Targets for interventions for faecal incontinence in inflammatory bowel disease: a systematic review (original) (raw)
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Faecal incontinence in inflammatory bowel disease: Associations and effect on quality of life
Background and aims: No previous study has reported on faecal incontinence (FI) amongst people with IBD. We aimed to determine the frequency and severity of FI in people with IBD, its association with known FI risk factors, and the effect on quality of life. Method: We randomly sampled 10,000 members of a national Crohn's and Colitis organisation over 18 years old. Demographic information, medical history, FI (ICIQ-B), urinary continence (ICIQ-UI), quality of life (IBD-Q) and free text responses about FI were collected. Current disease activity was reported using the Harvey Bradshaw Index for Crohn's Disease (CD), and the Walmsley Index for ulcerative colitis (UC). Data were managed using Excel, Stata and SPSS 18. Results: 4827 responses were received: 3264 were complete and included (32.6% response). 2178 respondents were female (66.7%); mean age 50.26 yrs (range 19–92); CD 1543 (46.98%); UC 1599 (48.97%); other IBD 126 (3.85%); no diagnosis given 6 (0.18%). 74% (2391) of respondents reported FI (95% CI 72–75). Nine percent (299) reported regular FI. No association was found between FI and diagnosis. Significant associations were found in multivariable analysis between FI and age (p = 0.005), gender (p b 0.001), anal stretch (p= 0.004), anal fistula surgery (p b 0.001), colo-rectal surgery (p = b 0.001), and urinary incontinence (p = b 0.001), but not with vaginal delivery. Quality of life was significantly affected by FI (p b 0.001).
Gut
procedures. Compliance rates increased in medical endoscopies to 79% (v 32%), nurses 63% (v 37%) compared to the previous audit. Dysplasia was found in 10 of the 87 cases. 8 showed low grade dysplasia in tubular adenomas, 1 was high grade dysplasia in DALM discovered using chromoendoscopy and colectomy was performed. Low grade dysplasia was also identified in one patient and they are awaiting discussion about colectomy. Conclusion There has been a significant improvement in adherence to current guidelines after dissemination of this information to the relevant clinicians. The use of chromoendoscopy has been successfully adopted in a significant number of patients. Streamlining of procedures to endoscopists with an interest in IBD surveillance has added to the improved compliance with guidelines but there are still a number of procedures performed outwith guidelines likely in part due to the 'generic pooling' of endoscopy lists. The setting up of specific surveillance lists may improve compliance and chromoendoscopy rates further. Disclosure of Interest None Declared.
Inflammatory Bowel Diseases
Background: Patients with inflammatory bowel disease (IBD) often experience functional bowel symptoms despite achieving disease remission. Although behavioral treatment (bowel and pelvic floor muscle retraining) is effective for managing constipation or fecal incontinence in non-IBD patients, there is limited evidence for its efficacy in patients with quiescent inflammatory bowel disease. The aim of this study was to evaluate the outcome of gut-directed behavioral treatment, including pelvic floor muscle training, for symptoms of constipation or fecal incontinence in patients with IBD in disease remission. Methods: The outcome of consecutive patients with IBD in remission and symptoms of constipation or fecal incontinence was evaluated. Patients referred to a multidisciplinary gastroenterology clinic underwent gut-directed behavioral treatment, including pelvic floor muscle training. The primary outcome was patient-reported rating of change in symptoms on a 7-point Likert scale at the completion of treatment. Results: Forty IBD patients (median age, 35 years; 80% female; 24 Crohn's disease [CD], 12 ulcerative colitis [UC], 4 UC with ileoanal pouch) with ongoing symptoms of constipation (55%) or fecal incontinence (45%), despite drug therapy, were included. The median symptom duration at referral was 2 years. Thirty-five (87%) completed treatment with a median of 2 sessions. Improvement of "6 = much better" or "7 = very much better" was reported by 77% (17/22) with fecal incontinence and 83% (15/18) with constipation. Improvement occurred irrespective of IBD diagnosis, previous perianal fistulae, colorectal surgery, presence of an ileoanal pouch, or past obstetric trauma. Conclusions: Behavioral treatment effectively improves functional gut symptoms in a large majority of patients who are in IBD disease remission and who have not responded to drug therapy.
Background: Inflammatory bowel disease, comprising Crohn's disease and ulcerative colitis, is a lifelong currently incurable illness. It causes bouts of acute intestinal inflammation, in an unpredictable relapsing-remitting course, with bloody diarrhoea and extreme urgency to access a toilet. Faecal incontinence is a devastating social and hygiene problem, impacting heavily on quality of life and ability to work and socialise. Faecal incontinence affects 2–10 % of adults in the general population. People with inflammatory bowel disease have a high risk of incontinence with up to 74 % affected. No previous study has explored conservative interventions for these patients. Methods: This randomised controlled trial will recruit 186 participants to answer the research question: does implementation of the UK nationally recommended guidance approach to stepwise management of faecal incontinence improve bowel control and quality of life in people with inflammatory bowel disease? We have worked with people with inflammatory bowel disease to translate this guidance into a condition-specific information booklet on managing incontinence. We will randomise participants to receive the booklet, or the booklet plus up to four 30-minute sessions with an inflammatory bowel disease specialist nurse. To be eligible, patients must be in disease remission and report incontinence. The primary outcome measure at 6 months after randomisation is the St Mark's incontinence score. Other outcomes include quality of life, MY-MOP (generic tool: participants set two goals for intervention, grading goals at baseline and then re-scoring after intervention) and EQ-5D-5 L to enable calculation of quality-adjusted life years. Analysis will be on an intention-to-treat basis. Qualitative interviews will explore participant and health professionals' views on the interventions.
Acta Chirurgica Belgica, 2019
Aim: To perform a review of the literature reporting on randomised controlled trials (RCTs) comparing treatments for faecal incontinence (FI) in adults. Methods: A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify RCTs reporting on treatments for FI. Results: The review included 60 RCTs reporting on 4838 patients with a mean age ranging from 36.8 to 88 years. From the included RCTs, 32 did not identify a significant difference between the treatments compared. Contradictory results were identified in RCTs comparing percutaneous posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation versus sham stimulation, biofeedback-pelvic floor muscle training (BF-PFMT) versus PFMT, and between bulking agents such as PTQ TM versus Durasphere V R. In two separate RCTs, combination treatment of amplitude-modulated medium frequency stimulation and electromyography-biofeedback (EMG-BF), was noted to be superior to EMG-BF and low-frequency electrical stimulation alone. Combination of non-surgical treatments such as BF with sphincteroplasty significantly improved continence scores compared to sphincteroplasty alone. Surgical treatments were associated with higher rates of serious adverse events compared to non-surgical interventions. Conclusions: The current evidence has not identified significant differences between treatments for FI, and where differences were identified, the results were contradictory between RCTs.
Faecal incontinence—the hidden scourge of irritable bowel syndrome: a cross-sectional study
BMJ Open Gastroenterology, 2014
Objective: Faecal incontinence (FI) is a devastating condition which is well recognised in the elderly and those with certain conditions such as inflammatory bowel disease. However, there is surprisingly little information on its prevalence in irritable bowel syndrome (IBS), especially in relation to bowel habit subtype, and this study aimed to answer this question. Design: 500 consecutive new and follow-up secondary care IBS outpatients (399 female, 101 male, age range 15-87, mean age 46) fulfilling Rome III criteria without any significant concomitant disease were studied. They completed a series of questionnaires documenting FI, IBS severity, IBS subtype, non-colonic symptoms, quality of life, anxiety, depression and any other factors that might be associated with FI. Results: 285 patients (57%) reported FI, which was mild in 68 (23.9%), moderate in 99 (34.7%) and severe in 91 (31.9%) and in response to laxatives in 27 (9.5%) with an equal prevalence in males and females. The prevalence of FI in patients classified as having mild, moderate or severe IBS was 62%, 49.5% and 61%, respectively. The prevalence of incontinence was 65.2% in diarrhoea IBS, 63.7% in alternating IBS and, surprisingly, 37.9% in constipation IBS, where it was in response to laxatives in 35.8%. Compared to continent patients, those with FI had a significantly higher prevalence of urinary incontinence, previous abdominal surgery, pregnancy and vaginal as opposed to caesarean delivery. 23.3% had not disclosed their incontinence to anyone and only 50.6% had told their general practitioner. 66% always carried a change of clothes and 30% used incontinence pads on a regular basis. Conclusions: The prevalence of FI in these relatively young patients approached that observed in elderly care homes. Hopefully, recognition of this problem will lead to improved management and reduce the trivialisation that unfortunately still continues to surround this condition.
Epidemiology of faecal incontinence in selected patient groups
International Journal of Colorectal Disease, 1991
It is known that only a minority of patients with faecal incontinence report these symptoms to their physicians. Epidemiological estimates based on medical chart data, therefore, may contain a detection bias. To evaluate such bias in epidemiological data, we evaluated prospectively the presence of faecal incontinence in selected patient groups with a proven high incidence of such symptoms and compared it to the incidence in a group of healthy controls. If the patient acknowledged faecal incontinence in the questionnaire, the medical chart was checked to see if these symptoms had been noted during previous work-up; this was used to estimate the number of unregistered cases if the epidemiological estimate is based on medical chart data. The incidence of incontinence was significantly elevated in all patient groups as compared to the controls, but only up to 5% of patients with faecal incontinence, regardless of the underlying mechanism, had these incontinence symptoms noted in the medical charts. We conclude that for the estimation of the prevalence and incidence of faecal incontinence, data from medical charts contain a detection bias which systematically underestimates the real presence of faecal incontinence. R~sum& On sait que seulement une minorit6 de patients atteints d'incontinence f6cale d6clarent ces symptomes fi leur m+decin. Les 6tudes 6pid6miologiques bas6es sur les dossiers m6dicaux, par cons6quent, contiennent un biais de recrutement. Pour +valuer un tel biais dans les 6tudes 6pid+miologiques nous avons +valu6 prospectivement la pr6sence d'une incontinence f+cale dans des groupes de patients s~lectionn6s avec une incidence 61ev6e prouv6e de tels symptomes et compar~e avec la m~me incidence dans un groupe de contr61es sain. Si le patient avouait une incontinence f6cale dans le questionnaire, le dossier mbdical btait &udi~ pour savoir si ces symptomes avaient +t6 notes au cours de l'6tude pr6c6dente; ceux ci 6taient utilis6s pour 6valuer le nombre de cas non enregistr+s si Supported by a grant from the Deutsche Forschungsgemeinschaft (Er 142/1) une estimation 6pid~miologique est bas~e sur les dossiers m6dicaux. L'incidence d'incontinences ~tait significativement 61ev6e chez tousles groupes de patients compar6s aux contr61es, mais seulement 5% des patients avec une incontinence f~cale, quelle qu'en soit le m~canisme, avaient ce syndrome d'incontinence not6 dans leur dossier m6dical. Nous concluons que pour une estimation sur le pr6valence et l'incidence d'une incontinence f6cale les 6lbments du dossier m6dical contiennent un biais de d6tection qui sous-estime syst6matiquement la prbsence effective d'une incontinence f~cale.
Advances in Clinical and Experimental Medicine, 2018
Background. Crohn's disease (CD) and ulcerative colitis (UC) typically clinically manifest with symptoms like chronic diarrhea, cramps, abdominal pain, and rectal bleeding. However, symptoms of abnormal anorectal function seem to be of equal importance, regardless of the presence or absence of perianal disease. Objectives. The aim of this study was to assess stool patterns and the prevalence of symptoms of disordered anorectal function, particularly urgency and fecal incontinence, and their severity in patients with inflammatory bowel diseases (IBDs). Material and methods. Thirty-three patients with CD and 38 patients with UC completed a questionnaire. A push/strain maneuver was performed on all patients and 20 controls. Results. Thirty-three patients had more than 3 bowel movements a day; 44 had loose/watery stools. Two patients had fewer than 3 bowel movements a week, 8 had hard/lumpy stools, and 3 used laxatives. Excessive straining and incomplete evacuation were reported by 17 and 38 patients, respectively. Fifty-two patients complained of urgency and 32 of tenesmus. Significantly, more UC patients than CD patients had urgency at least once a day (p < 0.04). The following symptoms were reported by patients in the following numbers: fecal incontinence (31), passive (20) and urge incontinence (16), incontinence to gas (24), as well as liquid (33) and solid stool (7). Stool/gas discrimination was defective in 28 patients. Eleven patients had to wear pads. Everyday functioning was worsened because of urgency/tenesmus in 39 patients and because of fecal incontinence in 28 patients. The push/strain maneuver was abnormal in 12 patients with CD, 15 patients with UC and 1 control subject. The differences between the 2 study groups and the controls were significant (p < 0.03 and p < 0.01). Conclusions. A majority of patients with IBD complain of urgency. Fecal incontinence is reported by over 50% of patients. Both worsen patients' everyday functioning. A relevant proportion of patients have symptoms consistent with constipation, which is in connection with an abnormal push/strain maneuver in more than 1/3 of them.