Management of faecal incontinence and constipation in adults with central neurological diseases.

BACKGROUND: People with neurological disease have a much higher risk of both faecal incontinence and constipation than the general population. There is often a fine dividing line between the two conditions, with any management intended to ameliorate, one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical with a limited research base. OBJECTIVES: To determine the effects of management strategies for faecal incontinence and constipation in people with neurological diseases affecting the central nervous system. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Trials Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE and all reference lists of relevant articles. Date of the most recent searches: May 2000. SELECTION CRITERIA: All randomised or quasi-randomised trials evaluating any types of conservative, or surgical measure for the management of faecal incontinence and constipation in people with neurological diseases were selected. Specific therapies for the treatment of neurological diseases that indirectly affect bowel dysfunction have also been considered. DATA COLLECTION AND ANALYSIS: All three reviewers assessed the methodological quality of eligible trials and two reviewers independently extracted data from included trials using a range of pre-specified outcome measures. MAIN RESULTS: Only seven trials were identified by the search strategy and all were small and of poor quality. Oral medications for constipation were the subject of four trials. Cisapride does not seem to have clinically useful effects in people with spinal cord injuries (two trials). Psyllium was associated with increased stool frequency in people with Parkinson's disease but not altered colonic transit time (one trial). Some rectal preparations to initiate defecation produced faster results than others (one trial). Different time schedules for administration of rectal medication may produce different bowel responses (one trial). Mechanical evacuation may be more effective than oral or rectal medication (one trial). The clinical significance of any of these results is difficult to interpret. REVIEWER'S CONCLUSIONS: It is not possible to draw any recommendation for bowel care in people with neurological diseases from the trials included in this review. Bowel management for these people must remain empirical until well-designed controlled trials with adequate numbers and clinically relevant outcome measures become available.

La mesure d'indépendance fonctionnelle et les interventions infirmières sur l'incontinence urinaire en gériatrie aux hug : une étude descriptive corrélationnelle

L'incontinence urinaire (IU) se définit comme une élimination involontaire d'urine. Le programme transverse des Hôpitaux universitaires de Genève (HUG) sur la prévention et les traitements de I'IU avance l'hypothèse qu'environ 400'000 personnes, en Suisse en souf- frent. Parmi les personnes hospitalisées en réhabilitation et gériatrie, la proportion d'IU at- teindrait même 56%. Cette proportion s'élève encore dans des services de long séjour pour atteindre 70%. Malgré l'inconfort causé par l'IU et son lien avec un déclin fonctionnel, la litté- rature démontre que l'IU reste trop peu reconnue par les infirmières en soins gériatriques. Cette étude de type quantitatif descriptif corrélationnel vise à mesurer la prévalence de l'IU lors d'une admission en gériatrie et à évaluer le niveau d'implication infirmière dans la prise en compte de celle-ci. Le modèle de Classification Internationale du fonctionnement du han- dicap de la santé de l'Organisation mondiale de la santé est utilisé. L'implication infirmière est caractérisée par la présence explicite dans les dossiers patients d'un diagnostic infirmier, d'une prescription infirmière ou d'une intervention infirmière relatifs à l'IU. Après analyse de 100 dossiers sélectionnés au hasard au sein d'un département gériatrique d'un hôpital uni- versitaire, les résultats indiquent une prévalence de 72% d'incontinence. La majorité des personnes touchées sont des femmes (64%). Dans l'ensemble des dossiers de personnes présentant IU, on retrouve que 1,4% ont un diagnostic infirmier, 54% une prescription infir- mière, et 72%, une intervention infirmière. La grande majorité des interventions sont de type palliatif. Des corrélations montrent une association entre l'IU et l'âge et entre les préoccupa- tions infirmières et la raison principale d'admission. Ces résultats sont discutés en lien avec la littérature et des recommandations sont proposées pour améliorer la pratique clinique et favoriser la poursuite de la recherche infirmière dans ce domaine.

Pelvic floor dysfunction 6 years post-anal sphincter tear at the time of vaginal delivery.

INTRODUCTION AND HYPOTHESIS: This study aims to estimate fecal, urinary incontinence, and sexual function 6 years after an obstetrical anal sphincter tear. METHODS: Among 13,213 women who had a vaginal delivery of a cephalic singleton at term, 196 women sustained an anal sphincter tear. They were matched to 588 controls. Validated questionnaires grading fecal and urinary incontinence, and sexual dysfunction were completed by the participants. RESULTS: Severe fecal incontinence was more frequently reported by women who had sustained an anal sphincter tear compared to the controls. Women with an anal sphincter tear had no increased risk of urinary incontinence, but reported significantly more pain, difficulty with vaginal lubrication, and difficulty achieving orgasm compared to the controls. A fetal occiput posterior position during childbirth was an independent risk factor for both severe urinary incontinence and severe sexual dysfunction. CONCLUSIONS: Fecal incontinence is strongly associated with an anal sphincter tear. A fetal occiput posterior position represents a risk factor for urinary incontinence and sexual dysfunction.

Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations.

PURPOSE: Transanal endoscopic microsurgery provides a minimally invasive alternative to radical surgery for excision of benign and malignant rectal tumors. The purpose of this study was to review our experience with transanal endoscopic microsurgery to clarify its role in the treatment of different types of rectal pathology. METHODS: A prospective database documented all patients undergoing transanal endoscopic microsurgery from October 1996 through June 2008. We analyzed patient and operative factors, complications, and tumor recurrence. For recurrence analysis, we excluded patients with fewer than 6 months of follow-up, previous excisions, known metastases at initial presentation, and those who underwent immediate radical resection following transanal endoscopic microsurgery. RESULTS: Two hundred sixty-nine patients underwent transanal endoscopic microsurgery for benign (n = 158) and malignant (n = 111) tumors. Procedure-related complications (21%) included urinary retention (10.8%), fecal incontinence (4.1%), fever (3.8%), suture line dehiscence (1.5%), and bleeding (1.5%). Local recurrence rates for 121 benign and 83 malignant tumors were 5% for adenomas, 9.8% for T1 adenocarcinoma, 23.5% for T2 adenocarcinoma, 100% for T3 adenocarcinoma, and 0% for carcinoid tumors. All 6 (100%) recurrent adenomas were retreated with endoscopic techniques, and 8 of 17 (47%) recurrent adenocarcinomas underwent salvage procedures with curative intent. CONCLUSIONS: Transanal endoscopic microsurgery is a safe and effective method for excision of benign and malignant rectal tumors. Transanal endoscopic microsurgery can be offered for (1) curative resection of benign tumors, carcinoid tumors, and select T1 adenocarcinomas, (2) histopathologic staging in indeterminate cases, and (3) palliative resection in patients medically unfit or unwilling to undergo radical resection.

Perineal stapled prolapse resection for external rectal prolapse: is it worthwhile in the long-term?

BACKGROUND: Perineal stapled prolapse (PSP) resection is a novel operation for treating external rectal prolapse. However, no long-term results have been reported in the literature. This study analyses the long-term recurrence rate, functional outcome, and morbidity associated with PSP resection. METHODS: Nine consecutive patients undergoing PSP resection between 2007 and 2011 were prospectively followed. Surgery was performed by the same surgeons in a standardised technique. Recurrence rate, functional outcome, and complication grade were prospectively assessed. RESULTS: All 9 patients undergoing PSP resection were investigated. The median age was 72 years (range 25-88 years). No intraoperative complications occurred. Faecal incontinence, preoperatively present in 2 patients, worsened postoperatively in one patient (Vaizey 18-22). One patient developed new-onset faecal incontinence (Vaizey 18). The median obstructive defecation syndrome score decreased postoperatively significantly from 11 (median; range 8-13) to 5 (median; range 4-8) (p < 0.005). At a median follow-up of 40 months (range 14-58 months), the prolapse recurrence rate was 44 % (4/9 patients). CONCLUSIONS: The PSP resection is a fast and safe procedure associated with low morbidity. However, the poor long-term functional outcome and the recurrence rate of 44 % warrant a cautious patient selection.

Fistula treatment: the unresolved challenge.

Fistulas are common complications in Crohn's disease, as their cumulative prevalence reaches up to two thirds of the patients in the long term. Fistulas worsen the overall patient prognosis, with permanent sphincter and perineal tissue destruction as well as professional and personal disabilities. The importance of healing these fistulas has been less well appreciated than mucosal healing for luminal disease. Management should not be left to any specialty alone, but requires an optimal combination of surgery, infection control, and immunosuppression. Outcome of therapy beyond fistula drainage is unclear and the means of assessing healing over a long time period is poorly characterized. Recent studies suggested that a substantial proportion of patients can achieve fistula healing with surgical and medical therapies. However, studies that measure the benefit of integrated approaches, of early intervention and of precise healing assessment are still missing. Such information is particularly needed in this subset of sick patients that undergo substantial physical and emotional distress because of pain, discharge, incontinence, perineal and genital disfigurement. The advent of adequate pelvic imaging, improved surgical outcomes, and potent biological therapies make it timely to develop best-management strategies and appropriateness of care criteria.

THE HIGH DIAGNOSTIC YIELD OF A GERIATRIC OUTPATIENT CLINIC

Objectives: To determine characteristics of older patients referred to a geriatric outpatient clinic; 2) to determine the prevalence of geriatric syndromes in this population; 3) to identify main recommendations made to referring primary care physicians. Design: Cross-sectional analysis Setting: Outpatient clinic of the service of geriatric medicine at the University of Lausanne Medical Center, Lausanne, Switzerland. Participants: Community-dwelling patients aged 65 and over referred to the clinic. Measurements: Demographics, social, functional and health status data, main diagnoses identified and recommendations made for primary care physicians were collected prospectively. Results: Subjects (N=206, mean age 79.7±7.6 years, 57.3% women, 48.5% living alone, 36.9% receiving formal home care) were referred by primary care physicians (76%), hospitalists (18%), or family members (7%). Main reasons for referral were request for comprehensive assessment, cognitive evaluation, and mobility assessment (45.2%, 26.2%, and 15.5%, respectively). 21.4% of patients are independent in Lawton's Instrumental ADL and 47.1% are independent in Katz's Basic ADL, and 57.3% of patients reported having fallen once or more over the last year. Overall, 76.2% of patients had gait and balance impairment, 72.8% cognitive impairment, 57.3% polypharmacy (≥6 drugs; median 6.5±3.9, IQR 4-8), 54.4% affective disorder, 48.3% osteoporosis, 45.1% urinary incontinence and 33.8% orthostatic hypotension. Polymorbidity (≥6 geriatric syndromes) was present in 58.3% of referred patients. On average, patients received 10.6±4.0 recommendations, including fall prevention interventions (85.2 % of patients: walking aid adaptation in 48.1%, vitamin D prescription in 59.7%, home hazards assessment in 59.2%, and exercise prescription in 53.4%), referral to a memory clinic (45.6%), and treatment modifications (69.9 % of all patients and 81.6% of patients with polypharmacy, mostly psychotropic drugs discontinuation). Conclusions: Polymorbidity was frequent in these older outpatients, with polypharmacy, mobility and cognitive impairments being most prevalent. Outpatient geriatric consultation is a good opportunity to identify geriatric syndromes and propose interventions to prevent or delay functional decline.

Urinary sphincter based on electronics and artificial muscles

Objectives: The AMS 800TM is the current artificial urinary sphincter (AUS) for incontinence due to intrinsic sphincter deficiency. Despite good clinical results, technical failures inherent to the hydraulic mechanism or urethral ischemic injury contribute to revisions up to 60%. We are developing an electronic AUS, called ARTUS to overcome the rigors of AMS. The objective of this study was to evaluate the technical efficacy and tissue tolerance of the ARTUS system in an animal model.Methods: The ARTUS is composed by three parts: the contractile unit, a series of rings and an integrated microprocessor. The contractile unit is made of Nitinol fibers. The rings are placed around the urethra to control the flow of urine by squeezing the urethra. They work in a sequential alternative mode and are controlled by a microprocessor. In the first phase a three-rings device was used while in the second phase a two-rings ARTUS was used. The device was implanted in 14 sheep divided in two groups of six and eight animals for study purpose. The first group aimed at bladder leak point pressure (BLPP) measurement and validation of the animal model; the second group aimed at verifying mid-term tissue tolerance by explants at twelve weeks. General animal tolerance was also evaluated.Results: The ARTUS system implantation was uneventful. When the system was activated, the BLPP was measured at 1.038±0.044 bar (mean±SD). Urethral tissue analysis did not show significant morphological changes. No infection and no sign of discomfort were noted in animals at 12 weeks.Conclusions: The ARTUS proved to be effective in continence achievement in this study. Histological results support our idea that a sequential alternative mode can avoid urethral atrophy and ischemia. Further technical developments are needed to verify long-term outcome and permit human use.

Experimental evaluation of an electromechanical artificial urinary sphincter in an animal model.

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The AMS 800 urinary control system is the gold standard for the treatment of urinary incontinence due to sphincter insufficiency. Despite excellent functional outcome and latest technological improvements, the revision rate remains significant. To overcome the shortcomings of the current device, we developed a modern electromechanical artificial urinary sphincter. The results demonstrated that this new sphincter is effective and well tolerated up to 3 months. This preliminary study represents a first step in the clinical application of novel technologies and an alternative compression mechanism to the urethra. OBJECTIVES: To evaluate the effectiveness in continence achievement of a new electromechanical artificial urinary sphincter (emAUS) in an animal model. To assess urethral response and animal general response to short-term and mid-term activation of the emAUS. MATERIALS AND METHODS: The principle of the emAUS is electromechanical induction of alternating compression of successive segments of the urethra by a series of cuffs activated by artificial muscles. Between February 2009 and May 2010 the emAUS was implanted in 17 sheep divided into three groups. The first phase aimed to measure bladder leak point pressure during the activation of the device. The second and third phases aimed to assess tissue response to the presence of the device after 2-9 weeks and after 3 months respectively. Histopathological and immunohistochemistry evaluation of the urethra was performed. RESULTS: Bladder leak point pressure was measured at levels between 1091 ± 30.6 cmH2 O and 1244.1 ± 99 cmH2 O (mean ± standard deviation) depending on the number of cuffs used. At gross examination, the explanted urethra showed no sign of infection, atrophy or stricture. On microscopic examination no significant difference in structure was found between urethral structure surrounded by a cuff and control urethra. In the peripheral tissues, the implanted material elicited a chronic foreign body reaction. Apart from one case, specimens did not show significant presence of lymphocytes, polymorphonuclear leucocytes, necrosis or cell degeneration. Immunohistochemistry confirmed the absence of macrophages in the samples. CONCLUSIONS: This animal study shows that the emAUS can provide continence. This new electronic controlled sequential alternating compression mechanism can avoid damage to urethral vascularity, at least up to 3 months after implantation. After this positive proof of concept, long-term studies are needed before clinical application could be considered.