Introduction

Fecal incontinence frequently affects multiparous women. The aim of this study was to evaluate the relationship of parity and anal sphincter function in female patients with fecal incontinence.

Aims & Methods

36 patients underwent HRAM procedure. Manometry was performed in the left lateral decubitus position. Reusable solid state HRAM catheter (MMS, the Netherlands) with 8 circumferential and one balloon pressure was used. We analyzed resting, squeeze and residual pressure in push test, cough pressure and rectal sensations (first sensation, urgency and intense urgency). Demographic data were also obtained and evaluated. ANOVA analysis was used to determine the relationship between parameters of anal sphincter function and parity, with post-hoc Tukey HSD test when appropriate. Significance was set at a p<0.05. The statistical package “R” was used for the analysis.

Results

36 females with fecal incontinence were included in the study. Median age was 63 years (25-82), parity 2 children (0-4), anal resting pressure 45.5mmHg (3-96), squeeze pressure 86mmHg (30-270), endurance pressure 88mmHg (18.6-716), push pressure 37.50mmHg (-4-100) and cough pressure 107.5mmHg (26-716). Median for the first sensation was 40ml of inflated air (20-360), urgency 80ml (40-390) and intense urgency 110ml (50-390). We found statistically significant difference for the resting pressure (F-value=3.06, p-value =0.031), with Tukey’s HSD test which found significant difference between group with four children and no children (p=0.02), as well as between group with four children and one child (p=0.029). There was no statistically significant difference between groups for any other pressure variable (p=0.294, p=0.69, p=0.214, p=0.8 for squeeze, endurance, push and cough pressure, respectively) or sensation (p=0.938, p=0.453 and p=0.5 for the first sensation, urgency or intense urgency, respectively).

Conclusion

Our results show that parity significantly affects basal anal tone in women who have more than three children. We found no relationship of parity to other parameters, which could be due to a relatively small number of patients investigated. There is also a high need to incorporate other variables which potentially alter anal sphincter function such as is the age at delivery, fetal weight and other comorbidities, mainly spinal injuries throughout life and obstetric tears.

Introduction

Fecal incontinence is a diagnosis represented by recurrent uncontrolled passage of fecal material for at least 3 months. It is relatively common, with an assumed prevalence of up to 7% of the worldwide population. The therapy is challenging and often with insufficient clinical results. It should be specifically tailored to different symptom presentations meaning urge or passive incontinence. One of the relatively and therefore not widely used treatment options for incontinence is local sphincter stimulation which is a safe non or minimally invasive method. This stimulation could be performed in at home setting, so it presents a substantial time and cost-saving option for the patient and for the healthcare system. However, the data published on this topic so far are scarce with heterogeneous studied populations and results with no universally accepted treatment protocol.

Aims & Methods

This study aims to evaluate the effect of local sphincter stimulation on the functional parameters of sphincters and symptoms based on the different phenotypes. This is a retrospective single-center study analysis on patients with fecal incontinence (age> 18 years). The duration of the training was 12 weeks, with training once daily for 6 days a week. The parameters of the home stimulation device were as follows: Frequency: 40 Hz; Impulse Width: 0.2 s; Ramp-up time: 1s; Workout time: 6s; Rest: 15s. Training duration: 20min. During the perceived stimulation patients were instructed to squeeze the sphincter. 3D anorectal manometry was performed according to the IAPWG protocol at the initiation visit and the control visit. Clinical evaluation was performed by self-reporting Wexner’s score for fecal incontinence at both visits.

Results

Twenty-three patients (23) were consecutively screened for eligibility and assigned for the therapy. Three patients (3) did not adhere to the training due to various personal reasons one (1) patient did not tolerate stimulation. Therefore, 19 patients (10 passive, 9 urge) completed the full treatment protocol for 12 weeks and were considered for the final analysis. The total average increase in sphincter rest medium pressure was 22.53%, with significantly higher improvement in the urge group compared to the passive group (46.24% vs. 1.18% respectively). The total average increase in sphincter rest maximum pressure was 25.69%, with significantly higher improvement in the urge group compared to the passive group (46.92% vs. 6.59% respectively). The total average increase in sphincter maximum squeeze pressure was 36.13%, with significantly higher improvement in the urge group compared to the passive group (57.82% vs. 16.61% respectively). The average improvement in Wexner score was 3.1 points, with higher improvement in the urge group compared to the passive group (4.2 points vs. 2.1 points respectively).

Conclusion

The home-administered local anal sphincter stimulation for 12 weeks seems to be an effective treatment option for both types of fecal incontinence and significantly more effective in the urge type. Therefore this could be considered as a cost and time-effective treatment option compared to standard office-based therapy. Although a home stimulation device is simple to use, the ability of the patient to adhere to the protocol should be evaluated during the screening process.
Funding: European Parliament and Council Recovery and Resilience Plan of the Slovak Republic 2021 – 2027, code: 09I03-03-V04-00761

Introduction

Gastrointestinal (GI) symptoms and their relationship with measures of GI function are incompletely understood.

Aims & Methods

We included patients investigated with OATT by use of radiopaque markers (ROM) between 2000 and 2022; one clinical audit cohort investigated because of disturbed bowel habits, and a cohort from IBS trials. In the clinical audit cohort, information on bowel habits were retrieved from referral notes and severity of abdominal pain, bloating and flatulence were rated daily by the patients during the week of the OATT measurement. In IBS patients, information on IBS subtype (IBS-C, IBS-D, IBS nonCnonD), severity of GI symptoms (GSRS), and stool frequency and consistency (Bristol stool form) from stool diaries were available. The aim of this study was to assess the outcome of oro-anal transit time (OATT) investigations in patients with disturbed bowel habits and its association with GI symptoms.

Results

We included 1142 patients (75% females) with a median age of 37(range 20-65) years with bowel symptoms. In the clinical audit cohort, slow transit was most common among patients with constipation (41%), whereas rapid transit was most frequent in patients with diarrhea (32%). In line with this, slow transit was predominantly seen in IBS-C (17%) and rapid transit in IBS-D (30%). However, in both cohorts, normal transit was most frequent.
Among patients in the clinical audit cohort, a positive correlation between OATT and the severity of bloating (r=0.17, p<0.001) was seen, but there was no association with abdominal pain (r=0.02, p=0.72) or flatulence (r=-0.10, p=0.07). In IBS patients, inverse correlations were seen between OATT and stool consistency (r=-0.38, p<0.0001), and frequency (r=-0.32, p<0.0001). In line with this, OATT was associated with the severity of diarrhea (r=-0.16, p<0.05), and constipation (r=0.27, p<0.001). In addition, a weak, but significant association was seen with satiety (r=0.16, p<0.05) but not with abdominal pain (r=0.06; p=0.23) or bloating (0.08; p=0.09).

Conclusion

Abnormal OATT is prevalent among patients with disturbed bowel habits and is a pathophysiologic mechanism of importance for the understanding of stool frequency and consistency, and the severity of diarrhea and constipation but less so with other GI symptoms.

Introduction

High-resolution anorectal manometry (HRAM) is the most commonly used technique for studying functional anorectal disorders, including chronic constipation. However, alterations in the defecatory maneuver are inconclusive for diagnosing defecatory dysfunction, necessitating additional confirmatory testing. The study of the geometry and distensibility of the anal canal may be useful in evaluating patients with chronic constipation.

Aims & Methods

To evaluate the manometric characteristics and anal canal distensibility in patients with chronic constipation compared to a control group of healthy volunteers (HV). The study included 15 healthy controls and 11 patients with chronic constipation. All participants underwent HRAM (Medtronic®), EndoFLIP (Medtronic®), and the balloon expulsion test (BET; Matla Systems®). HRAM was performed according to the London protocol. Distensibility index (DI) values were calculated at rest, during voluntary contraction (VC), and during the defecatory maneuver (DM) with volumes of 30, 40, and 50 mL.

Results

The mean age was 32.4 ± 12.8 in HV and 45.2 ± 12.4 in patients with CC (p = 0.012). Most patients with CC were women, 10 (90.9%). Among CC patients, 9.1% had stool consistency classified as Bristol 3-4 compared to 95% of HV (p < 0.001). The defecatory pattern was < 3 weekly bowel movements in 54.5% of CC patients. Obstructive defecation perception predominated in 7 patients (66.7%), while 1 (9%) had slow transit, and 3 (27.3%) had obstructive defecation and fecal incontinence (multiple sclerosis). All HV had normal BET, with a mean balloon expulsion time of 13.3 ± 10.4 seconds.
The HRAM findings revealed that the percentage of anal relaxation was 31.2 ± 18 in HV and 7 ± 23 in CC patients (p < 0.001). The rectoanal gradient (RAG) measured -28.3 ± 25 in HV and -51.5 ± 36.8 in CC patients (p = 0.06). Significant differences in rectal sensitivity were observed between CC patients and HV. The first sensation threshold was 50.5 ± 25.2 mL in HV compared to 87.3 ± 47.9 mL in CC patients (p = 0.018). Similarly, the urge threshold was 126.8 ± 35.4 mL in HV versus 177.5 ± 44 mL in CC patients (p = 0.004). The maximum tolerated volume also differed, recorded as 157.5 ± 37.9 mL in HV and 224.3 ± 60.3 mL in CC patients (p = 0.008).

EndoFlip results are presented in Table 1. The DI demonstrated better diagnostic performance than HRAM defecatory parameters for predicting balloon expulsion: DI-30 mL: 0.850; 95% CI: 0.701–0.999 (p=0.011); DI-40 mL: 0.817; 95% CI: 0.602–1 (p=0.021); DI-50 mL: 0.775; 95% CI: 0.525–1 (p=0.045); % anal relaxation: 0.742; 95% CI: 0.504–0.980 (p=0.078); RAG: 0.767; 95% CI: 0.540–0.993 (p=0.051).

Conclusion

Patients with chronic constipation exhibit significant differences in HRAM defecatory parameters and rectal sensitivity compared to control subjects. Although the sample size of patients with constipation is small, the DI demonstrates superior diagnostic performance compared to HRAM defecatory parameters about the BET.

References

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Disclosure

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Introduction

Fecal incontinence (FI) is a very prevalent health condition, affecting up to 15% of community-dwellers, 24% in the case of women. While the pathophysiological aspects of pelvic biomechanics associated with FI have been extensively studied, recent research has shown that neurophysiological alterations at a higher level (cortical or spinal) can also be present. The neurophysiology of the entire cortico-anal motor pathway and its possible dysfunction in FI is rather unknown.

Aims & Methods

To characterize the integrity of the cortico-spino-anorectal efferent pathways in women with FI, and compare them with age-matched healthy volunteers (AM-HV), and young nulliparous healthy volunteers (Y-HV), 18-35 years of age.
Observational study on 18 women with FI and a mean age of 63.4±11.5 years in whom sphincter function and structure were assessed with high-resolution anorectal manometry (HRAM) and endoanal ultrasound (EUS); neurophysiology was assessed by pudendal nerve terminal motor latency (PNTML) and anal and rectal motor evoked potentials (MEP) after transcraneal and translumbosacral magnetic stimulation (TMS and TLSMS) (efferent pathways). The main parameters evaluated were PNTML latency/amplitude of the action potential; and latency and amplitude of the anorectal MEPs in the cortico-ano-rectal segment, and lumbo-ano-rectal and sacro-anorectal segments, on both sides. In addition, the neurophysiology of a cohort of 15 AM-HV (60.7±9.01 years old) and 15 Y-HV (24.8±5.59 years old) was also studied.

Results

a) Structure and function. HRAM: 83.24% of patients with FI had impairment of the external anal sphincter (EAE), 40% of the internal (IAS), and 23.57% of both. EUS: 11.76% had injuries on the puborectalis, 58.82% showed tears in the EAE and 11.76% IAS disruptions.
b) Neurophysiology. Efferent motor pathways: mean left PNTML of the patients was 2.37±0.32; for HV was 2.29±0.29, and for YHV 1.9±0.33 (significant between patients and YHV; p<0.05). Right PNTML was 2.11 ± 0.34 and 2.14 ± 0.41 for patients and HV, respectively (ns). Among the patients, 20% showed motor neuropathy in at least one branch of the pudendal nerve. Motor pathways (MEP): Patients showed longer MEPs latencies compared to HV in several neural segments (cortico-spinal, lumbo-anal right, Lumbo-rectal right, and Sacro-anal right; (p<0.05). We also found statistically significant differences between all sacral segments between HV and YHV. Taking the reference values from HV, 50% of patients with FI had impairments in the cortico-spinal segment, also 50% in the lumbo-anal and 44.4% in the sacral segment. Overall, we found that 82.4% of patients showed delayed latencies in at least one of the cortico-ano-rectal segments studied.

Conclusion

We found a high prevalence of motor efferent cortico-ano-rectal pathway impairments in women with FI, with delayed latencies in most segments, beyond the pelvic floor. These findings suggest a complex pathophysiology of FI, which involves impairment of neural pathways at a higher level. Future treatment strategies based on neural stimulation at cortical or spinal level might be key in the rehabilitation of these patients.

Introduction

Fecal incontinence (FI) has a strong impact on quality of life (QoL). The main treatments focus on the rehabilitation of anorectal function. In a previous study we found that sphincter dysfunctions were severe and similar in patients with or without soft stools, but their presence worsened clinical severity and QoL significantly, requiring a specific diagnostic and therapeutic approach. FI and diarrhea are strongly associated, and treatment of the latter may be an effective method to ameliorate FI. Some studies show that loperamide or fiber supplements in these patients is effective at least in the short term, although effective long-term and specific treatments aimed at the cause of diarrhea need to be identified.

Aims & Methods

To assess the impact on clinical severity and QoL of specific treatments for soft stools or diarrhea in patients with FI and diarrhea.
Quasi-experimental study. We assessed anorectal function with high-resolution anorectal manometry, fecal consistency (Bristol Stool Chart), clinical severity (Wexner Score) and QoL (FIQL/EQ5D) in women with FI, and feces with Bristol≥5; patients underwent a breath-test to detect lactose, fructose/sorbitol malabsorption and SIBO, as potential causes of diarrhea, and an empirical test using cholestyramine to assess the presence of malabsorption of bile salts. Patients with SIBO were treated with Rifaximin 1200mg/day for 15 days. Those intolerant to lactose and fructose/sorbitol were given an exclusion diet. Those who did not show intolerances were administered Resincholestyramine 4g/12 hours for 15 days. Bristol, QoL and clinical severity were re-assessed in a follow-up visit one month later.

Results

Seventy-four women with FI and soft stools completed the study; mean age was 64.92±11.70 years. Of them, 59.18% had dysfunction of the external anal sphincter, 51.02% of the internal sphincter and 15.59% of both. Rectal hypersensitivity was shown in 12% of patients and 20% had hyposensitivity. Cough reflex was altered in 41.7%. Regarding the origin of the diarrhea, 43.9% showed bile salt malabsorption, 26.6% fructose/sorbitol intolerance, 17.1% SIBO and 12.2% lactose malabsorption. After one month of specific pharmacological treatment or exclusion diet we observed that 92.9% of the patients improved fecal consistency (Bristol 3-4). Clinical severity (Wexner) was reduced by 66% (11.61±3.64 pre-treatment vs 3.89±4.05 post-treatment; p<0.001). QoL improved in all dimensions of the FIQL score (pre/post-treatment): Lifestyle (2.69±0.91/3.40±0.72 p<0.01), coping (2.32±0.88/3.03±0.78 p<0.01), depression/self-perception (2.77±0.70/3.33±0.56 p<0.01) and embarrassment (2.77±0.90/3.33±0.77 p<0.01). Health perception (EQ5D) also improved after the treatment (61.96±15.91/70±7.39 p=0.017).

Conclusion

Presence of soft stools or diarrhea is a very prevalent and important risk factor in women with IF in addition to sphincteric and anorectal alterations. Our findings suggest that specific treatment aimed at the cause of diarrhea can be highly effective in improving patient outcomes and QoL, regardless of disorders of the anorectal function. We suggest that rehabilitation strategies must start after stool assessment. This study highlights the importance of continued research in this area to help improve treatment options for this debilitating condition.