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.

Introduction

Fecal incontinence is a diagnosis represented by recurrent uncontrolled passage of fecal material for at least 3 months. Although there are no sufficient data, based on large-community studies, FI is relatively common, with prevalence up to 7% of population worldwide. The therapy of fecal incontinence should be specifically tailored to each individual symptom presentation of the patients. One of the treatment options for incontinence is biofeedback training.
As office biofeedback is often time consuming and comes with substantially high cost there is an emerging trend of home biofeedback administration. However, only few studies considering this new approach were published so far and without consideration of commercially available biofeedback devices. Also, there are no relevant data published regarding the efficacy of commercially available devices.

Aims & Methods

The aim of this study is to evaluate the feasibility and efficacy of commercially available biofeedback devices. We performed a prospective single center study on patients with fecal incontinence (age> 18 years). The duration of the training was 12 weeks, with training twice (2) daily for 5-6 days a week. Two types of biofeedback devices were used, both with the application of local electric stimulation of sphincters during the training. Parameters for device one were: Frequency: 40 Hz; Impulse Width: 0.2 s; Ramp up time: 1s; Work out time: 6s; Rest: 15s;Training duration: 20min.Parameters for the second device: Continual stimulation with 35 Hz, 0.33 impulse width followed by workout: Frequency: 30 Hz; Impulse Width: 0.25 s; Ramp up time: 0.3s; Work out time: 5s; Ramp down time: 0.3s; Rest 5 s. Training duration: 6+20 min. 3D anorectal manometry was performed according to the IAPWG protocol at the initiation visit and at the control visit. Clinical evaluation was performed by self-reporting Wexner score for fecal incontinence at both visits.

Results

Twenty-seven patients (27) were randomly assigned either to device No. 1 or No.2. Two patients did not attend the control visit for unknown reasons and one patient stop the study because of adverse event (pain in rectum and worsening of the incontinence). Two patients did finish the study but did not attend the planned clinical control in the predefined date due to travel reasons and thus were excluded from the evaluation. Thus, twenty-two patients (22) were considered for the final evaluation. Average increase of sphincter rest medium pressure was 11.45% and average increase of maximum sphincter pressure was 26.1%. The absolute pooled average of the cohort for maximum voluntary pressure was significantly higher after the therapy compared to basal values (135.82 mmHg vs. 110.13 mmHg, p<0.05). This was not observed in the case of rest pressure (54.88 mmHg vs. 57.72 mmHg). The average improvement of Wexner score was 1.7 points and was statistically significant (p<0.05).

Conclusion

To our current knowledge this is a first study evaluating commercially available home biofeedback devices for fecal incontinence and one of few for home biofeedback devices in the defecation disorders generally. Here presented data shows the feasibility and safety of the home biofeedback device for the treatment of fecal incontinence as there was only one mild adverse event recorded. Efficacy is shown by significant improvement of the maximum voluntary sphincter pressure. Based on these results a randomized, double-blind study will be performed to further explore and evaluate the efficacy of the different devices.

Introduction

Pelvic floor dysfunction is highly prevalent. Posterior compartment disorders include fecal incontinence (FI) and obstructive defecation syndrome (ODS). Assessment of the sphincter complex's (SC) ability to resist or yield to distension may provide a valuable method for evaluating continence and defecatory function.

Aims & Methods

Women with FI, chronic constipation (CC) and suspected functional defecation disorder (FDD), as well as healthy volunteers (HV) were included. Impedance Planimetry (IP) was performed using the anal functional lumen imaging probe [EndoFLIP^TM System (Medtronic®) with an 8-cm catheter (EF-325N)]. A “stepwise” measurement protocol was applied, with bag filling from 0 to 50ml in 10-ml increments. Distensibility index (DI) was recorded at rest, voluntary squeeze, cough maneuver and during simulated evacuation at 30-, 40- and 50-ml volumes. Simulated defecation was evaluated by calculating the percentage change in the DI relative to resting values at each volume.

Results

Fifteen women were included: 4 HV (26.7%), 7 with FI (46.7%) and 4 with CC (26.7%). Women with FI were older than those in the CC and HV groups (median age: FI 72 years [66–75], CC 55 years [42-63], HV 48 years [ 43–53], p = 0.009. Median BMI was similar among groups [HV 24.0 Kg/m² (21.6 – 25.3), FI 27.0 Kg/m² (24.3 – 30.0) and CC 26.2 Kg/m² (21.5 – 30.5), p=0.367]. The DI was significantly higher in the FI group compared to CC and HV groups at rest, during squeeze and during cough maneuver across 30-, 40- and 50-ml volumes. The percentage change in DI during simulated defecation at 50 ml was significantly reduced in CC compared to HV (p=0.030). When groups were categorized based on suspected FDD (CC vs HV+FI), the percentage change in DI was significantly lower in CC at 40 ml [74% (37 – 109) vs 175% (100 – 250), p=0.037] and at 50 ml [81% (43 – 96) vs 111% (96 – 119), p=0.048].

Conclusion

Impedance planimetry proves to be a valuable tool for distinguishing pelvic floor dysfunctions, as women with FI show higher DI values, whereas those with suspected FDD exhibit reduced DI changes during simulated defecation. These findings support the hypothesis that impaired rectal distensibility is a key feature of FDD, highlighting its role in continence and evacuation disorders.

References

-Leroi AM, Melchior C, Charpentier C, et al. The diagnostic value of the functional lumen imaging probe versus high-resolution anorectal manometry in patients with fecal incontinence. Neurogastroenterol Motil. 2018;30(6):e13291. doi:10.1111/nmo.13291
-O'Connor A, Byrne CM, Vasant DH, et al. Current and future perspectives on the utility of provocative tests of anal sphincter function: A state-of-the-art summary. Neurogastroenterol Motil. 2023;35(7):e14496. doi:10.1111/nmo.14496

Introduction

Faecal incontinence (FI) is prevalent, being associated with a high biopsychosocial burden and considerable health costs. The pathophysiology of FI is varied and often multifactorial, representing a diagnostic and therapeutic challenge. Anorectal manometry is the first recommended diagnostic method, although its utility is debatable due to overlapping findings between healthy individuals and patients.

Aims & Methods

The aim of this study is to establish a relationship between FI clinical presentation, manometric findings, and imaging.
We prospectively included all patients undergoing high-resolution anorectal manometry, according to the London protocol, at a tertiary centre, who agreed to respond to a questionnaire to characterize their FI, between August 2021 and March 2023. Clinical records were consulted, in order to access demographic data and past imaging reports. Statistical analysis was performed using IBM SPSS Statistics version 26®.

Results

Forty-seven patients were included with a mean age of 63.5±11.6 years, 87.2% women, of whom 73.2% had an obstetric history. Depressive/anxious symptoms were described in 59.6%, previous perineal surgery in 38.3%, and concomitant urinary incontinence in 40.0%. Mean FI duration was 5.4±5.2 years, with 51.1% reporting daily complaints and a bowel movement median of 2.0 (IQR 3.0). Males tended to have more bowel movements than females (3.5 (IQR 5.0) vs 2.0 (IQR 2.0); p-value 0.03). FI for flatus and faeces was present in 57.4%, for faeces alone in 34.0%, and for flatus alone in 8.5%. Urgency FI was verified in 37.0%, passive FI in 37.0%, and mixed FI in 26.1%. Mean Wexner score was 10±5. Rectal examination revealed hypotonicity in 15.9%. Mean resting pressure on anorectal manometry was 55.9±22.5 mmHg, dyssynergy was identified in 16.7% and altered balloon expulsion in 19.5%. The mean value of first sensation, first urge to defecate, and maximum tolerated volume were within the normal range. Imaging was performed in 19 patients (40.4%), with external anal sphincter injury in 15.8% and internal sphincter injury in 10.5%. Mean thickness of the internal anal sphincter (IAS) was 2.3±1.0 cm. Patients with hypotonicity in rectal examination had lower anal resting pressure (35.7±16.0 mmHg vs 60.3±22.4 mmHg; p-value 0.09) and lower IAS thickness (1.6±0.8 mm vs 2.6±0.9 mm; p-value 0.07), although not statistically significant. Patients with depressive/anxious symptoms showed lower maximum incremental pressure (56.6±34.0 mmHg vs 81.2±46.2 mmHg; p-value 0.045), as well as females when compared to males (60.0±34.9 mmHg vs 108.7±53.2 mmHg; p-value 0.005). No other statistically significant results were found, especially correlating clinical findings with manometry or imaging.

Conclusion

Our study showed, as previously replicated, that clinical, manometric and imaging findings have low correlation in the assessment of FI, reflecting its pathophysiological complexity.

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