Christine Norton

Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma

BACKGROUND Anterior structural damage to the anal sphincter occurs in up to a third of women at first vaginal delivery, and of these a third have new bowel symptoms. The standard treatment for such structural damage is anterior overlapping anal-sphincter repair. We aimed to assess the long-term results of this operation. METHODS We assessed the long-term results in 55 consecutive patients who had had repair a minimum of 5 years (median 77 months [range 60-96]) previously. Questionnaire and telephone interview assessed current bowel function and continence, restriction in activities related to bowel control, and overall satisfaction with the results of surgery. 42 of these patients had been continent of solid and liquid stool at a median of 15 months after the repair. FINDINGS We were able to contact 47 (86%) of the 55 patients. One of these patients had required a proctectomy and end ileostomy for Crohns disease. Of the remaining 46 patients, 27 reported improved bowel control without the need for further surgery, and 23 rated their symptom improvement as 50% or greater. Seven patients had undergone further surgery for incontinence and one patient had not had a covering stoma closed. Thus, the long-term functional outcome of the sphincter repair alone could be assessed in 38 patients. Of these patients, none was fully continent to both stool and flatus; only four were totally continent to solid and liquid stool; six had no faecal urgency; and eight had no passive soiling. Of the 38 patients, 20 still wore a pad for incontinence and 25 reported lifestyle restriction. 14 reported the onset of a new evacuation disorder after sphincter repair. 23 of the 46 patients contacted had a successful long-term outcome (defined as no further surgery and urge faecal incontinence monthly or less). INTERPRETATION The results of overlapping sphincter repair for obstetric anal-sphincter damage seem to deteriorate with time. Preoperative counselling should emphasise that although most patients will improve after the procedure, continence is rarely perfect, many have residual symptoms, and some may develop new evacuation disorders.

Anal sphincter biofeedback and pelvic floor exercises for faecal incontinence in adults—a systematic review

: Faecal incontinence is a common health care problem. Biofeedback is extensively used in clinical practice to treat faecal incontinence.

Internal anal sphincter augmentation for fecal incontinence using injectable silicone biomaterial

PURPOSE: A disrupted or weak internal anal sphincter can lead to passive fecal incontinence. This muscle is not amenable to direct surgical repair. Previous preliminary attempts to restore functional continuity have included a cutaneous flap to fill an anal canal defect, and injection therapy using polytetrafluoroethylene, collagen, or autologous fat. Urologists have also used injections of collagen or silicone to enhance bladder neck function. This pilot study aimed to assess the efficacy of single or multiple injections of the silicone-based product Bioplastique™ for the symptoms of passive fecal incontinence caused by an anatomically disrupted or intact but weak internal anal sphincter. PATIENTS AND METHODS: Ten patients (6 females; median age, 64 ; range, 41–80 years) with passive incontinence secondary to a weak (n=6) or disrupted (n=4) internal anal sphincter were injected either circumferentially or at a single site, respectively. Patients were assessed before and six weeks after treatment by clinical assessment, two-week bowel diary card, anorectal physiologic testing, and endoanal ultrasound. Patients failing to show improvement after the first injection were offered a second injection six weeks after the first injection. Clinical assessment was further repeated at six months, and five patients had a further ultrasound examination. RESULTS: At six weeks, six of ten patients showed either marked improvement (n=3) or complete cessation of leakage (n=3). A further patient was greatly improved after a second injection. Three patients were not improved. At six months, two of the seven patients had maintained marked improvement, and one patient had maintained minor improvement; all of these three patients had circumferential multiple injections. Maximum resting and squeeze anal pressures did not differ significantly between beforevs. six weeks aftervs. six months after injection. At six weeks endoanal ultrasound (n=9) confirmed the presence and correct position of the silicone in all but one patient who had experienced obvious external leakage of the product. At six months the silicone remained in the correct position in the five endosonographically assessed patients. Five of the initial patients experienced pain or minor ulceration at the injection site. CONCLUSIONS: Although clinically effective immediately after injection, the benefit of an injectable biomaterial was maintained in only a minority of patients. This occurred despite the continued presence of material in the correct anatomical site. Patients with diffuse weakness treated by circumferential injection seemed to be the most responsive, but further studies are required to clarify this.

Treatment of Constipation and Fecal Incontinence in Stroke Patients Randomized Controlled Trial

Background and Purpose— Despite its high prevalence in stroke survivors, there is little clinical research on bowel dysfunction in this population. This is the first randomized controlled trial to evaluate treatment of constipation and fecal incontinence in stroke survivors. Methods— Stroke patients with constipation or fecal incontinence were identified by screening questionnaire (122 community, 24 stroke rehabilitation inpatients) and randomized to intervention or routine care (73 per group). The intervention consisted of a 1-off structured nurse assessment (history and rectal examination), leading to targeted patient/carer education with booklet and provision of diagnostic summary and treatment recommendations (after consultation with geriatrician) to patient’s general practitioner (GP)±ward physician. Results— Percentage of bowel movements (BMs) per week graded as “normal” by participants in a prospective 1-week stool diary was significantly higher in intervention versus control patients at 6 months (72% versus 55%; P=0.027), as was mean number of BMs per week (5.2 versus 3.6; P=0.005). There was no significant reduction in fecal incontinence, although numbers were small. At 12 months, intervention patients were more likely to be modifying their diets (odds ratio [OR], 3.1 [1.2 to 8.0]) and fluid intake (OR, 4.2 [1.4 to 12.2]) to control their bowels and to have visited their GP for their bowel problem (OR, 5.0 [1.4 to 17.5]). GP prescribing of laxatives and suppositories was significantly influenced at 12 months. Conclusions— A single clinical/educational nurse intervention in stroke patients effectively improved symptoms of bowel dysfunction up to 6 months later, changed bowel-modifying lifestyle behaviors up to 12 months later, and influenced patient–GP interaction and physician prescribing patterns.

Gut focused behavioural treatment (biofeedback) for constipation and faecal incontinence in multiple sclerosis

OBJECTIVES To determine whether gut focused behavioural treatment (biofeedback) is a useful therapy in multiple sclerosis patients referred for constipation, incontinence, or a combination of these symptoms. Most patients with multiple sclerosis complain of constipation, faecal incontinence, or a combination of the two. Patients rate these bowel symptoms as having a major impact on their life. Until now the management of these problems has been empirical, with a lack of evaluated therapeutic regimes. METHODS Thirteen patients (eight women, median age 38 years, median duration of multiple sclerosis 10 years) complaining of constipation, with or without faecal incontinence underwent a median of four sessions of behavioural treatment. Anorectal physiological tests were performed before therapy. Impairment and disability were rated with the Kurtzke score and the Cambridge multiple sclerosis basic score (CAMBS). Patients were contacted a median of 14 months after completion of treatment. RESULTS A beneficial effect was attributed to biofeedback in five patients. Mild to moderate disability, quiescent and non-relapsing disease, and absence of progression of multiple sclerosis over the year before biofeedback were predictive of symptom improvement. No physiological test predicted the response to therapy. CONCLUSION Biofeedback retraining is an effective treatment in some patients with multiple sclerosis complaining of constipation or faecal incontinence. A response is more likely in patients with limited disability and a non-progressive disease course.

Pathophysiology and management of bowel dysfunction in multiple sclerosis

The prevalence of bowel dysfunction in multiple sclerosis (MS) patients is higher than in the general population. Up to 70% of patients complain of constipation or faecal incontinence, which may also coexist. This overlap can relate to neurological disease affecting both the bowel and the pelvic floor muscles, or to treatments given. Bowel dysfunction is a source of considerable ongoing psychosocial disability in many patients with MS. Symptoms related to the bladder and the bowel are rated by patients as the third most important, limiting their ability to work, after spasticity and incoordination. Bowel management in patients with MS is currently empirical. Although general recommendations include maintaining a high fibre diet, high fluid intake, regular bowel routine, and the use of enemas or laxatives, the evidence to support the efficacy of these recommendations is scant. This review will examine the current state of knowledge regarding the pathophysiological mechanisms underlying bowel dysfunction in MS, outline the importance of proper clinical assessment of constipation and faecal incontinence during the diagnostic work-up, and propose various management possibilities. In the absence of clinical trial data on bowel management in MS, these should be considered as a consensus on clinical practice from a team specialized in bowel dysfunction.

Management of Fecal Incontinence in Adults

This article summarises the findings from the conservative management of faecal incontinence in adults committee of the International Consultation on Incontinence. We conducted comprehensive literature searches using the following keywords combined with the relevant intervention: “anal, anorectal, bowel, faecal, fecal, rectal, stool” and “continent

Patients' views of a colostomy for fecal incontinence.

or incontinent

Long-term results of repeat anterior anal sphincter repair

,” Prevalence etimates for faecal or anal incontinence vary widely, from 2.2% to 2.5%. Expert opinion supports the use of general health education, patient teaching about bowel function and advice on lifestyle modification, but the evidence base is small. Unlike urinary incontinence, few “lifestyle” associations have been identified with FI and little is known about whether interventions designed to reduce potential risk factors might improve FI. The article summarises the evidence and recommendations from the committee for clinical practice and future research. Neurourol. Urodynam. 29: 199–206, 2010.

Psychometric evaluation of a new patient-completed questionnaire for evaluating anal incontinence symptoms and impact on quality of life: the ICIQ-B.

INTRODUCTIONFormation of a permanent stoma often is seen as a last resort when all other interventions for fecal incontinence have failed. However, no previous study has examined patients’ views of a colostomy to manage fecal incontinence.METHODSPeople who had a colostomy to manage fecal incontinence were recruited via an advertisement in the magazine of the British Colostomy Association or from those operated at a specialist colorectal hospital. Four questionnaires were sent, asking about the stoma, previous incontinence, anxiety and depression, and quality of life.RESULTSA total of 69 replies were received. Respondents were 11 males and 58 females with a median age of 64 years and a median of 59 months since the operation. Rating their ability to live with their stoma now on a scale of 0 to 10, the median response was 8 (range, 0–10). The majority (83 percent) felt that the stoma restricted their life “a little” or “not at all” (a significant improvement from perceived restriction from former incontinence, P = 0.008). Satisfaction with the stoma was a median of 9 on a scale of 0 to 10 (range, 0–10). Eighty-four percent would “probably” or “definitely” choose to have the stoma again. Quality of life (SF-36) was poor, but neither depression nor anxiety was a prominent feature.CONCLUSIONSThe majority of previously incontinent people were positive about the stoma and the difference it had made to their life. However, a few had not adapted and disliked the stoma intensely. Health care professionals should discuss a stoma as an option with patients whose lives are restricted by fecal incontinence.