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2.
PLoS One ; 15(9): e0228761, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32991595

RESUMO

There is a need for a lower cost manometry system for assessing anorectal function in primary and secondary care settings. We developed an index finger-based system (termed "digital manometry") and tested it in healthy volunteers, patients with chronic constipation, and fecal incontinence. Anorectal pressures were measured in 16 participants with the digital manometry system and a 23-channel high-resolution anorectal manometry system. The results were compared using a Bland-Altman analysis at rest as well as during maximum squeeze and simulated defecation maneuvers. Myoelectric activity of the puborectalis muscle was also quantified simultaneously using the digital manometry system. The limits of agreement between the two methods were -7.1 ± 25.7 mmHg for anal sphincter resting pressure, 0.4 ± 23.0 mmHg for the anal sphincter pressure change during simulated defecation, -37.6 ± 50.9 mmHg for rectal pressure changes during simulated defecation, and -20.6 ± 172.6 mmHg for anal sphincter pressure during the maximum squeeze maneuver. The change in the puborectalis myoelectric activity was proportional to the anal sphincter pressure increment during a maximum squeeze maneuver (slope = 0.6, R2 = 0.4). Digital manometry provided a similar evaluation of anorectal pressures and puborectalis myoelectric activity at an order of magnitude less cost than high-resolution manometry, and with a similar level of patient comfort. Digital Manometry provides a simple, inexpensive, point of service means of assessing anorectal function in patients with chronic constipation and fecal incontinence.


Assuntos
Canal Anal/fisiopatologia , Constipação Intestinal/diagnóstico , Incontinência Fecal/diagnóstico , Manometria/instrumentação , Reto/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Constipação Intestinal/fisiopatologia , Estudos Transversais , Eletromiografia , Incontinência Fecal/fisiopatologia , Feminino , Voluntários Saudáveis , Humanos , Masculino , Manometria/economia , Manometria/métodos , Pessoa de Meia-Idade , Diafragma da Pelve/fisiopatologia , Pressão , Dispositivos Eletrônicos Vestíveis/economia
3.
Obstet Gynecol ; 136(4): 811-822, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925633

RESUMO

Nine percent of adult women experience episodes of fecal incontinence at least monthly. Fecal incontinence is more common in older women and those with chronic bowel disturbance, diabetes, obesity, prior anal sphincter injury, or urinary incontinence. Fecal incontinence negatively affects quality of life and mental health and is associated with increased risk of nursing home placement. Fewer than 30% of women with fecal incontinence seek care, and lack of information about effective solutions is an important barrier for both patients and health care professionals. Even among women with both urinary and fecal incontinence presenting for urogynecologic care, the rate of verbal disclosure of fecal incontinence symptoms remains low. This article provides an overview of the evaluation and management of fecal incontinence for the busy obstetrician-gynecologist, incorporating existing guidance from the American College of Obstetricians and Gynecologists, the American College of Gastroenterology, and the American Society of Colon and Rectal Surgeons. The initial clinical evaluation of fecal incontinence requires a focused history and physical examination. Recording patient symptoms using a standard diary or questionnaire can help document symptoms and response to treatment. Invasive diagnostic testing and imaging generally are not needed to initiate treatment but may be considered in complex cases. Most women have mild symptoms that will improve with optimized stool consistency and medications. Additional treatment options include pelvic floor muscle strengthening with or without biofeedback, devices placed anally or vaginally, and surgery, including sacral neurostimulation, anal sphincteroplasty, and, for severely affected individuals for whom other interventions fail, colonic diversion.


Assuntos
Tratamento Conservador , Incontinência Fecal , Procedimentos Cirúrgicos em Ginecologia/métodos , Qualidade de Vida , Idoso , Comorbidade , Tratamento Conservador/instrumentação , Tratamento Conservador/métodos , Incontinência Fecal/etiologia , Incontinência Fecal/fisiopatologia , Incontinência Fecal/psicologia , Incontinência Fecal/terapia , Feminino , Humanos , Anamnese/métodos , Administração dos Cuidados ao Paciente/métodos , Seleção de Pacientes
4.
Neurourol Urodyn ; 39(4): 1129-1136, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32163639

RESUMO

AIMS: The primary aim of this study was to assess the relationship between a strong desire to void (SDV) and rectal sensory function in patients with multiple sclerosis (PwMS) and anorectal disorders. The secondary aim was to identify clinical, urodynamic or manometric factors associated with greater rectal sensory function impairment in this population. METHODS: Thirty PwMS (mean age 49.2 ± 10.9 years) with anorectal disorders (constipation and/or fecal incontinence) participated in this observational study. Rectal sensory parameters during anorectal manometry were recorded at a strong desire to void and after urination (PV, post-void). The primary outcome was the desire to defecate volume. Secondary outcomes were first perception and maximum tolerated threshold volumes, presence and modulation of recto-anal inhibitory reflex. RESULTS: The mean desire to defecate volume was 125 ± 59 mL at SDV and 104 ± 64 mL at PV (P < .001). The mean maximum tolerated volume was 167 ± 61 mL at SDV vs 141 ± 64 mL after urination (P = .01). The other parameters were not different between SVD and PV conditions. No predictive factors for greater impairment of rectal sensory function were identified. CONCLUSION: This study suggests a relationship between bladder sensation and thus bladder capacity, and rectal sensory function in PwMS and with anorectal disorders.


Assuntos
Defecação/fisiologia , Incontinência Fecal/fisiopatologia , Esclerose Múltipla/fisiopatologia , Bexiga Urinária/fisiopatologia , Micção/fisiologia , Adulto , Idoso , Canal Anal/fisiopatologia , Constipação Intestinal/fisiopatologia , Feminino , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Reto/fisiopatologia , Sensação/fisiologia , Urodinâmica/fisiologia
6.
Neurourol Urodyn ; 39(3): 978-986, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32040860

RESUMO

BACKGROUND: There is a lack of evidence to assess whether gait functionality can be affected by the condition of the pelvic floor musculature in patients with multiple sclerosis (MS). OBJECTIVE: To evaluate the relationship between pelvic floor functionality and general functional performance, and also their relationship depending on dependence degree in MS patients. PARTICIPANTS: Forty-three MS patients performed the study. The pelvic floor musculature and its functionality were evaluated by urinary incontinence (UI), fecal incontinence, and constipation. General functional performance was evaluated by the Barthel index, the Health Status Questionnaire Short Form-12 (SF-12), and the Timed Up and Go (TUG) test. RESULTS: UI was moderately related to general functional performance (SF-12 Physical: R = -0.413; Barthel index: R = -0.501; TUG: R = 0.482). The comparative analysis showed differences between UI and gait functionality (P = .008), with poorer results in the TUG in patients with moderate/severe dependence (P < .001). CONCLUSION: UI appears to have a negative impact on the performance of daily living activities, walking, and the physical dimension of quality of life in patients with MS. In addition, patients with moderate or severe dependence showed higher UI and gait disturbance compared with those with mild dependence or independence.


Assuntos
Atividades Cotidianas , Marcha , Esclerose Múltipla/fisiopatologia , Distúrbios do Assoalho Pélvico/fisiopatologia , Diafragma da Pelve/fisiopatologia , Desempenho Físico Funcional , Qualidade de Vida , Adulto , Idoso , Constipação Intestinal/fisiopatologia , Incontinência Fecal/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Diafragma da Pelve/fisiologia , Estudos Prospectivos , Inquéritos e Questionários , Incontinência Urinária/fisiopatologia
8.
Dis Colon Rectum ; 63(4): 514-519, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31985515

RESUMO

BACKGROUND: Intersphincteric injectable bulking agents are one of the current treatment options for fecal incontinence, failing behavioral and medical therapy. Gatekeeper showed promising short-term results, but long-term outcomes are unknown. OBJECTIVE: The purpose of this study was to clinically evaluate a prospective cohort of fecal incontinence patients up to 36 months after implantation of Gatekeeper. DESIGN: This was a prospective clinical study. SETTINGS: The study was conducted at a large university tertiary care hospital. PATIENTS: Consecutive female patients were eligible if fecal incontinence onset was ≥6 months before the first visit and symptoms were refractory to standard conservative measures. INTERVENTIONS: All of the patients underwent implantation of 4 or 6 Gatekeeper prostheses. Three-dimensional endoanal ultrasonography and high-resolution anorectal manometry were performed preoperatively and postoperatively at 2 and 3 months after implantation. MAIN OUTCOME MEASURES: The Cleveland Clinic Fecal Incontinence score was calculated at baseline and 1, 3, 12, 24, and 36 months postoperatively. RESULTS: Twenty patients (all women; median age, 59 y) were enrolled, and all implants were uneventful. Postoperative endoanal ultrasonography showed normal prosthesis localization in 16 patients (80%). At manometry, mean anal resting pressure significantly improved (57.8 ± 7.5 mm Hg; p = 0.0004). Mean preoperative Cleveland Clinic Fecal Incontinence score was 12.4 ± 1.8, with significant improvements initially documented at 3 months (4.9 ± 1.5; p < 0.0001) and sustained up to 36 months (4.9 ± 1.7; p < 0.0001). Patients receiving only 4 (compared with 6) prostheses and those experiencing pudendal neuropathy (compared with those who did not) showed significantly higher Cleveland Clinic Fecal Incontinence score values in the middle term. LIMITATIONS: The study was limited by its small sample size and absence of quality-of-life data. CONCLUSIONS: Initial improvements after Gatekeeper implantation for fecal incontinence are sustained in the middle term. Accurate preoperative evaluation of coexistent clinical conditions that may negatively affect outcomes is recommended for patient selection. See Video Abstract at http://links.lww.com/DCR/B109. RESULTADOS A MEDIANO PLAZO EN LA IMPLANTACIÓN DE GATEKEEPER PARA LA INCONTINENCIA FECAL: Los agentes de volumen inyectables interesfintéricos, son opciones actuales de tratamiento para la incontinencia fecal, ante fallas de terapias conductuales y médicas. Gatekeeper mostró resultados prometedores a corto plazo, pero resultados a largo plazo aún son desconocidos.Evaluar clínicamente una cohorte prospectiva de pacientes con incontinencia fecal, hasta 36 meses después de la implantación de Gatekeeper.Estudio clínico prospectivo.El estudio se realizó en un gran hospital universitario de atención terciaria.Fueron elegibles pacientes femeninas consecutivas, si el inicio de la incontinencia fecal, fue al menos 6 meses antes de la primera visita, y que los síntomas fueron refractarios a las medidas conservadoras estandarizadas.Todas las pacientes fueron sometidas a implantación de 4 o 6 prótesis Gatekeeper. Se realizó ecografía endoanal de 3D y manometría anorrectal de alta resolución, antes de la implantación y después a los 2 y 3 meses.Se calculó el puntaje de incontinencia fecal de la Cleveland Clinic al inicio, y a los 1, 3, 12, 24 y 36 meses después de la operación.Se inscribieron veinte pacientes (todas mujeres; con edad media de 59 años), y todos los implantes transcurrieron sin incidentes. La ecografía endoanal postoperatoria, mostró localización normal de la prótesis en 16 (80%) pacientes. A la manometría, la presión media de reposo anal, mejoró significativamente (57.8 ± 7.5 mmHg, p = 0.0004). La puntuación media preoperatoria de la incontinencia fecal de la Cleveland Clinic, fue de 12.35 ± 1.75, con mejoras significativas documentadas inicialmente a los 3 meses (4.9 ± 1.5, p <0.0001) y sostenidas hasta los 36 meses (4.9 ± 1.7, p <0.0001). Los pacientes que recibieron solo 4 prótesis (en comparación con 6) y que padecían neuropatía pudenda (en comparación con aquellas que no la padecían), mostraron valores de puntaje de Incontinencia Fecal de la Clínica Cleveland, significativamente más altos en el mediano plazo.El tamaño pequeño de la muestra y la ausencia de datos en calidad de vida.Las mejoras iniciales después de la implantación de Gatekeeper para la incontinencia fecal, se mantienen en el mediano plazo. Para la selección de pacientes, se recomienda una precisa evaluación preoperatoria de las condiciones clínicas coexistentes, que puedan afectar negativamente los resultados. Consulte Video Resumen en http://links.lww.com/DCR/B109.


Assuntos
Defecação/fisiologia , Incontinência Fecal/cirurgia , Próteses e Implantes , Implantação de Prótese/métodos , Adulto , Idoso , Canal Anal , Endossonografia/métodos , Incontinência Fecal/diagnóstico , Incontinência Fecal/fisiopatologia , Feminino , Seguimentos , Humanos , Imageamento Tridimensional , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Prospectivos , Desenho de Prótese , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
9.
Ann Vasc Surg ; 66: 670.e1-670.e4, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31978482

RESUMO

BACKGROUND: Percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis is one of the most important methods for deep venous thrombosis treatment. Spontaneous spinal subdural hematoma is a remarkably rare complication in the thrombolysis process with catastrophic consequences, as shown in this case report. METHODS: Percutaneous mechanical thrombectomy, percutaneous angioplasty, and catheter-directed thrombolysis were performed for the patient. Postoperatively, the patient was diagnosed with spontaneous spinal subdural hematoma and received a series of medical treatments and surgical interventions. RESULTS: The patient was still paraplegic and incontinent at the postoperative 7-month follow-up. CONCLUSIONS: Neurologic symptoms must be monitored carefully both during and after the thrombolysis procedure. The onset of spinal neurologic deficits in any patient must raise the suspicion that a spinal subdural hematoma has occurred. Surgical decompression beyond 24 hr may cause permanent neurological damage.


Assuntos
Hematoma Subdural Espinal/etiologia , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Trombose Venosa/terapia , Terapia Combinada , Incontinência Fecal/etiologia , Incontinência Fecal/fisiopatologia , Feminino , Hematoma Subdural Espinal/diagnóstico por imagem , Hematoma Subdural Espinal/fisiopatologia , Hematoma Subdural Espinal/terapia , Humanos , Pessoa de Meia-Idade , Paraplegia/etiologia , Paraplegia/fisiopatologia , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento , Incontinência Urinária/etiologia , Incontinência Urinária/fisiopatologia , Trombose Venosa/diagnóstico por imagem
10.
J Wound Ostomy Continence Nurs ; 47(1): 54-64, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31929444

RESUMO

A multidisciplinary international expert panel was convened to provide input for a proposed decision support tool. This tool will assist health care professionals who are not specialized in incontinence care to assess individuals with urinary and/or fecal incontinence and recommend appropriate person-centered management options for the home care and ambulatory community settings. A targeted literature review was complemented by a series of interviews with experts in continence management, followed by a practitioner survey and rounds of expert opinion. A set of factors for assessment were defined, along with questions created to identify and quantify the factors. In addition, a range of lifestyle intervention, toileting and containment strategies were identified that were appropriate for the decision support tool. Future steps required to progress this work to a functioning tool are described.


Assuntos
Técnicas de Apoio para a Decisão , Incontinência Fecal/terapia , Incontinência Urinária/terapia , Atividades Cotidianas , Consenso , Incontinência Fecal/fisiopatologia , Humanos , Assistência Centrada no Paciente/métodos , Autocuidado , Incontinência Urinária/fisiopatologia
11.
Trials ; 21(1): 112, 2020 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-31992358

RESUMO

BACKGROUND: After low anterior resection (LAR), up to 90% of patients develop anorectal dysfunction. Especially fecal incontinence has a major impact on the physical, psychological, social, and emotional functioning of the patient but also on the Dutch National Healthcare budget with more than €2000 spent per patient per year. No standardized treatment is available to help these patients. Common treatment nowadays is focused on symptom relief, consisting of lifestyle advices and pharmacotherapy with bulking agents or antidiarrheal medication. Another possibility is pelvic floor rehabilitation (PFR), which is one of the most important treatments for fecal incontinence in general, with success rates of 50-80%. No strong evidence is available for the use of PFR after LAR. This study aims to prove a beneficial effect of PFR on fecal incontinence, quality of life, and costs in rectal cancer patients after sphincter-saving surgery compared to standard treatment. METHODS: The FORCE trial is a multicenter, two-armed, randomized clinical trial. All patients that underwent LAR are recruited from the participating hospitals and randomized for either standard treatment or a standardized PFR program. A total of 128 patients should be randomized. Optimal blinding is not possible. Stratification will be done in variable blocks (gender and additional radiotherapy). The primary endpoint is the Wexner incontinence score; secondary endpoints are health-related and fecal-incontinence-related QoL and cost-effectiveness. Baseline measurements take place before randomization. The primary endpoint is measured 3 months after the start of the intervention, with a 1-year follow-up for sustainability research purposes. DISCUSSION: The results of this study may substantially improve postoperative care for patients with fecal incontinence or anorectal dysfunction after LAR. This section provides insight in the decisions that were made in the organization of this trial. TRIAL REGISTRATION: Netherlands Trial Registration, NTR5469, registered on 03-09-2015. Protocol FORCE trial V18, 19-09-2019. Sponsor Radboud University Medical Center, Nijmegen.


Assuntos
Incontinência Fecal/reabilitação , Diafragma da Pelve , Modalidades de Fisioterapia , Complicações Pós-Operatórias/reabilitação , Protectomia , Neoplasias Retais/cirurgia , Análise Custo-Benefício , Incontinência Fecal/economia , Incontinência Fecal/fisiopatologia , Incontinência Fecal/psicologia , Custos de Cuidados de Saúde , Humanos , Países Baixos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/psicologia , Qualidade de Vida
12.
J Pediatr Surg ; 55(2): 261-264, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31918852

RESUMO

AIM OF THE STUDY: The aim of this study was to evaluate the impact of implementing a Bowel Management Program (BMP) on the quality of life (QOL) in children with pseudoincontinence. METHOD: Children aged 2.5-13 years with pseudoincontinence were included. Evaluations were performed before and after BMP implementation. Perceptions from parents about QOL were assessed by a QOL questionnaire, and the severity of fecal incontinence (FI) was assessed using the fecal incontinence index (FII) of the Wexner scale. RESULTS: 115 children (mean age of 7.54 ±â€¯2.48) were studied over a 3-12 month period (mean duration 4.36 months). QOL improved from 2.45 ±â€¯1.57 to 14.36 ±â€¯1.37, P˂0.05. There was a significant improvement of the FII: 18.65 ±â€¯1.25 versus 0.13 ±â€¯0.39, P˂ 0.05. There was a significant inverse correlation between the final scores of QOL (14.36 ±â€¯1.37) and FII (0.13 ±â€¯0.39) after implementation of the BMP (r = -0.53; P ˂ 0.05). CONCLUSION: This is the largest case series examining QOL in pseudoincontinent children. It demonstrates that BMP significantly improves the QOL of these children in the short and midterm. In addition, it is feasible to apply the FII in assessing incontinence in children. To our knowledge, this is the first study of its kind in our region. LEVEL OF EVIDENCE: Level IV.


Assuntos
Incontinência Fecal , Qualidade de Vida , Adolescente , Criança , Pré-Escolar , Egito , Incontinência Fecal/fisiopatologia , Incontinência Fecal/psicologia , Incontinência Fecal/terapia , Feminino , Seguimentos , Humanos , Masculino , Pais , Inquéritos e Questionários
13.
Am J Obstet Gynecol ; 222(6): 588.e1-588.e10, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31836546

RESUMO

BACKGROUND: Patient satisfaction and health-related quality of life are nowadays considered as the most important outcomes of pelvic organ prolapse treatment, and large, prospective clinical studies reporting the patient-reported surgical outcomes are needed. OBJECTIVE: To evaluate the effect of female pelvic organ prolapse surgery on health-related quality of life and patient satisfaction and to determine predictors of outcome. STUDY DESIGN: This prospective nationwide cohort study consisted of 3515 women undergoing surgery for pelvic organ prolapse in 2015. The outcomes were measured by validated health-related quality of life instruments (generic 15D, Pelvic Floor Distress Inventory-20, and Patient Global Impression of Improvement) at 6 months and 2 years postoperatively. The baseline predictors of outcomes were studied with logistic regression analysis. RESULTS: In total, 2528 (72%) women were eligible for analysis at 6 months and 2351 (67%) at 2 years. The mean change in the total 15D score suggested a clinically important improvement at 6 months but not at 2 years. However, an improvement in sexual activity, discomfort and symptoms, and excretion was observed during both follow-up assessments. Altogether, 77% and 72% of the participants reported a clinically significant improvement in Pelvic Floor Distress Inventory-20 at the 6-month and 2-year follow-ups, respectively. A total of 84% were satisfied with the outcome and 90% reported an improvement in comparison with the preoperative state with Patient Global Impression of Improvement-I. The strongest predictive factors for a favorable outcome were advanced apical prolapse (adjusted odds ratio, 2.06; 95% confidence interval, 1.58-2.70) and vaginal bulge (1.90, 1.30-2.80). Smoking was associated with an unfavorable outcome as measured by Patient Global Index of Improvement-I (1.69, 1.02-2.81). CONCLUSION: Pelvic organ prolapse surgery improved health-related quality of life in 7 of 10 patients over a 2-year follow-up period, and patient satisfaction was high. Apical prolapse beyond the hymen and vaginal bulge were the most consistent predictors for improvement. Our results suggest that patients should be encouraged to stop smoking to avoid an unfavorable outcome.


Assuntos
Incontinência Fecal/fisiopatologia , Prolapso de Órgão Pélvico/cirurgia , Qualidade de Vida , Disfunções Sexuais Psicogênicas/fisiopatologia , Incontinência Urinária/fisiopatologia , Idoso , Estudos de Coortes , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Modelos Logísticos , Sintomas do Trato Urinário Inferior/fisiopatologia , Pessoa de Meia-Idade , Diferença Mínima Clinicamente Importante , Razão de Chances , Satisfação do Paciente , Prolapso de Órgão Pélvico/epidemiologia , Prolapso de Órgão Pélvico/fisiopatologia , Prolapso de Órgão Pélvico/psicologia , Prognóstico , Procedimentos Cirúrgicos Reconstrutivos , Fumar/epidemiologia , Telas Cirúrgicas , Resultado do Tratamento
14.
Int J Colorectal Dis ; 35(1): 173-176, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31802189

RESUMO

PURPOSE: Temperature-controlled radiofrequency (RF) energy delivery to the sphincter complex has been proposed as an option for those patients not susceptible to a major surgical procedure for fecal incontinence (FI). The aim of the study was to evaluate the long-term (15 years) functional outcomes obtained after RF procedure for FI. METHODS: This was a retrospective analysis of our prospectively collected database of patients that underwent RF procedure for FI. Primary outcomes measured were the Cleveland Clinic Florida Fecal Incontinence scale (CCF-FI), Fecal Incontinence-related Quality of Life Score (FIQLS), the 36-Item Short Form survey (SF-36), endoanal ultrasound, and anorectal manometry. Evaluations were compared at baseline and at 15 years of follow-up. RESULTS: Ten patients were followed up 15 years after RF procedure. There was no significant improvement in the CCF-FI score (13.8 vs. 12.4, p = 0.24). No significant changes in the FIQLS were observed including lifestyle (2.39 vs. 2.13, p = 0.23), coping (1.91 vs. 1.92, p = 0.96), and embarrassment (1.66 vs. 1.86; p = 0.43). However, significant worsening was found in the depression category (2.47 vs. 1.60, p = 0.001). The SF-36 showed significant worsening in the mental (36.7 vs. 25.8, p < 0.001), physical (53.1 vs. 41.4, p = 0.01), and social functions (50.9 vs. 31.25, p = 0.001). Anorectal manometry and endoanal ultrasound showed no significant changes. No complications were found in the long-term follow-up. CONCLUSIONS: Radiofrequency procedure for fecal incontinence did not maintain its efficacy during long-term follow-up.


Assuntos
Incontinência Fecal/terapia , Terapia por Radiofrequência , Idoso , Incontinência Fecal/fisiopatologia , Feminino , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Qualidade de Vida , Fatores de Tempo , Resultado do Tratamento
15.
Neurourol Urodyn ; 39(1): 447-454, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31770467

RESUMO

BACKGROUND: Anal acoustic reflectometry (AAR) is a technique for measuring the physiological profile of the anal canal, primarily the internal anal sphincter. Evaluation of a new continuous method, recently developed for the urethra, would enable its future application for investigation of rectal reflexes. METHODS: Patients aged 18 and over with fecal incontinence (FI) were included. Stepwise AAR parameters were compared with continuous opening pressure (Op, cmH2 O), opening elastance (Oe, cmH2 O/mm2 ), closing pressure (Cp, cmH2 O), closing elastance (Ce, cmH2 O/mm2 ), hysteresis (Hys, [%]), squeeze opening pressure (SqOp, cmH2 O), and squeeze opening elastance (SqOe, cmH2 O/mm2 ). Vaizey incontinence and Manchester Health Questionnaire scores were also collected. RESULTS: Thirty-two patients, 26 females were analyzed. Median age: 60 (range, 32-75). Median AAR parameters of Op (37.50 vs 35.15, P = .031), Oe (1.31 vs 0.84, P < .0001), Ce (1.11 vs 0.88, P < .0001), Hys (37.75 vs 19.04, P < .0001), and SqOe (1.27 vs 1.06, P = .005) were significantly higher with the continuous method. Cp (22.70 vs 27.22, P = .003) is lower and SqOp (96.87 vs 59.47, P = .71) not significantly different. The continuous technique had superior repeatability between cycles for all AAR parameters except Oe, which was equivalent and continuous SqOp had a stronger negative correlation with Vaizey score than stepwise (-0.46, P = .009 vs -0.37, P = .038). CONCLUSIONS: The differences seen between the two techniques are likely to be related to the rate of stretch. The continuous technique appears to represent a more physiological measurement of anal sphincter function than the stepwise technique particularly in the assessment of voluntary squeeze function.


Assuntos
Canal Anal/fisiopatologia , Doenças do Ânus/diagnóstico , Incontinência Fecal/fisiopatologia , Reflexo/fisiologia , Adulto , Idoso , Doenças do Ânus/fisiopatologia , Feminino , Humanos , Masculino , Manometria/métodos , Pessoa de Meia-Idade , Reto/fisiopatologia
16.
Am J Obstet Gynecol ; 222(6): 590.e1-590.e8, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31765640

RESUMO

OBJECTIVE: Defecatory symptoms, such as a sense of incomplete emptying and straining with bowel movements, are paradoxically present in women with fecal incontinence. Treatments for fecal incontinence, such as loperamide and biofeedback, can worsen or improve defecatory symptoms, respectively. The primary aim of this study was to compare changes in constipation symptoms in women undergoing treatment for fecal incontinence with education only, loperamide, anal muscle exercises with biofeedback or both loperamide and biofeedback. Our secondary aim was to compare changes in constipation symptoms among responders and nonresponders to fecal incontinence treatment. STUDY DESIGN: This was a planned secondary analysis of a randomized controlled trial comparing 2 first-line therapies for fecal incontinence in a 2 × 2 factorial design. Women with at least monthly fecal incontinence and normal stool consistency were randomized to 4 groups: (1) oral placebo plus education only, (2) oral loperamide plus education only, (3) placebo plus anorectal manometry-assisted biofeedback, and (4) loperamide plus biofeedback. Defecatory symptoms were measured using the Patient Assessment of Constipation Symptoms questionnaire at baseline, 12 weeks, and 24 weeks. The Patient Assessment of Constipation Symptoms consists of 12 items that contribute to a global score and 3 subscales: stool characteristics/symptoms (hardness of stool, size of stool, straining, inability to pass stool), rectal symptoms (burning, pain, bleeding, incomplete bowel movement), and abdominal symptoms (discomfort, pain, bloating, cramps). Scores for each subscale as well as the global score range from 0 (no symptoms) to 4 (maximum score), with negative change scores representing improvement in defecatory symptoms. Responders to fecal incontinence treatment were defined as women with a minimally important clinical improvement of ≥5 points on the St Mark's (Vaizey) scale between baseline and 24 weeks. Intent-to-treat analysis was performed using a longitudinal mixed model, controlling for baseline scores, to estimate changes in Patient Assessment of Constipation Symptoms scores from baseline through 24 weeks. RESULTS: At 24 weeks, there were small changes in Patient Assessment of Constipation Symptoms global scores in all 4 groups: oral placebo plus education (-0.3; 95% confidence interval, -0.5 to -0.1), loperamide plus education (-0.1, 95% confidence interval, -0.3 to0.0), oral placebo plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2), and loperamide plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2). No differences were observed in change in Patient Assessment of Constipation Symptoms scores between women randomized to placebo plus education and those randomized to loperamide plus education (P = .17) or placebo plus biofeedback (P = .82). Change in Patient Assessment of Constipation Symptoms scores in women randomized to combination loperamide plus biofeedback therapy was not different from that of women randomized to treatment with loperamide or biofeedback alone. Responders had greater improvement in Patient Assessment of Constipation Symptoms scores than nonresponders (-0.4; 95% confidence interval, -0.5 to -0.3 vs -0.2; 95% confidence interval, -0.3 to -0.0, P < .01, mean difference, 0.2, 95% confidence interval, 0.1-0.4). CONCLUSION: Change in constipation symptoms following treatment of fecal incontinence in women are small and are not significantly different between groups. Loperamide treatment for fecal incontinence does not worsen constipation symptoms among women with normal consistency stool. Women with clinically significant improvement in fecal incontinence symptoms report greater improvement in constipation symptoms.


Assuntos
Antidiarreicos/uso terapêutico , Biorretroalimentação Psicológica , Constipação Intestinal/fisiopatologia , Incontinência Fecal/terapia , Loperamida/uso terapêutico , Educação de Pacientes como Assunto , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Constipação Intestinal/complicações , Incontinência Fecal/complicações , Incontinência Fecal/fisiopatologia , Feminino , Humanos , Manometria , Pessoa de Meia-Idade , Modalidades de Fisioterapia , Resultado do Tratamento
17.
Brain ; 143(1): 94-111, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31855247

RESUMO

Cerebral choline metabolism is crucial for normal brain function, and its homoeostasis depends on carrier-mediated transport. Here, we report on four individuals from three families with neurodegenerative disease and homozygous frameshift mutations (Asp517Metfs*19, Ser126Metfs*8, and Lys90Metfs*18) in the SLC44A1 gene encoding choline transporter-like protein 1. Clinical features included progressive ataxia, tremor, cognitive decline, dysphagia, optic atrophy, dysarthria, as well as urinary and bowel incontinence. Brain MRI demonstrated cerebellar atrophy and leukoencephalopathy. Moreover, low signal intensity in globus pallidus with hyperintensive streaking and low signal intensity in substantia nigra were seen in two individuals. The Asp517Metfs*19 and Ser126Metfs*8 fibroblasts were structurally and functionally indistinguishable. The most prominent ultrastructural changes of the mutant fibroblasts were reduced presence of free ribosomes, the appearance of elongated endoplasmic reticulum and strikingly increased number of mitochondria and small vesicles. When chronically treated with choline, those characteristics disappeared and mutant ultrastructure resembled healthy control cells. Functional analysis revealed diminished choline transport yet the membrane phosphatidylcholine content remained unchanged. As part of the mechanism to preserve choline and phosphatidylcholine, choline transporter deficiency was implicated in impaired membrane homeostasis of other phospholipids. Choline treatments could restore the membrane lipids, repair cellular organelles and protect mutant cells from acute iron overload. In conclusion, we describe a novel childhood-onset neurometabolic disease caused by choline transporter deficiency with autosomal recessive inheritance.


Assuntos
Antígenos CD/genética , Transtornos Heredodegenerativos do Sistema Nervoso/genética , Proteínas de Transporte de Cátions Orgânicos/genética , Adolescente , Ataxia/genética , Ataxia/fisiopatologia , Atrofia , Cerebelo/diagnóstico por imagem , Cerebelo/patologia , Colina/farmacologia , Disfunção Cognitiva/genética , Disfunção Cognitiva/fisiopatologia , Vesículas Citoplasmáticas/efeitos dos fármacos , Vesículas Citoplasmáticas/ultraestrutura , Transtornos de Deglutição/genética , Transtornos de Deglutição/fisiopatologia , Disartria/genética , Disartria/fisiopatologia , Retículo Endoplasmático/efeitos dos fármacos , Retículo Endoplasmático/ultraestrutura , Incontinência Fecal/genética , Incontinência Fecal/fisiopatologia , Feminino , Fibroblastos/efeitos dos fármacos , Fibroblastos/ultraestrutura , Mutação da Fase de Leitura , Globo Pálido/diagnóstico por imagem , Transtornos Heredodegenerativos do Sistema Nervoso/diagnóstico por imagem , Transtornos Heredodegenerativos do Sistema Nervoso/patologia , Transtornos Heredodegenerativos do Sistema Nervoso/fisiopatologia , Homozigoto , Humanos , Leucoencefalopatias/diagnóstico por imagem , Leucoencefalopatias/genética , Leucoencefalopatias/fisiopatologia , Imagem por Ressonância Magnética , Masculino , Microscopia Eletrônica , Mitocôndrias/efeitos dos fármacos , Mitocôndrias/ultraestrutura , Nootrópicos/farmacologia , Atrofia Óptica/genética , Atrofia Óptica/fisiopatologia , Linhagem , Ribossomos/efeitos dos fármacos , Ribossomos/ultraestrutura , Substância Negra/diagnóstico por imagem , Síndrome , Tremor/genética , Tremor/fisiopatologia , Incontinência Urinária/genética , Incontinência Urinária/fisiopatologia
18.
Am J Physiol Gastrointest Liver Physiol ; 318(1): G66-G76, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31736339

RESUMO

Cardiac loops have been used extensively to study myocardial function. With changes in cardiac pump function, loops are shifted to the right or left. Functional luminal imaging probe (FLIP) recordings allow for loop analysis of the anal sphincter and puborectalis muscle (PRM) function. The goal was to characterize anal sphincter area-pressure/tension loop changes in fecal incontinence (FI) patients. Fourteen healthy subjects and 14 patients with FI were studied. A custom-designed FLIP was placed in the vagina and then in the anal canal, and deflated in 20-ml steps, from 90 to 30 ml. At each volume, subjects performed maximal voluntary squeezes. Area-pressure (AP) and area-tension (AT) loops were generated for each squeeze cycle. Three-dimensional ultrasound imaging of the anal sphincter and PRM were obtained to determine the relationship between anal sphincter muscle damage and loop movements. With the increase in bag volume, AP loops and AT loops shifted to the right and upward in normal subjects (both anal and vaginal). The shift to the right was greater, and the upward movement was less in FI patients. The difference in the location of AP loops and AT loops was statistically significant at volumes of 50 ml to 90 ml (P < 0.05). A similar pattern was found in the vaginal loops. There is a significant relationship between the damage to the anal sphincter and PRM, and loop location of FI patients. We propose AP and AT loops as novel ways to assess the anal sphincter and PRM function. Such loops can be generated by real-time measurement of pressure and area within the anal canal.NEW & NOTEWORTHY We describe the use of area-pressure (AP) and area-tension (AT)-loop analysis of the anal sphincters and puborectalis muscles in normal subjects and fecal incontinent patients using the functional luminal imaging probe (FLIP). There are differences in the magnitude of the displacement of the loops with increase in the FLIP bag volume between normal subjects and patients with fecal incontinence. The latter group shifts more to the right in AP and AT space.


Assuntos
Canal Anal/diagnóstico por imagem , Defecação , Incontinência Fecal/diagnóstico por imagem , Músculo Esquelético/diagnóstico por imagem , Ultrassonografia , Adulto , Idoso , Canal Anal/fisiopatologia , Estudos de Casos e Controles , Incontinência Fecal/fisiopatologia , Feminino , Humanos , Imageamento Tridimensional , Pessoa de Meia-Idade , Músculo Esquelético/fisiopatologia , Valor Preditivo dos Testes , Pressão , Fatores de Tempo , Adulto Jovem
19.
Am J Obstet Gynecol ; 222(3): 247.e1-247.e8, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31526791

RESUMO

BACKGROUND: Pelvic floor dysfunction, including urinary and anal incontinence, is a common postpartum complaint and likely to reduce quality of life. OBJECTIVE: To study the effects of individualized physical therapist-guided pelvic floor muscle training in the early postpartum period on urinary and anal incontinence and related bother, as well as pelvic floor muscle strength and endurance. MATERIALS AND METHODS: This was an assessor-blinded, parallel-group, randomized controlled trial evaluating effects of pelvic floor muscle training by a physical therapist on the rate of urinary and/or anal leakage (primary outcomes); related bother and muscle strength and endurance in the pelvic floor were secondary outcomes. Between 2016 and 2017, primiparous women giving birth at Landspitali University Hospital in Reykjavik, Iceland, were screened for eligibilty 6-10 weeks after childbirth. Of those identified as urinary incontinent, 95 were invited to participate, of whom 84 agreed. The intervention, starting at ∼9 weeks postpartum consisted of 12 weekly sessions with a physical therapist, after which the main outcomes were assessed (endpoint, ∼6 months postpartum). Additional follow-up was conducted at ∼12 months postpartum. The control group received no instructions after the initial assessment. The Fisher exact test was used to test differences in the proportion of women with urinary and anal incontinence between the intervention and control groups, and independent-sample t tests were used for mean differences in muscle strength and endurance. Significance levels were set as α = 0.05. RESULTS: A total of 41 and 43 women were randomized to the intervention and control groups, respectively. Three participants and 1 participant withdrew from these respective groups. Measurement variables and main delivery outcomes were not different at recruitment. At the endpoint, urinary incontinence was less frequent in the intervention group, with 21 participants (57%) still symptomatic, compared to 31 controls (82%) (P = .03), as was bladder-related bother with 10 participants (27%) in the intervention vs 23 (60%) in the control group (P = .005). Anal incontinence was not influenced by pelvic floor muscle training (P = .33), nor was bowel-related bother (P = .82). The mean differences between groups in measured pelvic floor muscle strength changes at endpoint was 5 hPa (95% confidence interval, 2-8; P = .003), and for pelvic floor muscle endurance changes, 50 hPa/s (95% confidence interval, 23-77; P = .001), both in favor of the intervention group. The mean between-group differences for anal sphincter strength changes was 10 hPa (95% confidence interval, 2-18; P = .01) and for anal sphincter endurance changes 95 hPa/s (95% confidence interval, 16-173; P = .02), both in favor of the intervention. At the follow-up visit 12 months postpartum, no differences were observed between the groups regarding rates of urinary and anal incontinence and related bother. Pelvic floor- and anal muscle strength and endurance favoring the intervention group were maintained. CONCLUSION: Postpartum pelvic floor mucle training decreased the rate of urinary incontinence and related bother 6 months postpartum and increased muscle strength and endurance.


Assuntos
Terapia por Exercício , Incontinência Fecal/prevenção & controle , Diafragma da Pelve/fisiopatologia , Período Pós-Parto/fisiologia , Incontinência Urinária/prevenção & controle , Adulto , Incontinência Fecal/fisiopatologia , Feminino , Humanos , Contração Muscular/fisiologia , Força Muscular/fisiologia , Gravidez , Método Simples-Cego , Incontinência Urinária/fisiopatologia
20.
Dig Dis Sci ; 65(1): 250-259, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31372911

RESUMO

BACKGROUND: With a lifelong perspective, 12% of ulcerative colitis patients will need a colectomy. Further reconstruction via ileo-rectal anastomosis or pouch can be affected by patients' perspective of their quality of life after surgery. AIM: To assess the function and quality of life after restorative procedures with either ileo-rectal anastomosis or ileal pouch-anal anastomosis in relation to the inflammatory activity on endoscopy and in biopsies. METHOD: A total of 143 UC patients operated with subtotal colectomy and ileo-rectal anastomosis or pouches between 1992 and 2006 at Linköping University Hospital were invited to participate. Those who completed the validated questionnaires (Öresland score, SF-36, Short Health Scale) were offered an endoscopic evaluation including multiple biopsies. Associations between anorectal function and quality of life with type of restorative procedure and severity of endoscopic and histopathologic grading of inflammation were evaluated. RESULTS: Some 77 (53.9%) eligible patients completed questionnaires, of these 68 (88.3%) underwent endoscopic evaluation after a median follow-up of 12.5 (range 3.5-19.4) years after restorative procedure. Patients with ileo-rectal anastomosis reported better overall Öresland score: median = 3 (IQR 2-5) for ileo-rectal anastomosis (n = 38) and 10 (IQR 5-15) for pouch patients (n = 39) (p < 0.001). Anorectal function (Öresland score) and endoscopic findings (Baron-Ginsberg score) were positively correlated in pouch patients (tau: 0.28, p = 0.006). CONCLUSION: Patients operated with ileo-rectal anastomosis reported better continence compared to pouches. Minor differences were noted regarding the quality of life. Ileo-rectal anastomosis is a valid option for properly selected ulcerative colitis patients if strict postoperative endoscopic surveillance is carried out.


Assuntos
Colite Ulcerativa/cirurgia , Bolsas Cólicas/efeitos adversos , Defecação , Incontinência Fecal/etiologia , Proctocolectomia Restauradora/efeitos adversos , Qualidade de Vida , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Colite Ulcerativa/diagnóstico , Colite Ulcerativa/fisiopatologia , Colite Ulcerativa/psicologia , Incontinência Fecal/diagnóstico , Incontinência Fecal/fisiopatologia , Incontinência Fecal/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Fatores de Risco , Resultado do Tratamento , Adulto Jovem
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