Reduction In Fecal Incontinence Episodes Research Articles

The Long-term Outcomes of Sacral Neuromodulation for Fecal Incontinence: A Single Center Experience.

Sacral neuromodulation is an effective treatment for fecal incontinence. This study aimed to assess the long-term outcomes of sacral neuromodulation and establish the outcomes of patients with inactive devices. This is an observational study of patients treated for more than 5 years. A positive outcome was defined as a >50% reduction in fecal incontinence episodes or improvement in a symptom severity score. Data were reviewed from a prospectively managed database. This study was conducted at a single tertiary referral center. Data from 74 patients (72 female) were available at long-term follow up. Bowel diary, St. Mark's incontinence score, and Manchester Health Questionnaire data were prospectively recorded at baseline, after peripheral nerve evaluation, and at last follow-up. Patients were analyzed in cohorts based on time since sacral neuromodulation implantation: Group 1: 5-10 years (n = 20), Group 2: >10 years (n = 35), and Group 3: inactive SNM devices (n = 19). Median St. Mark's incontinence score and Manchester Health Questionnaire improved from baseline to last follow-up in Group 1 (p ≤ 0.05) and Group 2 (p ≤ 0.05), but in Group 3 results returned to baseline levels at last follow-up. Similarly, weekly fecal incontinence episodes improved in both active device groups at last follow-up. However, in Group 3 incontinence episodes were no different from baseline (p = 0.722). Despite active devices, fecal urgency episodes increased at last follow-up after more than 10 years since peripheral nerve evaluation (p ≤ 0.05). Complete continence was reported by 44% of patients, and at least a 50% improvement in 77% with active devices. This study is retrospective with some gaps in the available data at last follow-up. Sacral neuromodulation is an effective treatment for fecal incontinence in the long term, but all outcomes are adversely affected by device inactivity. Therefore, ongoing stimulation is required for continued benefit..

Non-retentive faecal incontinence in children: Conventional therapy alone or combined electrical stimulation.

To compare the effects of functional electrical stimulation (FES) with conventional therapy and conventional therapy alone on improvement of faecal incontinence (FI) symptoms in a number of children with functional non-retentive FI. Data of 28 children with FI were accepted for this retrospective study. The case group (n= 14) underwent FES + conventional therapy and the control group (n= 14) received conventional therapy only. Data of children with faecal retention, inflammatory, anatomic, metabolic and neurological disorders were excluded. Children were assessed with a paediatric FI score questionnaire, and a bowel habit diary both before treatment sessions, after they ended, and after 6 months. A FI quality of life questionnaire was completed before and after treatment for all children. Full response to the treatment (100% reduction in FI episodes) was significantly observed in 8/14 (57.1%) of children in the case group compared to 2/14 (14.2%) of children in the control group after the ending of treatment sessions (P= 0.005). The baseline mean ± SD of FI episodes per week was 3.7± 2.1 among both groups which significantly decreased after the ending of treatment sessions in the case group compared to the control group (1.4± 2.1 vs 3± 2.7; P= 0.05). Mean ± SD of FI score was significantly reduced in the case group compared to the controls after the ending of treatment sessions (3.9± 4.5 vs 8± 4.7; P= 0.02) and maintained after 6 months (P= 0.05). Functional electrical stimulation is a safe, effective, non-invasive, inexpensive, reproducible and easy-to-use modality for treatment of functional non-retentivefaecal incintinence in children.

Efficacy of Posterior Tibial Nerve Stimulation in the Treatment of Fecal Incontinence: A Systematic Review.

Fecal incontinence is a condition that carries high social stigmatization and a determining factor in the quality of life of the person who suffers from it. Its etiology is multifactorial and treatment includes surgical and conservative measures, including stimulation of the posterior tibial nerve. The aim of this review is to determine whether posterior tibial nerve stimulation (PTNS) is more effective than other treatments in reducing episodes of fecal incontinence in adults. A systematic review of randomized clinical trials that analyzed different approaches and comparisons with other treatments in adults without neurological or metabolic diseases was carried out, analyzing, fundamentally, the reduction of episodes of fecal incontinence. In general, a reduction in fecal incontinence episodes is observed in the experimental groups compared with the control groups, although these differences are not significant in most studies. The results regarding the effectiveness of PTNS in reducing episodes of fecal incontinence compared to other treatments are not entirely conclusive, although benefits are observed regarding the stimulation of sacral roots. More well-designed studies with a long-term follow-up of the results are needed so that the recommendation of this treatment can be generalized.

Management of post-surgical faecal incontinence due to anorectal malformations by pelvic floor rehabilitation.

Many patients with anorectal malformations (ARM) experience a long-lasting problem with faecal incontinence (FI). We assessed the effectiveness of a pelvic floor rehabilitation program including transcutaneous functional electrical stimulation (TFES) in combination with pelvic floor muscle (PFM) exercises on post-surgical FI in children with ARM. Data of 40 children at the age of 4 years or older who had undergone surgical correction for ARM and suffered from persistent FI referring for pelvic floor rehabilitation were analysed respectively. Patients underwent TFES and PFM exercises for 20 sessions. TFES was applied for 20-min during each session, two times a week. A paediatric FI score questionnaire and a bowel habit diary were completed both before and after the treatment for all children. We completed a FI quality of life questionnaire before the therapy and again after treatment for all patients. Twenty-two out of 40 (55%) patients responded completely to the treatment (100% reduction in FI episodes) after the completion of treatment sessions, sustained in 19/40 (47.5%) patients after 6months. Mean ± SD of FI score was 4.9± 3.6 at baseline that significantly reduced to 2.4± 1.3 and 2.4± 1.8 after completion of treatment sessions and 6months later, respectively (P< 0.05). Our results show that TFES and PFM exercises have a considerable beneficial impact on post-surgical FI in children with ARM.

A Randomized Pilot Study to Compare the Effectiveness of a Low FODMAP Diet vs Psyllium in Patients With Fecal Incontinence and Loose Stools.

INTRODUCTION:The aim of the study was to compare the effectiveness of a low fermentable oligosaccharide, disaccharide, monosaccharide, and polyol diet (LFD) vs psyllium on the frequency and severity of fecal incontinence (FI) episodes in patients with loose stools.METHODS:This was a single-center, randomized pilot trial of adult patients with FI (Rome III) with at least 1 weekly FI episode associated with loose stool. Eligible patients were randomized to 4 weeks of either a dietitian-led LFD or 6 g/d psyllium treatment.RESULTS:Forty-three subjects were randomized from October 2014 to May 2019. Thirty-seven patients completed the study (19 LFD and 18 psyllium). There was no statistically significant difference in the proportion of treatment responders (>50% reduction in FI episodes compared with baseline) for treatment weeks 1–4 (LFD 38.9%, psyllium 50%, P = .33). Compared with baseline, mean fecal incontinence severity index score significantly improved with LFD (39.4 vs 32.6, P = .02) but not with psyllium (35.4 vs 32.1, P = .29). Compared with baseline values, the LFD group reported improvements in fecal incontinence quality of life coping/behavior, depression/self-perception, and embarrassment subscales. The psyllium group reported improvement in incontinence quality of life coping/behavior.DISCUSSION:In this pilot study, there was no difference in the proportion of patients who reported a 50% reduction of FI episodes with the LFD or psyllium. Subjects in the psyllium group reported a greater reduction in overall FI episodes, whereas the LFD group reported consistent improvements in FI severity and quality of life. Further work to understand these apparently discrepant results are warranted but the LFD and psyllium seem to provide viable treatment options for patients with FI and loose stools.

The short-term effects of posterior tibial nerve stimulation on anorectal physiology in patients with faecal incontinence: a single centre experience.

Background:Posterior tibial nerve stimulation (PTNS) is a novel treatment for patients with faecal incontinence (FI) and may be effective in selected patients; however, its mechanism of action is unknown. We sought to determine the effects of PTNS on anorectal physiological parameters.Methods:Fifty patients with FI underwent 30 min of PTNS treatment, weekly for 12 weeks. High-resolution anorectal manometry, bowel diaries and Vaizey questionnaires were performed before and after treatment. Successful treatment was determined as a greater than 50% reduction in FI episodes.Results:Fifty patients with FI were studied; 39 women, median age 62 years (range 30–82). Compared with pretreatment, there were reductions in episodes of urgency (16.0 versus 11.4, p = 0.006), overall FI (14.5 versus 9.1, p = 0.001), urge FI (5.4 versus 3.2, p = 0.016) and passive FI (9.1 versus 5.9, p = 0.008). Vaizey score was reduced (16.1 versus 14.5, p = 0.002). Rectal sensory volumes (ml) decreased (onset 40.3 versus 32.6, p = 0.014, call 75.7 versus 57.5, p < 0.001, urge 104.1 versus 87.4, p = 0.004). There was no significant change in anal canal pressures (mmHg) (maximum resting pressure 41.4 versus 44.2, p = 0.39, maximum squeeze pressure, 78.7 versus 88.2, p = 0.15, incremental squeeze pressure 37.2 versus 44.1, p = 0.22). Reduction in FI episodes did not correlate with changes in physiological parameters (p > 0.05). Treatment success of 44% was independent of changes in manometric parameters (p > 0.05).Conclusions:PTNS has a measureable physiological effect on rectal sensory volumes without an effect on anal canal pressures. It also reduces FI episodes; however, this effect is independent of changing physiology, suggesting that PTNS has a complex mechanism of action.

Meta-analysis of sacral nerve stimulation for fecal incontinence

To evaluate the efficacy of sacral nerve stimulation (SNS) therapy for fecal incontinence. Clinical researches which evaluated the efficacy of SNS and were published between 1946 and 2016 were systematically searched from electronic databases, including PubMed, Ovid Medline, Web of Science, Wanfang database and Chinese Journal Full-text Database. Grey area literatures were also searched. Influence of SNS therapy on fecal incontinence episodes (FIE) or Wexner incontinence score (WIS) was systematically evaluated. The statistical analysis was performed by RevMan5.2. A total of 6 studies including 270 patients (147 patients in SNS group and 123 patients in control group) with fecal incontinence were enrolled in this systematic review. SNS therapy was associated with a significant reduction in FIE (SMD=-0.69, 95%CI: -0.97 to -0.41, P<0.001) and a significant reduction in WIS (SMD=-5.05, 95%CI: -8.73 to -1.36, P=0.007). Sensitivity analysis showed that the results of this study were stable and the direction and significance of results were not changed (P=0.000 for both). Publication bias was not found by funnel picture in this study. SNS significantly improves the outcome of patients with fecal incontinence.

Novel insights into fecal incontinence in men.

Fecal incontinence in men is common, yet data on sex differences in clinical features, physiology, and treatment are scarce. We provide evidence that men, compared with women, with fecal incontinence have unique clinical features and physiology and are less likely to have investigations and treatment despite successful outcome with anorectal biofeedback therapy.

Endpoints for therapeutic interventions in faecal incontinence: small step or game changer.

Faecal incontinence (FI) is common and its pathophysiology and treatments continue to evolve. However, a standard measure(s) for assessing its clinical outcome has been elusive. Consequently, over 100 measures and scoring systems, each with intrinsic biases have been reported. These include adequate relief or global satisfaction, ≥50% reduction in episodes or days without FI, quality of life (QOL), FI severity scales and composite indices. Earlier scales relied on the frequency and type of solid, liquid or flatus incontinence and effects on life style whereas newer scales have incorporated urgency, use of pads, antidiarrhoeals and amount of leakage, using prospective daily stool diaries or retrospective weekly or single point assessments. Such a plethora of measures have negatively impacted the assessment and outcome of clinical trials, and have made comparisons difficult. So, how does one sort out the grain from the chaff? In a provocative, post-hoc analysis published in this issue, the minimal clinically important difference, i.e. the smallest change detected by an instrument that is associated with a clinically meaningful change was used to assess FI endpoint. Based on this a ≥50% reduction in FI episodes is recommended as a clinically meaningful outcome measure when assessed by prospective stool diary, and it correlates with symptoms and severity. However, this requires further validation in multi-centre, longer duration and therapeutically effective clinical trial(s). Simultaneous assessment of coping strategies, QOL and psychosocial domains can provide further insights regarding the overall impact of treatments. This mini-review discusses the advances and controversies in defining meaningful FI endpoints.

A Vaginal Bowel-Control System for the Treatment of Fecal Incontinence

Fecal incontinence is a common problem in community-dwelling women. Prevalence rates range from 12% to 25%. The average age at onset is between 47 and 55 years. This condition is debilitating and emotionally devastating. Most women with fecal incontinence are socially isolated and do not seek care. Although the cause of fecal incontinence is multifactorial, there is often a history of damage to the pelvic region caused by pregnancy and childbirth, Contributory causes include congenital, neurologic, functional, and traumatic alterations of the continence mechanism. Current nonsurgical treatment options for fecal incontinence include antidiarrheal agents, fiber supplements, biofeedback therapy, passive anal barriers, and injectable agents. All have shortcomings in efficacy, morbidity, cost, and/or patient compliance. Surgical options such as anal sphincteroplasty, dynamic graciloplasty, and the artificial anal sphincter have higher morbidity than noninvasive treatments, and long-term results are disappointing. A nonsurgical vaginal bowel-control system (Eclipse System) was recently approved by the Food and Drug administration and is now available. The Eclipse System provides a low-risk, effective, and easily reversible treatment for fecal incontinence. This device consists of a vaginal insert and pressure-regulated pump that reversibly occludes the distal rectum, allowing the patient to control her own bowel movements. The aim of this prospective, open-label trial was to assess the effectiveness and safety of the Eclipse system in women with fecal incontinence. Women with a history of fecal incontinence for at least 6 months and a minimum of 4 incontinence episodes over 2 weeks were fitted with the device. Patients served as their own controls. The primary efficacy outcome was defined as a 50% or greater reduction in fecal incontinence episodes at 1 month and was assessed using a bowel diary. Participants successfully completing 1 month of use were invited into an optional extended-wear period of another 2 months. Secondary outcomes were validated measures of symptom improvement: the Fecal Incontinence Quality of Life scale, the Modified Manchester Health Questionnaire, and the Patient Global Impression of Improvement. Device-related adverse events were recorded. The intention-to-treat population was defined as all participants successfully fitted with the device. The per-protocol population included intention-to-treat participants with a valid 1-month treatment diary. A total of 110 participants from 6 clinical sites entered the fitting assessment. Of these, 61 (55.5%) were successfully fit and underwent treatment. At 1 month, treatment success was demonstrated in 78.7% (48/61) of participants in the intention-to-treat population and 85.7 (48/56) of those in the per-protocol population (both comparisons, P < 0.001). More than 85% of patients considered bowel symptoms to be very much better (57.1%) or much better (28.6%). There was also significant improvement at 1 month in all Fecal Incontinence Quality of Life (P < 0.001) and Modified Manchester (P ≤ 0.007) subscales. Nearly 90% of participants were satisfied with the device, and 98.2% would recommend it to others. There were no serious device-related adverse events; the most common study-wide event reported by 22.7% of women was pelvic cramping or discomfort. The majority (64%) of adverse events occurred during the fitting period. This nonsurgical bowel-control device offers a completely new treatment option for women with fecal incontinence. Women successfully fitted and treated with the device show significant improvement in fecal incontinence symptoms assessed by objective and subjective measures. The device is effective in most patients and has no serious adverse effects. Patient acceptance and satisfaction are high. A longer-term outcome study is being designed to provide additional information on potential adverse effects and tolerability as well as efficacy.

Sa1373 Significant Findings From a Randomised Control Trial of Posterior Tibial Nerve Stimulation in Systemic Sclerosis Associated Faecal Incontinence

Background The gastrointestinal tract is affected in up to 90% of Systemic Sclerosis (SSc) patients with faecal incontinence (FI) being reported in up to 38%. Passive faecal incontinence secondary to internal anal sphincter atrophy is the characteristic finding. We have shown that neuropathic changes are implicated in SSc patients with FI and sacral nerve stimulation has emerged as a potentially beneficial therapy in SSc. However this is expensive, invasive, not widely available and we have shown that medium term efficacy is poor. Posterior tibial nerve stimulation (PTNS) is a potential alternative to modulate the sacral plexus indirectly, with none of these disadvantages. This is the preliminary data on a randomized placebo controlled trial of PTNS versus sham PTNS to determine if nerve modulation is an effective treatment in SSc associated FI. Methods We commenced a prospective randomised singleblind study of SSc patients with FI in February 2013 from a specialist Scleroderma unit. Baseline symptom scoring (bowel diary, Wexner), manometry and endoanal ultrasound were completed prior to randomization to PTNS or sham. PTNS was administered conventionally, by insertion of an acupuncture needle according to anatomical landmarks, connected to an electrical stimulator. Sham PTNS was administered in identical fashion but the PTNS surface electrode was not connected and instead separate TENS surface electrodes were connected to a TENS unit. Each patient underwent blinded intervention for 30 minute periods, once a week for 12 weeks. The primary endpoints were reduction in faecal incontinence episodes/ week and a reduction in Wexner incontinence scores. A Wexner responder was defined as a post-treatment reduction in score to ≤ 10 with the maximum score at 20. Results A total of 23 SSc patients (20 f), mean age 62 (41-82) completed the trial by October 2014. Of these 12 (10 f) underwent PTNS and 11 (10 f) patients underwent sham stimulation. All PTNS patients showed a reduction in the number of FI episodes/week when compared to SHAM patients at 12 weeks (p=0.0025) (plot 1). 6/12 (50%) PTNS patients were Wexner responders compared to 0/11 SHAM patients with the% change inWexner score significantly reduced in the PTNS group (p=0.0019) (plot 2). Conclusion. Our results demonstrate significant short-term benefits of PTNS in SSc associated FI. This argues for a neuropathic and reversible cause for incontinence in SSc. PTNS could be considered as an alternative to permanent SNS placement.

Validity of the ≥50% Response Threshold in Treatment With NASHA/Dx Injection Therapy for Fecal Incontinence

Objectives:Many fecal incontinence (FI) studies define primary efficacy outcome as a decrease from baseline of ≥50% in the number of FI episodes; this threshold has never been validated. We aimed to establish the validity and responsiveness of ≥50% reduction in FI episodes (responder50) as the threshold indicative of clinically meaningful response.Methods:Adults with a Cleveland Clinic Florida fecal incontinence score ≥10 were randomized to receive nonanimal stabilized hyaluronic acid/dextranomer (NASHA/Dx) injection or sham treatment in a 6-month trial. Validity and responsiveness of the primary end point were evaluated post hoc. The data were compared using different thresholds for defining a responder for a number of end points.Results:Data from 206 patients (NASHA/Dx, n=136; sham, n=70) were evaluated. Incremental patient response threshold increases showed that although the percentage of patients who achieved response decreased with increasing threshold, the difference between treatments remained significant up to an 80% response threshold (NASHA/Dx, 23% sham, 10% P=0.02). Response thresholds between 40% and 80% demonstrated evidence for convergent validity, with the strongest correlation with the number of FI episodes, the number of FI episodes when the patient was awake, and the number of FI-free days observed at ≥40% and ≥50% thresholds. Further examination of the responder50 threshold indicated that, regardless of treatment (NASHA/Dx or sham), responders performed significantly better than nonresponders on nearly all secondary efficacy end points.Conclusion:This study demonstrates the responsiveness, validity, and clinical applicability of the ≥50% response threshold in clinical studies of patients with FI receiving treatment with NASHA/Dx.

PWE-183 Preliminary Significant Findings From A Randomised Control Trial Of Posterior Tibial Nerve Stimulation In Systemic Sclerosis Associated Faecal Incontinence

IntroductionThe gastrointestinal tract is affected in up to 90% of Systemic Sclerosis (SSc) patients with faecal incontinence (FI) being reported in up to 38%. Passive faecal incontinence secondary to internal...

Mo2015 Preliminary Significant Findings From a Randomised Control Trial of Posterior Tibial Nerve Stimulation in Systemic Sclerosis Associated Faecal Incontinence

Introduction The gastrointestinal tract is affected in up to 90% of Systemic Sclerosis (SSc) patients with faecal incontinence (FI) being reported in up to 38%. Passive faecal incontinence secondary to internal anal sphincter atrophy is the characteristic finding. We have shown that neuropathic changes are implicated in SSc patients with FI and sacral nerve stimulation has emerged as a potentially beneficial therapy in SSc. However this is expensive, invasive, not widely available and we have shown that medium term efficacy is poor. Posterior tibial nerve stimulation (PTNS) is a potential alternative to modulate the sacral plexus indirectly, with none of these disadvantages. This is the preliminary data on a randomised placebo controlled trial of PTNS versus sham PTNS to determine if nerve modulation is an effective treatment in SSc associated FI. Methods We commenced a prospective randomised single-blind study of SSc patients with FI in February 2013 from a specialist Scleroderma unit. Baseline symptom scoring (bowel diary, Wexner), manometry and endoanal ultrasound were completed prior to randomization to PTNS or sham. PTNS was administered conventionally, by insertion of an acupuncture needle according to anatomical landmarks, connected to an electrical stimulator. Sham PTNS was administered in identical fashion but the PTNS surface electrode was not connected and instead separate TENS surface electrodes were connected to a TENS unit. Each patient underwent blinded intervention for 30 min periods, once a week for 12 weeks. The primary endpoints were the percentage reduction in faecal incontinence episodes and change in Wexner incontinence scores. Results A total of 13 SSc patients (11 f), mean age 61 (36–72) completed the trial by October 2013. Of these 6 (5 f) underwent PTNS and 7 (6 f) patients underwent sham stimulation. All PTNS patients showed a reduction (5–100%) in the number of FI episodes in comparison to 0 sham patients at 12 weeks (p Conclusion This pilot data is demonstrating significant effects of PTNS in Scleroderma-associated FI. We present this significant initial data but anticipate having at least 25 completed patients by May 2014. Disclosure of Interest None Declared.

Quality of Life Is Markedly Improved in Patients With Fecal Incontinence After Sacral Nerve Stimulation

The aim of the present analysis was to report on the relationship between long-term improvement in quality of life (QOL) and fecal incontinence (FI) severity and long-term reduction in FI episodes after sacral nerve stimulation (SNS) or sacral neuromodulation. Patients who met inclusion/exclusion criteria, and initially had more than 2 FI episodes per week, were offered SNS therapy. Patients with 50% or higher reduction in FI during a 2-week test period were implanted with a neurostimulator (InterStim; Medtronic, Minneapolis, Minn). Assessments were completed by patients at baseline and at 3, 6, and 12 months after implant, and annually thereafter. The present report includes data from the 4-year postimplant follow-up. A total of 133 patients underwent test stimulation with a 90% success rate, and as a result, 120 (110 females) with a mean age of 60.5 years and a mean duration of FI of 6.8 years received long-term implantation. Of them, 78 patients completed all or part of the 4-year follow-up assessment. Fecal incontinence episodes decreased from a mean of 9.4 per week at baseline to 1.9 per week at 48 months (P < 0.001). The 4-year analyses showed that SNS had a positive and sustained impact on all 4 scales of the Fecal Incontinence Quality of Life questionnaire (P < 0.001), Fecal Incontinence Severity Index scores improved from a mean of 39.9 to 28 (P < 0.001), and self-rated bowel health scores improved from a mean of 3.5 to 6.9 (P < 0.001). Sacral nerve stimulation not only restores or improves continence in treated patients with chronic FI but also improves their quality of life and symptom severity.

Efficacy of Sacral Nerve Stimulation for the Treatment of Fecal Incontinence

Sacral nerve stimulation has been shown to be an effective treatment for fecal incontinence and early studies reported success rates of 67% to 100%. However, "success" has been arbitrarily set at a 50% reduction in symptoms, and data are rarely reported with "intention to treat." This study aimed to assess the true efficacy of sacral nerve stimulation for fecal incontinence compared with the published literature. This prospective 5-year study was conducted to assess 50 patients with fecal incontinence treated with sacral nerve stimulation. All analyses were performed on an intention-to-treat basis. This study took place in a single tertiary referral colorectal department. Fifty consecutive patients with fecal incontinence refractory to conservative management were included in the study. The interventions performed were temporary evaluation with or without permanent sacral nerve stimulation. : Primary outcome measures were 1) attainment of continence, 2) reduction in fecal incontinence episodes, 3) improvement in Cleveland Clinic Fecal Incontinence scores, and 4) improvement in the ability to defer defecation. Thirteen patients (26%) did not respond at the temporary evaluation stage or were dissatisfied with the result. Ten further patients (20%) did not achieve a 50% reduction in symptoms following permanent implantation. The median follow-up was 17 months (range, 2-55), at which time 27 patients (54%) experienced a 50% or more reduction in symptoms, including 13 (26%) who achieved apparent continence. Median fecal incontinence episodes per fortnight reduced from 14 (range, 0-53) to 2 (range, 0-20; P < .0001). Median Cleveland Clinic Fecal Incontinence scores reduced from 15 (range, 3-20) to 8 (range, 0-17; P < .0001). The ability to defer defecation improved significantly (P < .0001). These results compare favorably with the published literature. Quality of life was not assessed. This study demonstrates that sacral nerve stimulation can be an effective treatment for patients with fecal incontinence; however, when analyzed by intention to treat, the symptoms of fecal incontinence continue in the majority (74%) of patients.

The effects of clonidine on symptoms and anorectal sensorimotor function in women with faecal incontinence

Women with faecal incontinence and rectal urgency have increased rectal stiffness and sensation. To evaluate the effects of clonidine, an alpha(2) -adrenergic agonist, in faecal incontinence. In this open-label uncontrolled study, bowel symptoms and anorectal functions (anal pressures, rectal compliance, and sensation) were assessed before and during treatment with transdermal clonidine (0.2 mg daily, 4 weeks) in 12 women with urge-predominant faecal incontinence. Clonidine reduced the frequency (17.8 +/- 3.1 before vs. 8.8 +/- 3.9 after, P = 0.03) and number of days with faecal incontinence (11.8 +/- 1.6 before vs. 6.1 +/- 1.8 after, P = 0.02), faecal incontinence symptom severity score (max = 13, 8.3 +/- 0.7 vs. 5.6 +/- 0.9, P < 0.01), and allowed patients to defer defecation for a longer duration (P = 0.03). Although overall effects on anorectal functions were not significant, the treatment-associated reduction in faecal incontinence episodes was associated with increased rectal compliance (r = -0.58, P < 0.05) and reduced rectal sensation. (r = -0.73, P = 0.007 vs. desire to defecate pressure threshold). Clonidine improves symptoms in women with faecal incontinence; this improvement is associated with increased rectal compliance and reduced rectal sensitivity. A controlled study is necessary to confirm these observations.

Percutaneous Tibial Nerve Stimulation for the Treatment of Urge Fecal Incontinence

Percutaneous tibial nerve stimulation has been shown to be an effective treatment in patients with urinary disorders, but its benefit in fecal incontinence is uncertain. This study aimed to assess the efficacy of percutaneous tibial nerve stimulation in the treatment of urge fecal incontinence. This prospective study, conducted over a 14-month period, assessed 31 patients with urge fecal incontinence treated with percutaneous tibial nerve stimulation. The outcomes measured were: 1) reduction in fecal incontinence episodes, 2) improvement in Cleveland Clinic incontinence scores, and 3) improvement in ability to defer defecation. All analysis was performed on an intention-to-treat basis. The median follow-up was 9 months (range, 3-14). Twenty-one (68%) patients improved following percutaneous tibial nerve stimulation and remain satisfied with the clinical response. Median fecal incontinence episodes per week declined from 4 (range, 0-30) to 0 (range, 0-27) (P < .0001). Median Cleveland Clinic incontinence scores declined from 13 (range, 5-20) to 7 (range, 0-20) (P < .0001). Ability to defer defecation was improved significantly (P < .0001). No morbidity was encountered for any patient. This preliminary study demonstrates that percutaneous tibial nerve stimulation is an effective and very well tolerated treatment for patients with urge fecal incontinence with particular improvement in reducing fecal urgency.

Efficacy of Sacral Nerve Stimulation for Fecal Incontinence in Patients with Anal Sphincter Defects

Sacral nerve stimulation has traditionally been used to treat patients with fecal incontinence with intact anal sphincters. This rationale has been challenged, but it remains unknown if its efficacy is related to the extent of the sphincter injury. This was a prospective study of 15 patients with sphincter defects (9 combined, 2 external only, and 4 internal only) undergoing sacral nerve stimulation for fecal incontinence. Endoanal ultrasound scans were reviewed and defects scored (0-16) with use of a system published by two independent observers. These were correlated with the following outcomes: 1) reduction in fecal incontinence episodes, 2) reduction in soiling, 3) improvement in Cleveland Clinic scores, and 4) improvement in ability to defer defecation. All patients were studied after temporary stimulation and again at three to six months after permanent implantation. Thirteen patients (87%) progressed to permanent stimulation. Median fecal incontinence episodes per two weeks decreased from 15 (range, 1-53) to 3 (range, 0-16; P = 0.01). Median soiling episodes were reduced from 10 (range, 1-14) to 6 (range, 0-14; P = 0.009). Median Cleveland Clinic scores decreased from 12 (range, 9-18) to 9 (range, 4-14; P = 0.0005). The ability to defer defecation was improved significantly (P = 0.05). There were no relationships between sphincter defect scores and outcome measures after sacral nerve stimulation (r = 0.001-0.10; P = 0.28-0.94). Sacral nerve stimulation is an effective treatment in patients with fecal incontinence who have anal sphincter defects, and outcome is not associated with severity of sphincter disruption.

Effect of sacral neuromodulation for faecal incontinence on sexual activity

Faecal incontinence affects a percentage of the population and can have a significant effect on their ability to establish and maintain sexual relations. Sixteen consecutive patients with permanent sacral neuromodulation (SNM) for faecal incontinence completed a 'Sex Life Questionnaire' at their follow up visit to ascertain whether there was any improvement in this aspect of their life. Nine of the sixteen patients was sexually active. These nine patients (median age 56 (35-61) years) had a significant reduction in faecal incontinence episodes per week from a median of 12 (1-55) to 1.5 (0-8.5) (P = 0.008). All nine patients reported that their sex life had been affected by feacal incontinence prior to SNM and seven had felt benefit from implantation. The median improvement in their sex life was 40% (1-100) and the percentage improvement was inversely correlated to age (r = -0.834, P = 0.005). SNM improves the quality of sexual activity in 78% of patients. More improvement seems to be gained the younger the patients.