Functional outcomes and satisfaction rates of sacral nerve stimulation in the treatment of one and multiples pelvic floor dysfunctions

Objective: Few studies have addressed the use of sacral nerve stimulation (SNS) in the treatment of patients with multiple pelvic floor dysfunctions (PFD). So, we evaluated the functional outcomes and level of satisfaction with SNS in selected patients with one or multiples PFD. Methods: A prospective database was used to collect information on eligible patients treated for PFD with SNS, and severity of symptoms was assessed with scores and satisfaction rates by visual analogue scale (VAS) at baseline and by the end of follow-up. Results: We recruited 70 patients, 98.6% of whom responded positively during the evaluation period (Global Response Assessment ≥ 50% for at least one type of PFD), resulting in the implantation of a permanent SNS device. Additionally, 49 of the patients (71%) had a single PFD (fecal incontinence [FI] = 38; constipation/obstructed defecation syndrome [C/ODS] = 11), while 20 (29%) had more than one PFD (double incontinence/n = 12; double incontinence + C/ODS/n = 8). All scores improved significantly between baseline (pre-SNS) and the end of follow-up (post-SNS), as did VAS in all groups (single and multiple PFD). The pre-SNS scores were higher in patients with a single PFD, including FI (Cleveland clinic Florida incontinence score [CCF-FI]) and C/ODS (Cleveland clinic constipation score [C-CCF] and the Renzi ODS score). The pre-SNS impact of VAS scores was similar in all groups (single and multiple PFD), but the VAS (post-SNS) was significantly lower (better response) for FI alone compared with multiple PFD. Conclusion: The SNS technique is an effective and safe option for patients with one or more PFD refractory to conservative measures. Response was positive for at least two PFD, based on reduced correspondent scores and satisfaction rate. (AU)

PREDICTORS OF UNSUCCESSFUL OF TREATMENT FOR FECAL INCONTINENCE BIOFEEDBACK FOR FECAL INCONTINENCE IN FEMALE.

BACKGROUND: Biofeedback is an effective method of treatment for fecal incontinence but there is controversy regarding factors that may be correlated with its effectiveness. OBJECTIVE: To evaluate the efficacy of biofeedback in the treatment of fecal incontinence, identifying the predictive factors for unsuccessful treatment. METHODS: Consecutive female patients who had fecal incontinence and were treated with a full course of biofeedback were screened. The symptoms were evaluated using Cleveland Clinic incontinence (CCF) score before and six months after the completion of therapy. Patients had a satisfactory clinical response to biofeedback if the CCF score had decreased by more than 50% at six months (GI) and an unsatisfactory response if the CCF score did not decrease or if the score decreased by <50% (GII). The groups were compared with regard to age, score, anal resting and squeeze pressures and sustained squeeze pressure by manometry, history of vaginal delivery, number of vaginal deliveries, menopause, hysterectomy, and previous anorectal surgery. RESULTS: Of 124 women were included, 70 (56%) in GI and 54 (44%) in GII. The median CCF score decreased significantly from 10 to 5 (P=0.00). FI scores were higher in GII. Patients from GII had more previous vaginal deliveries and previous surgeries. The mean sustained squeeze pressure was higher in GI. Patients from GI and GII had similar ages, number of vaginal deliveries, menopause, hysterectomy, anal pressures, and sphincter defects. The median sustained squeeze pressure increased significantly before and after biofeedback in GI. CONCLUSION: Biofeedback therapy shows effective treatment with 50% reductions in FI score in half of patients. Factors associated with unsuccessful outcome include FI score ≥10, previous vaginal delivery, previous anorectal and/or colorectal surgery, and reduced mean sustained squeeze pressure.

Fatores preditivos de insucesso do biofeedback para tratamento da incontinência fecal em mulheres / Predictors of unsuccessful of treatment for fecal incontinence biofeedback for fecal incontinence in female

ABSTRACT BACKGROUND: Biofeedback is an effective method of treatment for fecal incontinence but there is controversy regarding factors that may be correlated with its effectiveness. OBJECTIVE: To evaluate the efficacy of biofeedback in the treatment of fecal incontinence, identifying the predictive factors for unsuccessful treatment. METHODS: Consecutive female patients who had fecal incontinence and were treated with a full course of biofeedback were screened. The symptoms were evaluated using Cleveland Clinic incontinence (CCF) score before and six months after the completion of therapy. Patients had a satisfactory clinical response to biofeedback if the CCF score had decreased by more than 50% at six months (GI) and an unsatisfactory response if the CCF score did not decrease or if the score decreased by <50% (GII). The groups were compared with regard to age, score, anal resting and squeeze pressures and sustained squeeze pressure by manometry, history of vaginal delivery, number of vaginal deliveries, menopause, hysterectomy, and previous anorectal surgery. RESULTS: Of 124 women were included, 70 (56%) in GI and 54 (44%) in GII. The median CCF score decreased significantly from 10 to 5 (P=0.00). FI scores were higher in GII. Patients from GII had more previous vaginal deliveries and previous surgeries. The mean sustained squeeze pressure was higher in GI. Patients from GI and GII had similar ages, number of vaginal deliveries, menopause, hysterectomy, anal pressures, and sphincter defects. The median sustained squeeze pressure increased significantly before and after biofeedback in GI. CONCLUSION: Biofeedback therapy shows effective treatment with 50% reductions in FI score in half of patients. Factors associated with unsuccessful outcome include FI score ≥10, previous vaginal delivery, previous anorectal and/or colorectal surgery, and reduced mean sustained squeeze pressure.

RESUMO CONTEXTO: Biofeedback é um método eficaz de tratamento para a incontinência fecal. No entanto, há controvérsias sobre fatores que podem ser correlacionados com a sua eficácia. Objetivo - Avaliar a eficácia do biofeedback no tratamento da incontinência fecal (IF), identificando os fatores preditivos relacionados ao insucesso do tratamento. MÉTODOS: Consecutivos pacientes do sexo feminino com IF e submetidos a terapia com biofeedback que aceitaram participar do estudo foram incluídos. Os sintomas foram avaliados utilizando o escore de incontinência da Cleveland Clinic-CCF antes e seis meses após termino da terapia. Os pacientes com resposta satisfatória ao biofeedback apresentaram redução no escore de IF ≥50% (GI) e resposta insatisfatória a redução no escore de IF <50% (GII) em seis meses. Os grupos foram comparados de acordo com a idade, escore, pressões anais quantificada pela manometria anorretal (repouso, contração e capacidade de sustentação em 30 segundos), parto vaginal prévio, número de partos vaginais, menopausa, histerectomia e cirurgia anorretal e/ou colorretal prévia. RESULTADOS: Total de 124 mulheres incluídas, 70 (56%) em GI e 54 (44%) em GII. A mediana do CCF escore reduziu significativamente de 10 para 5 (P=0.00). FI escore foi mais elevado no GII, assim como foi observado o maior número de mulheres submetidas a partos vaginais e cirurgias prévias. A pressão média de contração foi significante maior no GI. No entanto, idade, número de partos vaginais, menopausa, histerectomia, pressões anais e presença de defeito esfincteriano foram similares nos dois grupos. A pressão média de sustentação mantida por 30 seg aumentou significamente comparando pré com pós biofeedback no GI. CONCLUSÃO: O biofeedback é um tratamento eficaz com redução em 50% no escore de IF em mais da metade dos pacientes. Os fatores associados ao insucesso do tratamento incluem o escore de IF ≥10, parto vaginal prévio, cirurgia anorretal prévia e pressão média de sustentação reduzida.

Use of Biofeedback Combined With Diet for Treatment of Obstructed Defecation Associated With Paradoxical Puborectalis Contraction (Anismus): Predictive Factors and Short-term Outcome.

BACKGROUND: Numerous studies have described the use of biofeedback therapy for the treatment of anismus. Success rates vary widely, but few data are available regarding factors predictive of success. OBJECTIVE: Our aim was to evaluate short-term results of biofeedback associated with diet in patients with obstructed defecation because of anismus and to investigate factors that may affect the results. DESIGN: Patients were identified from a single-institution prospectively maintained database. SETTINGS: This study was conducted in a tertiary hospital. PATIENTS: Consecutive patients who had obstructed defecation associated with anismus and were treated with biofeedback associated with diet were eligible. INTERVENTIONS: Each patient underwent anal manometry and/or dynamic anal ultrasound. Patients with anismus and were treated with biofeedback associated with diet. MAIN OUTCOME MEASURES: Patients classed as having a satisfactory response to therapy and those classed as having an unsatisfactory response were compared with regard to sex, age, Cleveland Clinic Florida constipation score, functional factors (anal resting and squeeze pressures and reversal of paradoxical puborectalis contraction on manometry), and anatomic factors in women (history of vaginal delivery, number of vaginal deliveries, menopause, hysterectomy, and previous anorectal surgery). RESULTS: A total of 116 patients were included (75 women and 41 men). Overall, 59% were classed as having a satisfactory response (decrease in constipation score, >50%). Patients with satisfactory responses to biofeedback plus diet did not differ from those with unsatisfactory responses with regard to clinical, anatomic, and physiological factors. LIMITATIONS: This was not a randomized controlled trial. CONCLUSIONS: Biofeedback combined with diet is a valuable treatment option for patients with obstructed defecation syndrome associated with anismus, and more than half of our patients of both sexes achieved a satisfactory response. Improvement was not related to reversal of paradoxical contraction of puborectalis muscles at manometry. Patient sex, age, previous anorectal surgery, anorectal manometry pressures, and vaginal delivery, menopause, and hysterectomy in women did not significantly affect outcome.

Prospective multicenter trial comparing echodefecography with defecography in the assessment of anorectal dysfunction in patients with obstructed defecation.

BACKGROUND: Defecography is the gold standard for assessing functional anorectal disorders but is limited by the need for a specific radiologic environment, exposure of patients to radiation, and inability to show all anatomic structures involved in defecation. Echodefecography is a 3-dimensional dynamic ultrasound technique developed to overcome these limitations. OBJECTIVE: This study was designed to validate the effectiveness of echodefecography compared with defecography in the assessment of anorectal dysfunctions related to obstructed defecation. DESIGN: Multicenter, prospective observational study. PATIENTS: Women with symptoms of obstructed defecation. SETTING: Six centers for colorectal surgery (3 in Brazil, 1 in Texas, 1 in Florida, and 1 in Venezuela). INTERVENTIONS: Defecography was performed after inserting 150 mL of barium paste in the rectum. Echodefecography was performed with a 2050 endoprobe through 3 automatic scans. MAIN OUTCOME MEASURES: The κ statistic was used to assess agreement between echodefecography and defecography in the evaluation of rectocele, intussusception, anismus, and grade III enterocele. RESULTS: Eighty-six women were evaluated: median Wexner constipation score, 13.4 (range, 6-23); median age, 53.4 (range, 26-77) years. Rectocele was identified with substantial agreement between the 2 methods (defecography, 80 patients; echodefecography, 76 patients; κ = 0.61; 95% CI = 0.48-0.73). The 2 techniques demonstrated identical findings in 6 patients without rectocele, and in 9 patients with grade I, 29 with grade II, and 19 patients with grade III rectoceles. Defecography identified rectal intussusception in 42 patients, with echodefecography identifying 37 of these cases, plus 4 additional cases, yielding substantial agreement (κ = 0.79; 95% CI = 0.57-1.0). Intussusception was associated with rectocele in 28 patients for both methods (κ = 0.62; 95% CI = 0.41-0.83). There was substantial agreement for anismus (κ = 0.61; 95% CI = 0.40-0.81) and for rectocele combined with anismus (κ = 0.61; 95% CI = 0.40-0.82). Agreement for grade III enterocele was classified as almost perfect (κ = 0.87; 95% CI = 0.66-1.0). LIMITATIONS: Echodefecography had limited use in identification of grade I and II enteroceles because of the type of probe used. CONCLUSIONS: Echodefecography may be used to assess patients with obstructed defecation, as it is able to detect the same anorectal dysfunctions found by defecography. It is minimally invasive and well tolerated, avoids exposure to radiation, and clearly demonstrates all the anatomic structures involved in defecation.