Assessing the Psychological Impact of Daily Bowel Preparation on Prostate Patients Who Receive Radiation Therapy.

PURPOSE: Evidence has shown that the prostate moves depending on filling of the rectum and, to a lesser extent, the bladder; many radiation therapy departments have adopted standardized bladder filling/rectal emptying protocols for radiotherapy treatment. Daily treatments may be delayed until appropriate volumes are attained; the resultant psychological impact of these delays on patients is unknown. The purpose of this study was to determine levels of anxiety, depression, distress, and bother related to bowel preparation for prostate cancer patients undergoing radiation therapy treatment. METHODS: A prospective cohort analysis of prostate cancer patients undergoing external beam radiation therapy was completed. Patients were assigned to one of three groups; Group A was standard of care, Group B was standard of care plus increased educational information regarding bowel preparation, Group C was standard of care plus increased educational information regarding bowel preparation plus an anti-flatulent medication. Hospital Anxiety and Depression Scale, Distress Thermometer, and a Bowel Status Bother survey were completed by participants at the start of theircourse of radiation treatment, mid-way through, and at the end. Analysis of variance testing was completed to determine differences in mean scores between the three groups. RESULTS: Mean age of patients (N = 30) was 66 years; 50% of the participants had a university education; 80% were married. Anxiety levels decreased over time in all groups (P = .039) with no difference between groups (P = 0.447). Depression levels across time for each group remained low (P = .577). Overall distress levels associated with bowel preparation were low among each group, and no significant differences were reported (P = .978). All groups reported high rates of quality of life. CONCLUSIONS: Findings from this study indicate that collectively across three groups and over time, there were low levels of anxiety, depression, and distress from bowel preparation. Amount, timing, quality, and approach to educational information are important factors to ensure patients feel prepared for their radiation therapy treatments.

Lack of Agreement on How to Use Antegrade Enemas in Children.

OBJECTIVES: The aim of the present study was to provide an overview of the existing literature regarding the outcomes of the antegrade continence enema (ACE) procedure and to assess the present practices of physicians worldwide regarding the use of the ACE. METHODS: A search of the MEDLINE database was performed using the following criteria: having a clear definition of "successful outcome," published in full manuscript form, sample size >20 patients, age <25 years. We then conducted a survey among 23 pediatric gastroenterologists and surgeons worldwide who were known to use the ACE using an 18-item questionnaire. RESULTS: A total of 21 articles met the inclusion criteria. Successful outcomes were reported in 15% to 100%. Thirteen studies classified the outcome as full continence (success) or incontinence (failure), with a mean successful outcome of 75.6%. The 23 physicians who completed the questionnaire differed in their opinions about indications and mandatory preoperative testing. Constipation with (78%) or without (91%) fecal incontinence, anorectal malformations (96%), and spinal abnormalities (100%) were considered suitable indications for the ACE by the majority. There was less agreement regarding the required preoperative diagnostic workup. Most physicians (70%) start infusions using saline solutions and do not add a stimulant laxative to the cleansing solution. DISCUSSION: There is a wide variation in the reported outcome of the ACE procedure and in the way success is defined. The survey identifies important differences among physicians using the ACE. Consensus on optimal use of the ACE could improve outcome of this treatment option.

The interrelationships between and contributions of background, cognitive, and environmental factors to colorectal cancer screening adherence.

OBJECTIVES: We examined the interrelationships between and contributions of background, cognitive, and environmental factors to colorectal cancer (CRC) screening adherence. METHODS: In this study, 2,416 average risk patients aged 50-75 from 24 Veterans Affairs medical facilities responded to a mailed survey with phone follow-up (response rate 81%). Survey data (attitudes, behaviors, demographics) were linked to facility (organizational complexity) and medical records data (diagnoses, screening history). Patients with a fecal occult blood test within 15 months, sigmoidoscopy or barium enema within 5.5 years, or colonoscopy within 11 years of the survey were considered adherent. Logistic regressions estimated the association between adherence and background, cognitive, and environmental factors. Deviance ratios examined interrelationships between factors. Population attributable risks (PAR) were used to identify intervention targets. RESULTS: The association of background factors with adherence was partially explained by cognitive and environmental factors. The association of environmental factors with adherence was partially explained by cognitive factors. Cognitive and environmental factors contributed equally to adherence. Factors with the highest PARs for non-adherence were age 50-64, less than two comorbidities, and lack of physician recommendation. CONCLUSIONS: Efforts to increase physician screening recommendations for younger, healthy patients at facilities with the lowest screening rates may improve CRC adherence in this setting.

Patient experiences of colonoscopy, barium enema and CT colonography: a qualitative study.

Previous studies of patient experience with bowel screening tests, in particular CT colonography (CTC), have superimposed global rating scales and not explored individual experience in detail. To redress this, we performed qualitative interviews in order to characterize patient expectations and experiences in depth. Following ethical permission, 16 patients undergoing CTC, 18 undergoing colonoscopy and 15 undergoing barium enema agreed to a semi-structured interview by a health psychologist. Interviews were recorded, responses transcribed and themes extracted with the aim of assimilating individual experiences to facilitate subsequent development and interpretation of quantitative surveys of overall satisfaction with each diagnostic test. Transcript analysis identified three principal themes: physical sensations, social interactions and information provision. Physical sensations differed for each test but were surprisingly well tolerated overall. Social interactions with staff were perceived as very important in colouring the whole experience, particularly in controlling the feelings of embarrassment, which was critical for all procedures. Information provision was also an important determinant of experience. Verbal feedback was most common during colonoscopy and invariably reassuring. However, patients undergoing CTC received little visual or verbal feedback and were often confused regarding the test outcome. Barium enema had no specific advantage over other tests. Qualitative interviews provided important perspectives on patient experience. Our data demonstrated that models describing the quality of medical encounters are applicable to single diagnostic episodes. Staff interactions and information provision were particularly important. We found advantages specific to both CTC and colonoscopy but none for barium enema. CTC could benefit greatly from improved information provision following examination.

Transanal irrigation for bowel management.

Maureen Coggrave summarises the results of a randomised controlled trial of transanal irrigation versus conservative bowel management in patients with spinal cord injuries. The full study was published in Gastroenterology (Christensen et al, 2006).

Gender differences in colorectal cancer screening barriers and information needs.

CONTEXT: Several prior studies have found that women are less likely to be screened for colorectal cancer (CRC) than men. While the source of this screening differential is unknown, recent studies suggest gender differences in barriers to screening might explain the disparity. OBJECTIVE: This formative study was designed to explore CRC screening barriers, attitudes and preferences by gender. METHODOLOGY: Focus group interviews with groups stratified by gender and screening status. Participants included 27 females and 43 males between the ages of 50 and 75 years who receive primary care at the Minneapolis VA Medical Center. We conducted interpretive and grounded text analysis of semi-structured focus group interviews to assess how knowledge, experiences and sociocultural norms shape female and male preferences and barriers to current CRC screening guidelines. RESULTS: Female and male participants reported similar preferences for CRC screening mode, but there were notable differences in the barriers and facilitators to screening. Key findings suggest that women viewed the preparation for endoscopic procedures as a major barrier to screening while men did not; women and men expressed different fears and information preferences regarding endoscopic procedures; and women perceive CRC as a male disease thus feeling less vulnerable to CRC. Gender-specific barriers may explain women's lower rate of screening for CRC. CONCLUSION: Colorectal cancer screening promotion interventions, decision aids and clinical practice may benefit by being tailored by gender.

Examining bowel preparation before flexible sigmoidoscopy.

AIM: To investigate bowel preparation for a flexible sigmoidoscopy, particularly the procedure for the administration of a phosphate enema and patient expectation to 'wait as long as they can' before the urge to rush to the toilet. METHOD: A survey approach was used with a questionnaire recording the time to toilet after the enema and level of bowel clearance. RESULTS: Over half of participants (24 of 40) chose to use the toilet immediately. Bowel clearance was reported as good in 32 of the 40 participants and side-effects were reduced. CONCLUSION: Giving patients choice when to visit the toilet after an enema improved their experience and achieved good bowel clearance for the procedures. Further research should be undertaken due to the small size of the study.

Comparative study of enema retention and preference in ulcerative colitis.

BACKGROUND: Therapeutic enemas are often used to treat active colitis but their retention may be limited because of urgency to defecate. Some preparations may be better retained and tolerated than others because of their physical properties. AIM: To compare patient preference and retention of four therapeutic enemas, including a nicotine enema, in patients with ulcerative colitis (UC). METHODS: Twenty four patients with active UC received the four trial enemas-corticosteroid, 5-amino salicylate (5-ASA), and nicotine liquid enemas and a corticosteroid foam, in a randomised order, taking one enema on each of four successive nights. Patients scored them 1 to 4 for ease of administration and retention, degree of abdominal bloating, and for their overall preference. RESULTS: Fifteen patients rated nicotine their overall favourite or second favourite, compared with 14 for corticosteroid foam and 11 for 5-ASA and corticosteroid liquids, but this was not significant (p = 0.302). Overall, there was no significant difference in overnight retention. However, the nicotine enema tended to be less well retained in patients with milder urgency but a higher proportion retained it overnight with more severe urgency (p = 0.031 compared with 5-ASA enema). CONCLUSION: There was no significant difference in patient preference or overall duration of retention for the four enemas.

A survey of individual preference for colorectal cancer screening technique.

BACKGROUND: Due to the low participation in colorectal cancer screening, public preference for colorectal cancer screening modality was determined. METHODS: A cross-sectional survey was performed of healthy ambulatory adults in a pediatrics primary care office and neighboring church. Overall preference was ranked for each of four colorectal cancer screening modalities: Faecal Occult Blood, Fiberoptic Sigmoidoscopy, Barium Enema and Colonoscopy. Four additional domains of preference also were ranked: suspected discomfort, embarrassment, inconvenience and danger of each exam. RESULTS: 80 surveys were analyzed, 57 of which were received from participants who had experienced none of the screening tests. Fecal Occult Blood Testing is significantly preferred over each other screening modality in overall preference and every domain of preference, among all subjects and those who had experienced none of the tests. CONCLUSIONS: Efforts to increase public participation in colorectal cancer screening may be more effective if undertaken in the context of public perceptions of screening choices.

Appendicostomy for antegrade enema: effects on somatic and psychosocial functioning in children with myelomeningocele.

OBJECTIVE: To assess changes in somatic variables, psychosocial functioning, mental health and self-esteem after appendicostomy for antegrade enema (MACE) in children with myelomeningocele (MMC). METHODS: We performed the MACE procedure in 20 children, aged 6.3 to 17.0 years. Twelve patients had an open and 8 had a laparoscopic operation. Somatic function was assessed preoperatively and 6 and 16 months postoperatively. Psychosocial functioning and mental health were assessed preoperatively and 6 months postoperatively by a structured clinical interview and standardized questionnaires, Youth Self-Report, Child Behavior Checklist, and Harter's Self-Perception Profile for Adolescents. RESULTS: Preoperatively, 9 patients had fecal leaks several times a week, 7 had leaks 1 to 4 times per month, and 4 were continent. The corresponding numbers 6 and 16 months postoperatively were 0, 6, and 14 and 0, 3, and 16. Six patients have had postoperative stoma complications that required surgery; 5 had a well-functioning stoma thereafter, and 1 had a colostomy 7 months later. Preoperatively, 14 patients reported considerable, 4 moderate, 2 minor, and 0 no psychosocial problems related to bowel control and emptying regimen. Six months postoperatively, the corresponding numbers were 1, 2, 6, and 11. The standardized questionnaires revealed substantial psychopathology in the MMC patients. The Child Behavior Checklist and Youth Self-Report scores were not significantly changed postoperatively, but global self-esteem score and close friends score from the Self-Perception Profile for Adolescents were significantly improved. CONCLUSIONS: Fecal incontinence and constipation were greatly reduced by MACE. Children with MMC often have psychological and psychosocial problems, but important improvements in self-esteem and psychosocial function were observed 6 months after the MACE procedure.

Hot, high and horrible. Should routine enemas still be given to women in labour?

The effect of a soap enema on the progress of labour was studied in 160 women admitted for delivery in Esigodini District Hospital. The study was set up as a 1:1 randomised case control study in 200 women. It was changed to a 1:3 case control study after 82 subjects had been studied, when it became apparent that the midwives were no longer willing to follow the study protocol. Forty women received an enema and 120 did not. Two focus group discussions were held with 16 women who had an enema. The 12 hospital midwives were asked to give their opinion on enemas. Focus group discussions were also held with 28 traditional midwives. Dilation of the cervix was 2.19 cm/hour in the non-enema group (95pc confidence interval 1.86-2.52) and 2.00 cm/hour in the enema group (95pc confidence interval 1.38-2.62). The difference is not significant (t-test:p-value = 0.58). Pregnant women did not like enemas, midwives preferred not to administer them and were not concerned with contamination during delivery. Traditional midwives do not use enemas in labouring women and consider the possible contamination as normal. It is concluded that there is no benefit from routine enemas in labour.

Soothing techniques used in barium enema examinations.

This article is part of a research project being carried out to explore and develop stress reduction methods which can be used in x-ray departments. It describes the results of a survey which shows that a high proportion (90%) of those involved in barium examinations agree there is a relationship between the anxiety of the patient and the difficulty of the examination. Many of those involved in the examination (87%) report using methods which they think are effective in reducing patients' anxiety. There is little difference between the opinions of the various professional groups involved in barium enema examinations. From this research a list has been developed of the anxiety reduction techniques presently employed during barium enema examinations. The article endorses the need for further study of methods for reducing patients' anxiety during x-ray examinations.

Choice and predictability in the preparation for barium enemas: a person-by-situation approach.

The effects of choice and predictability information regarding preparation for a barium enema procedure was investigated for patients differing in desire for control (DFC) and in experience with the barium enema exam. One-third of the patients, randomly assigned to the choice condition, were selected from three equally effective preparations. For these patients, choice and predictability information are confounded. Patients in the instruction only and information conditions were yoked to choice patients to control for type of preparation. Patients in the information condition were given the same sensation information about their specific preparation as those in choice. Instruction only was effective for low DFC patients, but contrary to prediction the choice was problematic for high DFC patients. It was suggested that the limited choice created reactance for these patients. The differential effectiveness of health care interventions in relation to patient predispositions was stressed.

Colon cleansing: acceptance by older patients.

The influence of age on patient acceptance and adequacy of preparation was evaluated in 557 patients from our previous colon cleansing studies for colonoscopy, barium enema, and elective colon surgery. Since study design was similar for all studies, the patients were combined and stratified to those over age 60 (old) and those 60 or younger (young). Patients were previously randomized in their respective studies to polyethylene glycol electrolyte gut lavage solution (old, 105; young, 181) or standard prep (old, 71; young, 20). Patient response data were analyzed in two fashions; distribution of response scores and minimal responses. When the distribution of scores were compared, older gut lavage patients had fewer cramps but more overall discomfort than younger patients receiving the lavage preparation. Older standard prep patients had less overall discomfort than younger standard prep subjects. Comparison of responses rated as minimal showed the older lavage patients to have fewer cramps than younger lavage patients and fewer cramps than standard preparation patients of similar age. None of the other assessed symptoms was significantly different between age groups or prep method. Most patients had minimal symptoms regardless of age or prep. Age did not influence adequacy of preparation for gut lavage or standard prep methods.