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PubMed2001

Treatment options for fecal incontinence.

PURPOSE: Fecal incontinence is a socially devastating disorder which affects at least 2.2 percent of community dwelling adults and 45 percent of nursing home residents. Most incontinent patients can be helped, but physicians are poorly informed about treatment options. The aim of this study was to develop a consensus on treatment options by convening a conference of surgeons, gastroenterologists, nurses, psychologists, and patient advocates. METHOD: A 1-1/2 day conference was held in April, 1999. Experts from different disciplines gave overviews, followed by extended discussions. Consensus statements were developed at the end of the conference. This summary statement was drafted, circulated to all participants, and revised based on their input. CONCLUSIONS: 1) Diarrhea is the most common aggravating factor for fecal incontinence, and antidiarrheal medications such as loperamide and diphenoxylate or bile acid binders may help. Fecal impaction, a common cause of fecal incontinence in children and elderly patients, responds to combinations of laxatives, education, and habit training in approximately 60 percent. These causes of fecal incontinence can usually be identified by history and physical examination alone. 2) In patients who fail medical management or have evidence of sphincter weakness, anorectal manometry and endoanal ultrasound are recommended as helpful in differentiating simple morphologic defects from afferent and efferent nerve injuries and from combined structural and neurologic injuries. 3) Biofeedback is a harmless and inexpensive treatment which benefits approximately 75 percent of patients but cures only about 50 percent. It may be most appropriate when there is neurologic injury (i.e., partial denervation), but it has been reported to also benefit incontinent patients with minor structural defects. 4) External anal sphincter plication with or without pelvic floor repair is indicated when there is a known, repairable structural defect without significant neurologic injury. It is effective in approximately 68 percent. 5) Salvage operations are reserved for patients who can not benefit from biofeedback or levator-sphincteroplasty. These include electrically stimulated gracilis muscle transpositions and colostomy. 6) Antegrade enemas delivered through stomas in the cecum or descending colon reduce or eliminate soiling in approximately 78 percent of children with myelomeningocele; this operation may come to be more widely applied. 7) Investigational treatments include implanted nerve stimulators, artificial sphincters, and anal plugs. 8) Patient characteristics which influence choice of treatment include mental status, mobility impairment, and typical bowel habits. 9) Additional research is needed to better define the mechanisms responsible for fecal incontinence, to assess the efficacy of these treatments, to develop better treatments for nursing home residents, and to identify predictors of outcome.

Fecal Incontinence↗

PubMed2000

Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence.

PURPOSE: This goal of this research was to develop and evaluate the psychometrics of a health-related quality of life scale developed to address issues related specifically to fecal incontinence, the Fecal Incontinence Quality of Life Scale. METHODS: The Fecal Incontinence Quality of Life Scale is composed of a total of 29 items; these items form four scales: Lifestyle (10 items), Coping/Behavior (9 items), Depression/Self-Perception (7 items), and Embarrassment (3 items). RESULTS: Psychometric evaluation of these scales demonstrates that they are both reliable and valid. Each of the scales demonstrate stability over time (test/retest reliability) and have acceptable internal reliability (Cronbach alpha >0.70). Validity was assessed using discriminate and convergent techniques. Each of the four scales of the Fecal Incontinence Quality of Life Scale was capable of discriminating between patients with fecal incontinence and patients with other gastrointestinal problems. To evaluate convergent validity, the correlation of the scales in the Fecal Incontinence Quality of Life Scale with selected subscales in the SF-36 was analyzed. The scales in the Fecal Incontinence Quality of Life Scale demonstrated significant correlations with the subscales in the SF-36. CONCLUSIONS: The psychometric evaluation of the Fecal Incontinence Quality of Life Scale showed that this fecal incontinence-specific quality of life measure produces both reliable and valid measurement.

Adaptation, Psychological↗

PubMed2003

[Pudendal neuropathy: correlation with demographic data, severity index and pressoric parameters in patients with fecal incontinence].

BACKGROUND: Fecal incontinence stands for inability in maintaining the control of defecation to a socially acceptable and adequate time and place, resulting in unwanted release of gas, liquid or solid stool. The diagnosis needs multiple exams. Anorectal manometry is mandatory for this study. The correlation between manometry with electophysiological studies and symptoms is not yet clear in the literature. AIMS: Correlate values of anal manometry, pudental nerve terminal motor latency and co morbidity in fecal incontinence patients. METHODOLOGY AND PATIENTS: Patients with clinical fecal incontinence, who attended the outpatient department of "Hospital Nossa Senhora da Concei o", Porto Alegre, RS, Brazil, between March 1997 and June 2000, were studied prospectively. Every single patient has undergone a general investigation, incontinence score, anal manometry, bilateral pudendal nerve terminal motor latency and physical examination. For statistical purposes the patients were separated in groups according to the results of the anal manometry, pudendal neuropathy, for age and sex. RESULTS/CONCLUSION: Thirty-nine patients were studied, 85,6% female, average age 60,1 years (+/- 12,89). The average index of the fecal incontinence was of 9,30 (+/- 4,93). In the anorectal manometry 23 patients showed low pressure. The pressures were significantly higher among males. The nerve terminal motor latency and pudental nerve (neuropathy) time was greater in 14 patients (35,9%). The age and the time of pudental nerve terminal motor were significantly co related. The other co relations were not statistically significant.

Adult↗

PubMed1992

[Psychosocial aspects of fecal incontinence].

Although fecal incontinence is one of the more frequent clinical symptoms of the gastrointestinal tract, its assessment is often neglected in clinical practice. The psychosocial aspects of the symptoms are also often overlooked: The number of undetected cases in comparison to those registered illustrates that not only patients but also physicians avoid this topic during clinical routine. Consequences of fecal incontinence for the quality of life of patients have rarely been investigated, but we could show that there are specific impacts of incontinence on family life, specifically with respect to sexuality, and on the job situation of those affected. Finally, it has been shown that in most cases continence can be achieved by management strategies deriving from psychological learning theory such as biofeedback training.

Adaptation, Psychological↗

PubMed2007

Pharmacotherapy for fecal incontinence: a review.

Fecal incontinence is a common clinical problem that often is frustrating to the patient and treating physician. Nonsurgical management for fecal incontinence includes dietary manipulation, Kegel exercises, perianal skin care, and biofeedback therapy. Pharmacotherapies often are used to assist in management of fecal incontinence. A variety of pharmacotherapies have been utilized for the management of fecal incontinence; limited data from randomized, placebo-controlled trials are available. This is a review of the existing literature on clinical trials of several classes of drugs and other medical therapies that may be beneficial for patients with fecal incontinence. The information in this article was obtained by a MEDLINE search for all clinical trials of drug therapy for fecal incontinence. These treatments and the existing data on their use are summarized. Treatments reviewed include stool bulking agents, with an emphasis on the most promising effect obtained with calcium polycarbophil, constipating agents, including loperamide, codeine, amitriptyline, atropine, and diphenoxylate agents injected into the anal sphincter, drugs to enhance anal sphincter function, including topical phenylepherine and oral sodium valproate, and trials of fecal disimpaction. A new classification to easily remember the treatment categories for this condition, based on the "ABCs of treatment for fecal incontinence," has been introduced into the structure of this review.

Chronic Disease↗

PubMed2004

Management of Fecal Incontinence in Children Without Functional Fecal Retention.

The management of the fecal incontinence in children is difficult, and its social consequences are usually devastating. The general objectives of any bowel program are to produce social continence, predictability, and eventually independence. How to achieve those goals depends in part on the underlying condition. In children, fecal incontinence can occur from a variety of conditions. The most common is overflow incontinence from functional fecal retention, but it can also occur in otherwise healthy children with functional nonretentive fecal soiling or in children with organic causes of fecal incontinence, such as congenital malformations, or any other condition affecting the anorectum, anal sphincters, or the spinal cord. The therapeutic regimen that is recommended in patients with nonretentive fecal soiling consists of explanation and support for the child and parents, a nonaccusatory approach, and a toilet training program with a rewarding system. Biofeedback does not play an important role, and laxatives need to be used with caution, as they may exacerbate the incontinence. For those patients with congenital/neuropathic incontinence a combination of maneuvers to change stool consistency, colonic transit, anorectal function, and rectosigmoid evacuation is used. Stool consistency can be changed with the use of dietary interventions or medications. Stool transit can be slowed (antimotility agents) or accelerated (laxatives) with the use of medications. Anorectal function can be improved with the use of biofeedback or procedures to alter sphincter pressure, and the production of a bowel movement can be induced with maneuvers to empty the sigmoid (suppositories, enemas). With the recent advent of the Antegrade Colonic Enema (ACE), the patient is then able to be predictable and independent. This procedure creates a continent conduit from the skin to the cecum that can be catheterized or accessed for self-administration of enemas. The ACE has revolutionized the treatment of children with fecal incontinence.

Journal Article↗

PubMed2004

The perspective of a gynecologist on treatment-related research for fecal incontinence in women.

Fecal incontinence affects between 1% and 16% of women, with prevalence increasing with age. The most common cause of fecal incontinence in otherwise healthy women is damage to the anal sphincter(s) during childbirth. As such, the most important tool in the "treatment" of fecal incontinence is its prevention, which should be the first research priority for gynecologists. Routine midline (median) episiotomy has no place in modern obstetrics; when episiotomy must be performed for obstetric indications, use of mediolateral episiotomy should result in fewer anal sphincter injuries than use of midline episiotomy. Additional research questions that gynecologists hope to address are as follows. (1) When anal sphincter injury occurs at delivery, what is the most effective method of repair? Even when repair is performed, women frequently have symptoms of altered bowel function ranging from fecal urgency to frank fecal incontinence. (2) Is it possible to improve the relatively poor results of a strictly surgical repair? Does pelvic muscle rehabilitation (performed either after vaginal delivery or after secondary repair remote from delivery) add significantly to the outcome of women after anal sphincteroplasty? (3) Another more general research priority is to understand the shared and independent factors in the pathophysiology of fecal and urinary incontinence so as to identify modifiable risk factors in women.

Delivery, Obstetric↗

PubMedDate not supplied

Silicone elastomer sling for fecal incontinence in dogs.

Fecal incontinence was created by bilateral pudendal neurectomy in 12 dogs. In six dogs, the fecal incontinence was treated by implantation of a polyester-impregnated silicone elastomer sling to form an artificial external anal sphincter. Six dogs underwent the same operative procedure without the implant to serve as controls. Five dogs regained total continence and one dog regained partial continence after implantation of the sling. Four control dogs remained incontinent and two control dogs regained partial continence. The difference between the dogs with slings and the controls was statistically significant (P less than 0.01). The only complication was infection in one dog, which was treated successfully. Histologic reaction to the implant was confined to a zone of fibrosis 1 to 3 mm surrounding the implant. The sling was well tolerated clinically and appeared to offer a successful method for correction of fecal incontinence in dogs.

Anal Canal↗

PubMed1994

Results of sphincter repair in postobstetric fecal incontinence.

BACKGROUND: Postobstetric fecal incontinence is a rare and severe complications of vaginal delivery. Most often, it is the result of a tear of the anal sphincter, pudendal neuropathy, or a combination of the two. STUDY DESIGN: Thirty-six patients operated upon at our institution for postobstetric fecal incontinence during a ten year period (1983 to 1992) were questioned (score) and examined to assess the operative results. RESULTS: Preoperatively, all 36 patients (mean age of 37 years, range of 24 to 70 years) had sphincter tears and 32 patients were totally incontinent (score of 16 to 18). Three patients were moderately incontinent (score of 9) and one patient was incontinent of flatus only (score of 3). Eighty percent of the patients were referred with delay. Thirty-six sphincteroplasties with various degrees of rectovaginal and perianal reconstructions were performed. Twenty-eight women (78 percent) are continent (score of zero to 3), seven patients (19 percent) are partially incontinent (score of 4 to 6), and one patient (3 percent) is totally incontinent (score of 18). There was no mortality. Among the six postoperative complications, there were two sphincter breakdowns with persistent incontinence and four minor local complications. CONCLUSIONS: Careful assessment and operative management of sphincter damage at the time of delivery as well as counseling of all women at risk for fecal incontinence are essential. Sphincteroplasty is a simple and safe procedure that offers symptomatic relief in almost all patients with sphincter lesions and cure in 80 percent.

Adult↗

PubMed2000

Fecal incontinence: a clinical approach.

"Fecal incontinence" is defined as the involuntary loss of stool at any time of life after toilet training. It is a socially and psychologically devastating condition for patients and their families, and a topic which both patients and physicians are reluctant to approach. Although the true prevalence of fecal incontinence is unknown, studies have reported it to be as high as 2. 2% in the general population, with significantly higher rates among nursing home residents and hospitalized elderly. Risk factors include advancing age, female gender and multiparity. An understanding of pelvic floor anatomy and physiology is required to appreciate how diverse medical conditions can affect mechanisms involved in normal continence. The rectum serves as a storage reservoir until elimination can take place at a socially acceptable time and place. The pelvic floor muscles help to regulate the defecatory process and maintain continence. These muscles include the internal anal sphincter, the external anal sphincter and the puborectalis muscle. Each muscle contributes to normal continence, although the relative importance of each is controversial. Neurologic integrity and sensation are also key factors. Conditions associated with fecal incontinence include diarrheal states, fecal impaction, idiopathic neurologic injury, surgical and obstetric injury, pelvic trauma, collagen vascular disease, and neurologic impairment related to stroke, diabetes, or multiple sclerosis. Evaluation of the patient with fecal incontinence includes a directed history and physical examination, with particular attention paid to integrity of the perineum and rectum, and a complete neurologic evaluation. Diagnostic tools such as stool studies, anorectal manometry, defecography, electromyography, pudendal nerve conduction, and endoanal ultrasound may be employed in an outpatient setting. Fecal incontinence may be treated conservatively by employing such methods as dietary restriction, stool bulking agents, and biofeedback. Surgery may be the best option for cases refractory to medical treatment, or for those patients with rectocele or obstetrical injury. In this article, we review the presentation, epidemiology, pathophysiology, and etiology of fecal incontinence. Evaluation, including key components of directed history and physical examination, and the appropriate use of diagnostic studies and indications for treatment options are also addressed.

Defecation↗

PubMed2002

Importance of colonic transit evaluation in the management of fecal incontinence.

BACKGROUND AND AIMS: Fecal incontinence is common. The potential contribution of colon function to continence has not been studied. Treatment is poorly codified. To evaluate colonic transit time (CTT) and its importance in the management of fecal incontinence we analyzed in a retrospective study the CTT in patients with fecal incontinence, and on this basis in a prospective study used a treatment algorithm taking colonic transit into account. PATIENTS AND METHODS: We studied 30 healthy subjects and 171 patients (110 in the retrospective and 61 in the prospective study). Anorectal manometry and CTT measurement using radio-opaque markers were performed. Patients were divided into three groups according to their CTT: rapid (<24 h), normal, and delayed (>65 h). In patients with abnormal CTT modifiers of transit time were used as first line of treatment. Biofeedback therapy was used alone in patients with normal transit and used in the other patients after 6 weeks of medication when there was no or only partial improvement. RESULTS: Incontinent patients had less upper and lower anal pressure and maximal squeeze pressure and longer CTT than controls. Rapid and delayed transit times were found, respectively, in 17% and 32% of patients. After 6 weeks of treatment 77% of patients had recovered from fecal incontinence. Biofeedback therapy increased total improvement to 95%. CONCLUSION: We conclude that evaluation of CTT is useful in the management of fecal incontinence, and that medical therapy is sufficient to treat most incontinent patients. This implies the use of a careful selection algorithm prior to surgery for fecal incontinence.

Adult↗

PubMed1988

Internal anal sphincter in neurogenic fecal incontinence.

In neurogenic fecal incontinence there is denervation of the external anal sphincter and pelvic floor muscles but the role of the internal anal sphincter is incompletely understood. We have evaluated the internal anal sphincter in 6 patients with neurogenic incontinence undergoing postanal repair and in 7 control subjects. All the incontinent subjects, but none of the controls, had evidence of pudendal neuropathy. Surface electromyography studies of the internal anal sphincter showed absence of electrical activity in 4 of 6 incontinent subjects; in the remaining 2 subjects and in 6 of 7 controls normal slow waves were present. Internal sphincter muscle strips from control subjects showed normal in vitro responses to noradrenaline, isoprenaline, dimethyl-phenylpiperazinium, and electrical field stimulation; muscle strips from the incontinent patients showed complete insensitivity except in 2 patients in whom there was contraction to noradrenaline and relaxation to isoprenaline. Electron microscopy showed normal smooth muscle in 5 control subjects and minor changes in 1 subject; all the incontinent patients showed abnormalities in the smooth muscle cells of the internal anal sphincter. These findings indicate that in neurogenic fecal incontinence neurogenic weakness of the external anal sphincter and pelvic floor muscles is associated with damage to the internal anal sphincter.

Adult↗

PubMed2000

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 on vs. turned off (Patient 1, 20 vs. 2 episodes; Patient 2, 4 vs. 0 episodes; off vs. on). There was an increase in squeeze pressure (Patient 1, 70 vs. 100 cm H2O; Patient 2, 60 vs. 90 cm H2O; off vs. on), with moderate increases in resting pressure and rectal threshold and urge volumes. Quality-of-life measurements showed a marked improvement prestimulation vs. 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.

Aged↗

PubMed2007

Functional nonretentive fecal incontinence in children.

Fecal incontinence, the loss of feces in the underwear after age 4 years, is a frustrating phenomenon for children and their parents. It is difficult to treat, presenting as a single symptom without any organic cause or signs of constipation. This review addresses the definition of functional nonretentive fecal incontinence and provides an overview of its epidemiology, pathophysiology, clinical features, diagnostic work-up and prognosis.

Child↗

PubMed1997

Continent appendicostomy in the bowel management of fecally incontinent children.

BACKGROUND: Fecal incontinence is common in children who have anorectal malformations, Hirschsprung's Disease, and spina bifida and can negatively impact their emotional and social development. Enemas have been used as an artificial way to keep children clean and to improve their quality of life. This method is unpleasant for many children, particularly when they reach adolescence. Malone in 1990 described an alternative method in which the appendix is used as a conduit to administer an antegrade enema. METHODS: The authors describe their experience with this new procedure, modified by them, and used in 20 patients. In the original procedure, the base of the appendix is divided, inverted, and reimplanted into the cecum with an antireflux technique. The authors simplify this by plicating the cecum around the appendix to create a one-way valve mechanism but leaving the appendix in its original position. The authors also mobilize the cecum and exteriorize the appendix at the umbilicus to create an inconspicuous stoma. If the native appendix is absent a neoappendix was created from a flap of cecum. RESULTS: Nineteen of 20 patients (95%) are now completely clean 24 hours a day. Stricture of the stoma occurred in two patients and required revision. Leakage at the appendicostomy site occurred in three patients, and two required a tighter plication. CONCLUSIONS: The technique is used to change the route of enema administration, and is only used in patients for whom bowel management with rectal enemas has been proven successful. The appendix must be preserved whenever possible in patients at risk for fecal incontinence.

Adolescent↗

PubMed2006

Longitudinal follow-up of children with functional nonretentive fecal incontinence.

BACKGROUND & AIMS: Functional nonretentive fecal incontinence (FNRFI), incontinence in the absence of signs of fecal retention, is a frustrating phenomenon in children. No data on long-term outcome are available. The aim was to investigate the long-term outcome of FNRFI patients after intensive medical treatment. METHODS: Between 1990 and 1999, 119 patients (96 boys) with FNRFI were enrolled in 2 prospective, randomized trials investigating the effect of biofeedback training and/or laxative treatment. Follow-up (FU) was performed at 6 months, 1 year, and thereafter annually until September 2004. A standardized questionnaire was used to evaluate symptoms. Success was defined as a fecal incontinence frequency <1 per 2 weeks. RESULTS: Median age (25th-75th percentiles) was 9.2 years (range, 7.9-11.6 years). A 90% FU was achieved at all stages of the study. After 2 years of intensive therapy, 33 of 112 (29.5%) patients were successfully treated. The cumulative success percentage after 7 years of FU was 80%. At the biologic ages of 12 and 18 years, 49.4% (40/81) and 15.5% (9/58), respectively, of the patients still had fecal incontinence. Duration of fecal incontinence, with 4 years of age as the starting age for fecal incontinence (when a child should be toilet trained), was not related to successful outcome or relapse. Relapse occurred in 37% of patients. CONCLUSIONS: Only 29% of the patients with FNRFI were successfully treated after 2 years of intensive treatment. Despite recovery in the majority of patients beyond puberty, at age 18 years, 15% continued to have fecal incontinence.

Biofeedback, Psychology↗

PubMed2006

Injectable silicone biomaterial (PTQ) to treat fecal incontinence after hemorrhoidectomy.

PURPOSE: Passive fecal incontinence after hemorrhoidectomy may occur and is socially incapacitating. There has been no effective treatment for passive fecal incontinence caused by internal anal sphincter dysfunction. This case series reviewed the outcome of therapy with injectable silicone biomaterial (PTQ) in patients who had passive fecal incontinence after hemorrhoidectomy. METHODS: From 2003 to 2004, seven patients referred with passive fecal incontinence after hemorrhoidectomy (Milligan-Morgan hemorrhoidectomy n = 5; stapled hemorrhoidectomy n= 2) were treated with injectable PTQ implants. All were assessed with anorectal physiology testing, Wexner continence score, and objective quality of life questionnaires before and after treatment. RESULTS: The Wexner continence score improved significantly at three months (P= 0.016) after the injectable PTQ implant and continued to improve significantly for up to 12 months (P = 0.016). The global quality of life scores (Visual Analog Scale) showed similar improvement (P = 0.016 at 3 months; P = 0.016 at 12 months). Three domains (life style, coping behavior, and depression/self-perception) of Fecal Incontinence Quality of Life Scale were significantly improved. The manometric studies showed significant improvement in maximum resting anal canal pressures (P= 0.016) after the injectable PTQ implant. CONCLUSIONS: The injectable silicone biomaterial is an effective treatment for passive fecal incontinence after hemorrhoidectomy providing good medium-term improvement in fecal incontinence and fecal incontinence-related quality of life.

Adult↗

PubMed2002

The effects of a progressive exercise program with surface electromyographic biofeedback on an adult with fecal incontinence.

BACKGROUND AND PURPOSE: Fecal incontinence often compromises a person's ability to participate in work and recreational activities. Incontinence may also diminish a person's willingness to take part in social events, leading to feelings of isolation. This case report describes physical therapy designed to reduce a patient's pelvic-floor muscle dysfunction and fecal incontinence. CASE DESCRIPTION: The patient was a 30-year-old woman whose fecal incontinence began after the complicated vaginal birth of her first child that required a vacuum extraction and episiotomy. Intervention included soft tissue techniques, electromyographic biofeedback, strength training, relaxation training, patient education, and a home program. The patient completed a questionnaire at initial evaluation and at discharge to assess her perceived limitations in functional activities. Electromyographic analysis was used to measure changes in the patient's pelvic-floor muscle control. OUTCOMES: The social, occupational, and sexual domains, which the patient initially judged to be the most compromised, showed the greatest improvement. Electromyographic data for the final treatment session indicated improved strength, endurance, and control of her pelvic-floor muscles. The patient reported no episodes of fecal incontinence over the last month of the 3 months of therapy. DISCUSSION: The physical therapy program may have led to improved bowel continence and greater control of the pelvic-floor muscles, resulting in greater confidence and comfort in social and work situations and less restriction in the patient's physical relationship with her spouse.

Adult↗