Comparison of Patient Impact and Clinical Characteristics Between Urgency and Passive Fecal Incontinence Phenotypes.

OBJECTIVE: To determine if categorizing fecal incontinence (FI) as urgency or passive FI is clinically meaningful, we compared clinical severity, quality of life, physical examination findings, and functional and anatomic deficits between women with urgency and passive FI. METHODS: This study is a prospective cross-sectional study of women with at least monthly FI. All women completed the St Mark's Vaizey and the Fecal Incontinence Quality of Life questionnaires and underwent anorectal manometry and endoanal ultrasound. We compared women with urgency FI to women with passive FI. RESULTS: Forty-six women were enrolled, 21 (46%) with urgency FI and 25 (54%) with passive FI. Clinical severity by Vaizey score did not differ between groups (urgency 11.7 ± 1.6 vs passive 11.0 ± 1.0, P = 0.51). Women with urgency FI had worse median (range) lifestyle and coping scores than passive FI (Fecal Incontinence Quality of Life: lifestyle domain 2.5 [1, 4] vs 3.8 [1, 4], P = 0.04; coping domain 1.7 [1, 3] vs 2.4 [0.9, 4], P < 0.01). Women with urgency FI had higher anal resting and squeeze pressure than passive FI (60 ± 4 mm Hg vs 49 ± 3 mm Hg, P = 0.03; 78 [48, 150] mm Hg vs 60 [40, 103], P = 0.05). Internal anal sphincter defects were more common in women with passive FI (41.7% vs 30.0%, P = 0.53) and external anal sphincter defects more common in women with urgency FI (25% vs 16.7%, P = 0.71), but this did not reach statistical significance. CONCLUSIONS: We identified functional and anatomic differences between women with urgency FI and passive FI. Pheonotyping women with FI into these subtypes is clinically meaningful.

Urinary and faecal incontinence: psychological factors and management recommendations.

BACKGROUND: Urinary and faecal incontinence substantially impacts upon physical health and is associated with significant psychological distress and reduced quality of life. Due to stigma and embarrassment, many patients do not present for management of their incontinence. AIM: The objective of this article is to summarise the forms and causes of urinary and faecal incontinence, highlight the psychological mechanisms and psychopathology associated with incontinence, and provide management recommendations. CONCLUSION: Urinary and faecal incontinence can have a significant impact on an individual's psychological wellbeing and quality of life. Psychological factors may either contribute to or arise from incontinence and should be addressed as part of the overall management plan.

Critical analysis of fecal incontinence scores.

INTRODUCTION: Objectively evaluating the lack of bowel control (fecal incontinence) continues to be a challenge. Many have attempted to measure the severity of fecal incontinence and to evaluate its impact on the quality of life by developing standardized scoring systems. Some of these systems have been validated but none have achieved widespread use and all have limitations in evaluating pediatric patients. METHODS: A review of the literature was performed looking for validated scoring systems of fecal incontinence that are currently used for either adult or pediatric patients. The identified scoring systems were then critically analyzed and their applicability for managing fecally incontinent children considered. RESULTS: Thirteen of the most frequently used fecal incontinence scoring systems were selected (6 for adults and 7 for children). Quality of life questionnaires were excluded not only because of their length and complexity, but mostly because they do not accurately reflect a measurement of bowel control. Our analysis revealed that all pediatric scoring systems require some degree of interpretation as they included at least one subjective parameter. These unverifiable subjective parameters were: "sensation of rectal fullness", "sphincter squeeze", and "anal shape". Equally problematic, the pediatric systems frequently focused on factors unrelated to fecal continence such as "frequency of bowel movements", "rectal prolapse", "abdominal pain", "blood in the stool", "leakage of urine", "diarrhea", and "constipation". The most objective system found from our review is the Krickenbeck system, which focuses upon two objective factors. Those two factors are the absence of voluntary bowel movements and the presence of soiling in the underwear. The major weakness of the Krickenbeck system is that it does not allow for reassessment after medical or surgical interventions. In this paper, we propose a modification of the Krickenbeck system that allows for such an assessment to be applied to those patients who are able to achieve voluntary bowel movements with the aid of laxatives or constipating agents. CONCLUSIONS: Most scoring systems are flawed because they invite bias and interpretation due to their subjective nature, while systems focused on measuring quality of life do not address the fundamental issue of bowel control. The Krickenbeck score seems to be the most applicable and objective method of evaluating bowel control in pediatric patients that may be more useful when modified to assess patients after medical intervention.

Does Functional Outcome Improve with Time Postsurgery for Hirschsprung Disease?

PURPOSE: Constipation and incontinence are significant problems following pull-through surgery for Hirschsprung disease (HD). There is evidence that these problems improve with time. However, there is also evidence showing no improvements and furthermore, significant long-term data are lacking for the newer endorectal pull-through. We aim to determine if there is clinical evidence that show improvements in functional outcomes with time after an endorectal pull-through surgery for HD. METHODS: We utilized the validated pediatric incontinence and constipation scoring system (PICSS) to score 51 consecutive children 3 months to 15 years posttransabdominal or transanal endorectal pull-through for HD. Cases of total colonic aganglionosis and Down syndrome were excluded. PICSS scores below the age-specific lower limit 95% confidence interval scores represent incomplete continence or constipation, respectively. We performed linear regression to analyze the relationship between PICSS scores and the follow-up duration and then compared the demographics of children with and without incomplete continence and constipation, respectively. Significance was set at p < 0.05. RESULTS: The median age at PICSS interview was 71 months (range, 6-191 months). Incontinence scores obtained from 42 children older than 35 months showed a positive relationship with the follow-up duration (p = 0.03). Constipation scores obtained from 51 children were unrelated to follow-up duration (p = 0.486). When demographics were compared, the continent children had longer follow-up than those with incomplete continence (mean, 111.64 vs. 69.19 months; p = 0.051), however follow-up duration did not differ in the group of constipated children compared with the nonconstipated group (mean, 61.88 vs. 71.80 months; p = 0.321). CONCLUSION: These findings suggest that after an endorectal pull-through, improved continence should be expected with time but constipation often continues to be an ongoing problem.

Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop.

In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, and pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, passive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.

[Update on fecal incontinence]. / Stuhlinkontinenz - ein Update.

Fecal incontinence is defined as an accidental loss of stool or the inability to control defecation. There are three subtypes of fecal incontinence: passive incontinence, urge incontinence and soiling. About 8% of the adult population suffer from fecal incontinence, but only 1/3 consults a doctor. Beside the individual handicap, fecal incontinence has a huge socio-economic impact. Causes of fecal incontinence are changes in the quantity or quality of the stool and structural or functional disorders. Diagnostics encompass the medical history, clinical examination including the digital rectal examination, imaging (particularly endoanal ultrasound) as well as functional diagnostics (anal manometry and defecography). Nowadays, the most promising conservative treatment option consists of loperamide and biofeedback therapy. The most successful invasive method is the sacral neuromodulation.

L'incontinence fécale est définie comme une perte accidentelle de selles ou l'incapacité de contrôler la défécation. Il y a trois types d'incontinence fécale: l'incontinence passive, le besoin irrépressible et les salissures. Approximativement 8% de la population adulte souffre d'incontinence fécale, mais seulement 1/3 d'entre eux consultent un médecin. En plus de l'handicap individuel, l'incontinence fécale a un impact socio-économique considérable. Les causes de l'incontinence fécale comportent des modifications de la quantité ou de la qualité des selles et des anomalies structurelles ou fonctionnnelles. L'approche diagnostique comporte l'anamnèse médicale, l'examen clinique incluant un toucher rectal, le recours à l'imagerie (en particulier l'ultrasonographie endoanale) et des examens fonctionnels comme la manométrie anale et la défécographie. Aujourd'hui le traitement conservateur le plus prometteur se base sur le loperamide et la thérapie par biofeedback. La méthode invasive la plus efficace est la neuromodulation sacrée.

Impact of spinal dysraphism on urinary and faecal prognosis in 25 cases of cloacal malformation.

OBJECTIVE: Urinary and faecal continence are key challenges goal of cloacal malformation management. Most well-known prognostic factors are the length of common channel (CC) and the presence of a sacral defect, but the impact of associated spinal dysraphism is less well documented. The aim of this study was to investigate the impact of different types of dysraphism on urinary and faecal continence in this patient population. MATERIALS AND METHODS: From 1991 to 2011, charts and office notes of 25 patients with cloacal malformation were retrospectively reviewed. At last clinic visit, urinary and faecal continence status according to Krickenbeck criteria were correlated with the length of CC, the presence of a sacral defect (sacral ratio), and the presence of different types of spinal cord dysraphism using magnetic resonance imaging (MRI) and Fisher's exact test. RESULTS: Mean follow-up was 8 years (4 months-21 years). The sacral ratio was abnormal (below 0.74) in 18 cases out of 25 (72%). MRI review showed normal spinal cord in eight out of 23 cases (Group 1), spinal cord anomaly in 15 out of 23 cases (65%) including nine cases of tethered cord complex (Group 2) and six cases of a short spinal cord (Group 3). While statistical analysis showed a difference regarding urinary prognosis between the groups (p=0.005), no significant difference was found regarding faecal prognosis. None of the six patients with short spinal cord were continent for both urinary and faecal prognosis. CONCLUSIONS: This is the first study, which highlights the impact of different types of spinal dysraphism on functional outcome in patients with cloaca. Short spinal cord seemed to carry the worst prognosis. A prospective study with a larger series is mandatory to confirm these preliminary results.

Anal incontinence severity assessment tools used worldwide.

OBJECTIVE: To conduct an international survey of anal incontinence assessment tools and the need to evaluate frequency of occurrence of fecal urgency. METHODS: A questionnaire on the use of anal incontinence assessment tools was distributed between May and December 2012 among clinicians and researchers dealing with anal incontinence, primarily in North America, Europe, and Asia. RESULTS: A total of 143 responses were collected from 56 (39.2%) obstetricians, gynecologists, and urogynecologists; 71 (49.7%) colorectal surgeons, proctologists, and general surgeons; and 16 (11.2%) physiotherapists, theoretical scientists, and gastroenterologists. Fourteen different tools were reported-most commonly Wexner score (n=78; 48.8%) and St Mark's score (n=29; 18.1%). No scoring system was used by 24 (16.8%) respondents. Thirty-four (28.6%) used multiple tools. There was variation in the reasons given for scoring the frequency of fecal urgency as 4 points when using St Mark's score. Of 96 respondents responding to a query about modifying the St Mark's score, 88 (91.7%) agreed that fecal urgency should be scored according to the frequency of occurrence. CONCLUSION: Although the Wexner score neglects fecal urgency, it is the most commonly used scoring system. The study contributes to the standardization of terminology and reproducibility of results in research and clinical management of anal incontinence.

[Classification of enuresis/encopresis according to DSM-5]. / Klassifikation der Enuresis/ Enkopresis im DSM-5.

Elimination disorders are common in childhood and adolescence. Enuresis is traditionally defined as wetting from the age of 5 years and encopresis as soiling from 4 years onwards - after all organic causes have been excluded. In the past decades, many subtypes of elimination disorders have been identified with different symptoms, etiologies, and specific treatment options. Unfortunately, the DSM-5 criteria did not integrate these new approaches. In contrast, classification systems of the International Children's Incontinence Society (ICCS) for enuresis and urinary incontinence as well as the ROME-III criteria for fecal incontinence offer new and relevant suggestions for both clinical and research purposes.

Fecal incontinence: help for patients who suffer silently.

Once you've identified patients with this embarrassing condition, achieving optimal outcomes hinges on your familiarity with advances like sacral nerve stimulation.

[Pelvic floor functions: from the beginning of the second phase of labor to the postpartum consultation]. / Fonctions du plancher pelvien: de la phase expulsive à la consultation du post-partum.

Vaginal delivery can cause lesions of the various pelvic structures responsible for the mechanisms of continence. These lesions may perhaps be prevented in the future by measuring pressure generated during childbirth. Tear of the anal sphincter during childbirth is a marker of a global impairment of the urinary, ano-rectal and sexual pelvic functions in the short and medium term. Persistence of a defect of the anal sphincter is frequent in spite of immediate suture. The correlation between these defects and ano-rectal incontinence are not established in our experience. The quality of the contraction of the sphincter complex and pubo-rectal sling seems to play a more important role in ano-rectal continence after a traumatic childbirth.

Colonic hyperactivity results in frequent fecal soiling in a subset of children after surgery for Hirschsprung disease.

BACKGROUND AND AIM: Fecal soiling is a challenging problem in some children after pull-through surgery for Hirschsprung disease (HSCR). The prevailing perception is that soiling results from overflow incontinence; however, its treatment with laxatives yields mixed results. Colonic manometry studies are reported to be normal in most patients in this population. The interpretation of these findings does not support the physiology of fecal overflow incontinence in these children. The aim of the present study was to define the physiology underlying daily, frequent fecal soiling in children after surgery for HSCR using manometric techniques. PATIENTS AND METHODS: Four pediatric motility centers in the United States participated in the study; medical records and manometric tracings (anorectal and colonic) of children (n = 59; 6.5 years; 48 boys) who had pull-through surgery for HSCR and presented with daily, frequent fecal soiling were examined. Children referred for evaluation of constipation who had normal colonic manometry served as controls (n = 25; 6.7 years; 12 boys). The patients with HSCR were divided into 2 groups (Hirschsprung disease groups 1 and 2 [HD1, HD2]) based on the absence or presence of high-amplitude propagated contractions (HAPCs). A control group that included children with chronic constipation was also studied. We compared the mean HAPC frequency between the HD2 and control groups. RESULTS: HD1 included 21 patients who had no HAPCs in fasting or postprandial periods. HD2 included 38 patients who had an average of 0.07 HPACs/min while fasting and 0.13/min in the postprandial state. In this subset the number of HAPCs in the fasting state (P = 0.04) and the postprandial state (P < 0.001) was greater when compared with controls. Additionally, there was a significant increase in HAPCs/min from the fasting to the postprandial state (P = 0.01). In the HD2 group 40% had colonic hyperactivity. CONCLUSIONS: Daily, frequent fecal soiling after pull-through surgery for HSCR may be due to colonic hyperactivity in some children. It is imperative that this unique subset be identified because the management strategy would include avoidance of laxatives, contrary to standard current practice.

A new sphincter-preserving operation for low rectal cancer: ultralow anterior resection and colorectal/coloanal anastomosis by supporting bundling-up method.

PURPOSE: The introductions of total mesorectal excision and double-stapling technique into colorectal surgery have promoted the clinical application of sphincter preservation. However, for the tumors localized on the middle or lower level of rectum, sphincter-preservation approaches might be problematic in some patients. We introduce in this report a new sphincter-preserving technique for low rectal cancer. METHODS: Between August 1999 and May 2004, 310 patients underwent ultralow anterior resection and colorectal/coloanal anastomosis by supporting bundling-up method for low rectal cancer localized in the lower third of rectum. Postoperative evaluation included anal function, anastomotic leakage, anastomotic stenosis, cumulative survival rate, and local recurrence. RESULTS: Three hundred ten patients received the sphincter-preserving operation without severe intraoperative complications. One patient died of lung dysfunction (0.3%). All patients had satisfactory anal function without soiling. The median follow-up was 84 months (9-136 months) and overall survival rate was 97.0% at 1 year, 73.5% at 3 years, and 66% at 5 years. Thirty-six patients (11.6%) patients developed local recurrence. Postoperative complications included anastomotic leakage (1.6%), anastomotic stenosis (2.5%), and local and distant recurrence (11.6% and 18.4%, respectively). CONCLUSIONS: Ultralow anterior resection and colorectal/coloanal anastomosis by supporting bundling-up method may be one of the best choices of sphincter-preserving operation for low rectal cancer.

[Functional outcome after hand-sewn versus stapled colonic J pouch anastomosis for rectal carcinoma]. / Anastomoses colo-anale manuelles (ACA) et colo-sus-anale mécaniques (ACSA) avec réservoir en J, après proctectomie pour cancer: comparaison des résultats fonctionnels.

STUDY AIM: The aim of this study was to compare the surgical and functional results of hand-sewn and stapled colonic J-pouch anastomoses after proctectomies for cancer. PATIENTS AND METHODS: Over a 6-year period, 120 patients had a laparotomic conservative rectal excision with total mesorectal excision but without intersphincteric dissection, for cancer of the mid- and lower rectum: the colonic J-pouch anastomosis was hand-sewn for 49 and stapled for 71 patients. The functional results were assessed at 1 year, by a questionnaire completed by the patient. RESULTS: Morbidity was 37% in the hand-sewn group and 38% in the stapled group (ns). Mean duration of surgery in the hand-sewn group was 288 minutes and in the stapled group, 246 minutes (p<0.001). At 1 year, the rate of perfect continence was 71% for the hand-sewn group and 76% for the stapled group (ns). Significantly, more patient from the hand-sewn groups used enemas (16% versus 3%, p<0.005). On the other hand, there was no significant difference between the two groups for wearing protection, urgency, number of stools a day or gas/stool discrimination. CONCLUSIONS: There is no major difference in either the surgical or functional results between hand-sewn or stapled colonic J-pouch anastomosis by laparotomy for rectal cancer. Because it is simpler and faster to perform, a stapled pouch is preferable when the tumor site so permits.

[German-language questionnaires for the standardized assessment of fecal incontinence and quality of life]. / Deutschsprachige Fragebögen zur standardisierten Erfassung von Stuhlinkontinenz und Lebensqualität.

BACKGROUND AND OBJECTIVE: The severity of fecal incontinence is usually assessed in grades based on medical history. However, this grading does not consider stool frequency and thus the impairment suffered by the patients. A German translation of the incontinence scores of the Cleveland Clinic (CCS) for a standardized measurement disability has been recommended but not yet tested. Similarly, the impact of fecal incontinence on quality of life needs to be assessed with a specific assessment. The Fecal Incontinence Quality of Life Scale (FIQoL) is available for this, but not yet a German-language version. PATIENTS AND METHODS: For the German version of the CCS and the FIQoL we first evaluated linguistic aspects via translation and back-translation. We then compared the response to the translated questionnaires of a sample of 158 German patients who had fecal incontinence with those reported in English-language publications. RESULTS: The German versions were judged to be successful. The comparison with six published studies showed similar scores in the CCS and in all subscales of the FIQoL. CONCLUSION: Satisfactory German-language questionnaires are now available to assess the severity of fecal incontinence and specific aspects of the quality of life.

Comparison of recall and daily self-report of fecal incontinence severity.

PURPOSE: Fecal incontinence (FI) severity is determined by self-report, and most tools rely on recall of symptoms. This study examined whether recall of FI severity differed from daily reports on a diary and the factors influencing any difference. INSTRUMENTS AND DESIGN: Data of 96 participants (mean age 59 years, 78% female) reported on 3 data collection forms (a demographics form, a bowel history, and a stool diary) were analyzed. Data collected during an initial bowel history when participants reported FI severity using recall were compared to similar data participants recorded on a 14-day daily stool diary during a baseline period of a study investigating the effects of different types of dietary fiber on FI. RESULTS: The total FI severity score from the daily stool diary (median 5.0, range 1.2-15.5; P = .04) was significantly higher (worse FI) than the recalled bowel history (median 3.0, range 0.36-27.5). A higher, more positive difference in scores between recall and daily diary reporting indicated greater underreporting on recall. Caregivers underreported FI severity on recall compared to noncaregivers (P = .003). CONCLUSIONS: Reasons for underreporting FI are probably multifactorial; findings suggest that being a caregiver and having double incontinence are contributing factors. Clinicians should inquire about FI with a discerning yet sensitive approach. Use of a daily stool diary is recommended in research and may be useful in practice.

[Anal incontinence]. / Incontinence anale.

Anal incontinence today is more frequent than current estimates indicate. When a patient seeks care for this condition, its cause and severity are assessed by a careful history and clinical examination. Two essential atraumatic examinations are decision-support tools: transrectal ultrasound and anal manometry. Treatment should always be proposed. Surgery is necessary in some cases: obvious rupture of the external sphincter, if possible confirmed by transrectal ultrasound, should be directly repaired. Should this treatment fail, a repeated repair or a sphincter replacement (graciloplasty or artificial sphincter) is called for. Neuromodulation therapy is often indicated in the absence of obvious rupture, especially in cases of pudendal neuropathy.

[Proposal for a new consensus classification for faecal incontinence]. / Propuesta de una nueva clasificación de consenso para la incontinencia fecal.

Due to the complexities of the mechanisms involved in incontinence, there are many potential causes for this disorder. The causes of incontinence and the grouping of patients according to aetiological factors are described in the literature in various forms, without there being a consensus as such. Therefore, the objective of this review is to propose a new classification of faecal incontinence to the scientific community, which will enable criteria to be unified, which should lead to an improvement in the diagnosis and treatment of patients with faecal incontinence. It is an aetiopathogenic classification that can be obtained from the clinical history of the patient along with an endoanal ultrasound.

Long-term bowel function and quality of life in children with Hirschsprung's disease.

BACKGROUND/PURPOSE: Little is known about the quality of life (QOL) of children with Hirschsprung's disease (HD) as they grow older. The purpose of this study was to measure the QOL and bowel function of these children as they mature. METHODS: All children who were surgically treated for HD at British Columbia Children's Hospital, Vancouver, British Columbia, Canada between 1986 and 2003 were invited to participate. Each family was sent 3 previously validated questionnaires exploring current QOL and bowel function. RESULTS: Fifty-one families participated (49%), with children between the ages of 3 and 21 years. Fecal continence improved significantly with age (P = .04) and was the strongest predictor of QOL scores of all variables in our study. There was no statistically significant difference in QOL scores between children with HD and healthy children, although a clinically relevant impairment in QOL may be present, especially in psychosocial scores. CONCLUSIONS: Fecal continence is an important predictor of overall QOL in children surgically treated for HD. Although continence tends to improve with age, a number of older children still have ongoing continence problems, and they seem to be a group at risk for impaired QOL. Our study indicates that interventions for children with incontinence may offer gains in QOL as well as bowel function.