Noel N. Thin

Systematic review of the clinical effectiveness of neuromodulation in the treatment of faecal incontinence

Over the past 18 years neuromodulation therapies have gained support as treatments for faecal incontinence (FI); sacral nerve stimulation (SNS) is the most established of these. A systematic review was performed of current evidence regarding the clinical effectiveness of neuromodulation treatments for FI.

Prospective randomized double-blind study of temporary sacral nerve stimulation in patients with rectal evacuatory dysfunction and rectal hyposensitivity.

Objective:Prospective randomized double-blind placebo-controlled crossover trial of 14 female patients (median age 52 [30–69] years) with proctographically defined evacuatory dysfunction (ED) and demonstrable rectal hyposensitivity (elevated thresholds to balloon distension in comparison with age- and sex-matched controls). Background:Sacral nerve stimulation (SNS) is an evolving treatment for constipation. However, variable outcomes might be improved by better patient selection. Evidence that the effect of SNS may be mediated by modulation of afferent signaling promotes a role in patients with ED associated with rectal hyposensation. Methods:SNS was performed by the standard 2-stage technique (temporary then permanent implantation). During a 4-week period of temporary stimulation, patients were randomized ON-OFF/OFF-ON for two 2-week periods. Before insertion (PRE), and during each crossover period, primary (rectal sensory thresholds) and secondary (bowel diaries, constipation, and GIQoL [gastrointestinal quality of life] scores) outcome variables were blindly assessed. Results:Thirteen patients completed the trial. Following stimulation, defecatory desire volumes to rectal balloon distension were normalized in 10 of 13 patients (PRE: mean 277 mL [234–320] vs ON: 163 mL [133–193] vs OFF: 220 mL [183–257 mL]; P = 0.006) and maximum tolerable volume in 9 of 13 (PRE: mean 350 mL [323–377] vs ON: 262 mL [219–305] vs OFF: 298 mL [256–340 mL]; P = 0.012). There was a significant increase in the percentage of successful bowel movements (PRE: median 43% [0–100] vs ON: 89% [11–100] vs OFF: 83% [11–100]; P = 0.007) and Wexner constipation scores improved (PRE: median 19 [9–26] vs ON: 10 [6–27] vs OFF: 13 [5–29]; P = 0.01). There were no significant changes in disease-specific or generic quality of life measures. Eleven patients progressed to permanent stimulation (9/11 success at 19 months). Conclusions:Most patients with chronic constipation secondary to ED with rectal hyposensitivity responded to temporary SNS. The physiological results presented support a mechanistic role for rectal afferent modulation.

Randomized clinical trial of sacral versus percutaneous tibial nerve stimulation in patients with faecal incontinence

Sacral nerve stimulation (SNS) is a well established therapy for faecal incontinence (FI). Percutaneous tibial nerve stimulation (PTNS) is a newer, less invasive, treatment. The effectiveness and acceptability of these treatments have not been compared systematically.

Systematic review of tibial nerve stimulation to treat faecal incontinence

Two forms of tibial nerve stimulation are used to treat faecal incontinence (FI): percutaneous (PTNS) and transcutaneous (TTNS) tibial nerve stimulation. This article critically appraises the literature on both procedures.

Diagnostic disagreement between tests of evacuatory function: a prospective study of 100 constipated patients

Evacuatory dysfunction (ED) is a common cause of constipation and may be sub‐classified on the basis of specialist tests. Such tests may guide treatment e.g., biofeedback therapy for ‘functional’ defecatory disorders (FDD). However, there is no gold standard, and prior studies have not prospectively and systematically compared all tests that are used to diagnose forms of ED.

Outcome of sacral nerve stimulation for fecal incontinence in patients refractory to percutaneous tibial nerve stimulation.

BACKGROUND: Percutaneous tibial nerve stimulation and sacral nerve stimulation are both second-line treatments for fecal incontinence, but the comparative efficacy of the 2 therapies is unknown. In our institution, patients with refractory fecal incontinence are generally treated with percutaneous tibial nerve stimulation before being considered for sacral nerve stimulation. OBJECTIVE: The aim of this study was to assess the outcome associated with this treatment algorithm in order to guide future management strategies. DESIGN: All patients with fecal incontinence treated over a 3-year period with tibial nerve stimulation before receiving sacral nerve stimulation were identified from a prospectively recorded database. Demographics and pretreatment anorectal physiological data were available for all patients. SETTINGS: This study was conducted at an academic colorectal unit in a tertiary center. PATIENTS: Twenty patients (17 female:3 male, median age 55 (33–79) years) were identified to be refractory to percutaneous tibial nerve stimulation. MAIN OUTCOME MEASURES: Clinical outcome data were collected prospectively before and after treatment, including 1) Cleveland Clinic Florida-Fecal Incontinence scores and 2) number of incontinence episodes per week. RESULTS: The mean (±SD) pretreatment incontinence score (11.7 ± 3.5) did not differ from the mean incontinence score after 12 sessions of tibial nerve stimulation (10.9 ± 3.6, p = 0.42). All patients were subsequently counseled for sacral nerve stimulation, and 68.4% of them reported a significant therapeutic benefit with an improved incontinence score (7.7 ± 4.1, p = 0.014). LIMITATIONS: This was a nonrandomized study with a relatively small number of patients CONCLUSION: Sacral nerve stimulation appears to be an effective treatment for patients who do not gain an adequate therapeutic benefit from percutaneous tibial nerve stimulation and, thus, should be routinely considered for this patient cohort.

Advancement anoplasty and sacral nerve stimulation: an effective combination for radiation-induced anal stenosis.

IntroductionPelvic radiotherapy can cause anal stenosis. Patients can be left with severe rectal evacuatory difficulties, anal fissuring and resistant faecal incontinence. The management of such patients is difficult since surgical treatment can worsen faecal incontinence.Case studyWe report a patient who was treated for recurrent fissuring and faecal incontinence secondary to severe anal stenosis caused by external beam radiotherapy to his prostate. A 74-year-old male patient underwent excision of the fissuring, fibrotic anal mucosa and internal sphincter and was then treated with a broad-based House advancement anoplasty. The patient’s fissuring was successfully treated but he still suffered from faecal incontinence. The patient underwent sacral nerve stimulation with significant improvement in all faecal incontinence symptoms.ConclusionThe use of a novel combination of a House advancement anoplasty and sacral nerve stimulation is a safe and effective treatment rationale for treatment of radiation-induced anal stenosis.