somewhat empirical surgical procedures implies that patients should be investigated fully, indications for surgery should be clear, and disability should be serious enough to demand surgical intervention. Dietary adjustments and medical treatment should be tried first. Unwelcome though it is, colostomy may be the ultimate remedy in some patients.

Fecal Incontinence↗

PubMed1998

[Diagnosis and therapy of fecal incontinence].

Fecal incontinence is not a diagnosis, but a symptom which can have multiple causes. The aim of any therapy should be to treat the underlying disorder. This requires a detailed diagnostic procedure in each patient. If no underlying disorder can be found, therapy becomes symptom oriented. Besides drug treatment anal biofeedback training is the most important form of medical therapy. Except for special situations surgery is indicated only if medical therapy has failed.

Diagnosis, Differential↗

PubMed1997

Laparoscopic appendicostomy for management of fecal incontinence.

Fecal incontinence from any cause is a socially unacceptable condition and a major detriment to educational and psychosocial development in young people with certain disabilities. Recently several procedures have been described that allow antegrade colonic enemas in the treatment of this problem. We report here an additional method of establishing this proximal colon access, namely laparoscopic appendicostomy. Although not applicable to all patients, this procedure has been successful in a select group with excellent results, and we recommend its consideration when open surgery is not otherwise required.

Adolescent↗

PubMed1983

Posterior sagittal anorectoplasty as a secondary operation for the treatment of fecal incontinence.

Fecal incontinence is still a frequent postoperative sequelae in dealing with high rectal anomalies. Posterior sagittal anorectoplasty (PSARP) has been previously used in 87 cases as a primary procedure and allows full exposure of the anorectal region. Through this approach, full understanding of the anatomic damage is obtained and consequently a rational reconstructive plan can be designed in each case. Eight patients were operated on using this approach as a secondary operation. Surgical findings included anteriorly placed anus in all cases, a laterally misplaced anus in one of them, different degree of levator destruction in all of them, a missed portion of levator muscle anterior to the rectum and posterior to the urethra in one case, and variable degrees of megarectum in all cases. Reconstruction included tapering and replacement of the rectum and anus to surround them by striated muscle, reconstruction of levator mechanism, and repair of a persistent cloaca in one case. Postoperative assessment included a clinical as well as manometric and radiological evaluation. There were excellent results in five patients. Three patients showed significant improvement, including one patient with no sacrum.

Adolescent↗

PubMed1999

Endoanal MR imaging of the anal sphincter in fecal incontinence.

Fecal incontinence is a major medical and social problem. The most frequent cause is a pathologic condition of the anal sphincter. Endoanal magnetic resonance (MR) imaging allows detailed visualization of the normal anatomy and pathologic conditions of the anal sphincter. The hyperintense internal sphincter appears as a continuation of the smooth muscle of the rectum; the hypointense external sphincter surrounds the lower part of the internal sphincter. A sphincteric defect is seen as a discontinuity of the muscle ring. Scarring appears as a hypointense deformation of the normal pattern of the muscle layer. Two external sphincteric patterns may be misdiagnosed as defects: a posterior discontinuity (often seen in young male patients) and an anterior discontinuity (often seen in female patients). Atrophy of the external sphincter is easily detected on coronal MR images by comparing the thicknesses of all anal muscles. Endoanal MR imaging is superior to endoanal ultrasonography because of the multiplanar capability and higher inherent contrast resolution of the former. Use of endoanal MR imaging may lead to better selection of candidates for surgery and therefore better surgical results. Endoanal MR imaging is the most accurate technique for detection and characterization of sphincteric lesions and planning of optimal therapy.

Anal Canal↗

PubMed2005

Fecal incontinence.

Fecal incontinence is a multifactorial disorder that is often poorly understood and treated primarily by practicing physicians. Fecal impaction with overflow incontinence can be identified by patient history and physical examination and can be appropriately treated. For the remaining patients, diarrhea is a common aggravating factor that is frequently modulated by dietary changes, antidiarrheal agents, and occasionally by bile salt binders. When patients do not respond to conservative therapy, diagnostic studies to evaluate anorectal continence mechanisms are very helpful. Available therapies include biofeedback and pelvic floor retraining, surgery, and in the future, sacral nerve stimulation in carefully selected patients.

Journal Article↗

PubMed2003

Treatment of Fecal Incontinence.

Fecal incontinence is a symptom of many disorders that can affect the nerves and muscles controlling defecation; it is not just due to exceptionally voluminous diarrhea. Underlying problems should be identified and treated, because that may improve incontinence. If treatment of the underlying problem does not correct incontinence, several approaches can be employed successfully. General approaches include stimulation of defecation at intervals to empty the rectum under supervised conditions; treatment of diarrhea, if present; addressing coexisting psychologic problems, such as depression; use of continence aids, such as adult diapers; and perineal skin care to prevent skin breakdown. Drug therapy includes use of constipating drugs, such as loperamide or diphenoxylate, that can impede the gastrocolic reflex, thereby limiting rectal filling and the likelihood of incontinence. Biofeedback training is useful in patients with some ability to sense rectal distention and to contract the external anal sphincter; instrumental learning using manometric or electromyographic biofeedback can be used to reinforce the rectoanal contractile response to rectal distention. Improvement in continence has been noted in up to 70% of suitable candidates with a single biofeedback training session. Patients with external anal sphincter disruption due to childbirth injury or other trauma may benefit from direct external anal sphincter repair (sphincteroplasty). In others, tightening up the anal canal by encirclement with nonabsorbable mesh (Thiersch procedure), perianal injection of fat, collagen, or synthetic gel, or radiofrequency electrical energy (Stretta procedure) may provide some palliation. Creation of a new sphincter mechanism by muscle transposition and encirclement of the anal canal is another approach that has been improved by use of electrical stimulators to keep the neosphincter contracted. Artificial anal sphincters patterned after artificial urinary sphincters have met with some success, but local infection remains problematic. When all else fails, fecal diversion (ileostomy, colostomy) can be effective in rehabilitating patients.

Journal Article↗

PubMed2000

Validation of a questionnaire to assess fecal incontinence and associated risk factors: Fecal Incontinence Questionnaire.

PURPOSE: Although fecal incontinence is a topic of considerable importance, there are no validated self-report measures of fecal incontinence available. The aim of this study was to develop a questionnaire to measure fecal incontinence and its risk factors in the community. METHOD: The reliability and concurrent validity of the fecal incontinence questionnaire were measured by test-retest procedures in a population of clinic patients. The questionnaire was created for a sixth-grade reading level, with large print. Ninety-four adult patients were surveyed. Thirty-four patients repeated the questionnaire through the mail. Forty-one patients were independently retested over the telephone by a physician to assess concurrent validity. Nine patients refused retest, and ten patients did not respond to a second contact. RESULTS: The fecal incontinence questionnaire was well understood and well accepted. Reliability (overall median kappa, 0.68; interquartile range, 0.03-1) and validity (overall median kappa, 0.59; interquartile range, 0.27-1) were acceptable for the mailed retest and the telephone retest, respectively. The presence of fecal incontinence as measured by questionnaire was greatly increased when compared with physician history in clinical records; only 3 percent of patients reported no fecal incontinence on the questionnaire when the clinic chart had documented this problem. CONCLUSION: Our initial results indicated that this new self-report questionnaire is a useful tool for assessing the presence of fecal incontinence in the population and has greater sensitivity compared with a standard physician interview. Specific attention should be given to identifying fecal incontinence and associated symptoms during history taking.

Adult↗

PubMed2001

Sacral nerve stimulation for treatment of fecal incontinence: a novel approach for intractable 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 210 microsec, 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.

Adult↗

PubMed2004

Continent appendicostomy in the treatment of fecal incontinence.

BACKGROUND: Fecal incontinence is common in children with anorectal anomalies or spina bifida. If it is possible to achieve fecal control, patients are given a large volume of enema once a day. Retrograde enemas are often unpleasant in children, particularly in adolescents. Malone procedure of antegrade appendicostomy achieves antegrade colonic irrigation. MATERIAL AND METHODS: From 1996 to 2003 Malone antegrade appendicostomy was performed in 10 patients with fecal incontinence. The patients were aged from 5 to 24 years. In 4 patients fecal incontinence was due to an anorectal anomaly, and in 6 patients spina bifida. Preoperatively, all patients were given a clysma to control fecal incontinence. The patients, who remained clean with regular usage of the clysma for 24 hours or longer, fulfilled the criterion for the formation of continent appendicostomy. In 9 patients the cecal appendix was used to create a stoma, while in another one a lateral tubularized cecal flap was applied. In 3 patients a continent conduit was also done due to urinary incontinence. The follow-up period was from 1 to 8 years. A patient was reoperated due to stenosis of the stomal aperture, while another one has not been using the stoma because of social reasons. CONCLUSION: Continent appendicostomy is a simple surgery, which is effective in the control of fecal incontinence in most children. It is indicated only in patients in whom the rerograde clysma successfully cleans the colon and if patient and parents are motivated to use it. Possible complications, among which stenosis is the most frequent, can be solved with a reoperation.

Adolescent↗

PubMed2005

Costs of outpatients with fecal incontinence.

OBJECTIVE: Fecal incontinence is a problem with a high prevalence. Patients generally suffer from their problems for many years. It has been shown that quality of life is negatively affected but health economic data for fecal incontinence are limited. The aim of this study was to estimate the costs associated with fecal incontinence in a large outpatient study group, taking a societal perspective. MATERIAL AND METHODS: Based on questionnaire data, we calculated the costs of health-care resources, out-of-pocket expenses and costs associated with production losses in paid and unpaid work. RESULTS: Data were available for 253 patients, of which 228 (90%) were female and 209 (83%) were treated in an academic medical center. The mean age of patients was 59 years (SD+/-13) with a mean duration of incontinence of 8.5 years (SD+/-8.3). Total costs were estimated on C2169 per fecal incontinent patient per year. Production losses in paid and unpaid work accounted for more than half of the total costs and costs of health-care visits accounted for almost a fifth of total costs. Costs associated with protective material (partially reimbursable and not reimbursable) formed only one-tenth of total costs, while incontinence medication was responsible for only 5% of total costs. CONCLUSIONS: More than half of total costs of fecal incontinence are made up of indirect non-medical costs. The costs associated with the use of incontinence material and other personal expenses are limited.

Absenteeism↗