Clinical Review

2019 Update on pelvic floor dysfunction

OBG Manag. 2019 September;31(9):23, 24, 26-30

Conservative to invasive approaches are available for treating women with fecal incontinence, but how do they stack up in terms of efficacy and safety? Two experts review recent evidence on first- and second-line treatments, a vaginal bowel control system, and a sacral neuromodulation device.

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References

Sultan AH, Monga A, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction. Neurourol Urodyn. 2017;36:10-34.
Bharucha AE, Dunivan G, Goode PS, et al. Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol. 2015;110:127-136.
Bharucha AE, Zinsmeister AR, Locke GR, et al. Symptoms and quality of life in community women with fecal incontinence. Clin Gastroenterol Hepatol. 2006;4:1004-1008.
Perry S, Shaw C, McGrother C, et al; Leicestershire MRC Incontinence Study Team. Prevalence of faecal incontinence in adults aged 40 years or more living in the community. Gut. 2002;50:480-484.
Ditah I, Devaki P, Luma HN, et al. Prevalence, trends, and risk factors for fecal incontinence in United States adults, 2005-2010. Clin Gastroenterol Hepatol. 2014;12:636-643.e1-2.
Brown HW, Wexner SD, Lukacz ES. Factors associated with care seeking among women with accidental bowel leakage. Female Pelvic Med Reconstr Surg. 2013;19:66-71.
Norton NJ. The perspective of the patient. Gastroenterology. 2004;126(1 suppl 1):S175-S179.
Guan W, Schmuhl NB, Brown HW. Response re: If we don't ask, they won't tell: screening for urinary and fecal incontinence by primary care providers. J Am Board Fam Med. 2019;32:119.3-120.
Whitehead WE, Borrud L, Goode PS, et al; Pelvic Floor Disorders Network. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology. 2009;137:512-517.
Wald A, Bharucha AE, Cosman BC, et al. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. 2014;109:1141-1157.
Bharucha AE, Zinsmeister AR, Schleck CD, et al. Bowel disturbances are the most important risk factors for late onset fecal incontinence: a population-based case-control study in women. Gastroenterology. 2010;139:1559-1566.
Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997;32:920-924.
Paquette IM, Varma MG, Kaiser AM, et al. The American Society of Colon and Rectal Surgeons' clinical practice guideline for the treatment of fecal incontinence. Dis Colon Rectum. 2015;58:623-636.
American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 210: Fecal incontinence. Obstet Gynecol. 2019;133:e260-e273.
Heymen S, Scarlett Y, Jones K, et al. Randomized controlled trial shows biofeedback to be superior to pelvic floor exercises for fecal incontinence. Dis Colon Rectum. 2009;52:1730-1737.
Wexner SD, Coller JA, Devroede G, et al. Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study. Ann Surg. 2010;251:441-449.
Leroi AM, Parc Y, Lehur PA, et al. Efficacy of sacral nerve stimulation for fecal incontinence: results of a multicenter double-blind crossover study. Ann Surg. 2005;242:662-669.

Fecal incontinence (FI), also known as accidental bowel leakage, is the involuntary loss of feces, which includes both liquid and solid stool as defined by the International Continence Society (ICS) and the International Urogynecological Association (IUGA).^1,2 Fecal incontinence is common, occurring in 7% to 25% of community-dwelling women, and it increases with age.^2-6 The condition is rarely addressed, with only 30% of women seeking care.^6-8 This is due to patient embarrassment and the lack of a reliable screening tool. However, FI affects quality of life and mental health, and the associated economic burden likely will rise given the increased prevalence of FI among older women.^2,4,7,9

Fecal incontinence occurs due to poor stool consistency, anal and pelvic muscle weakness, reduced rectal compliance, reduced or increased rectal sensation, or bowel inflammation or dysfunction. Many conditions can cause FI (TABLE 1).^5,10,11 It is therefore important to elicit a full medical history with a focus on specific bowel symptoms, such as stool consistency type (TABLE 2),¹²FI frequency, and duration of symptoms, as well as to perform a complete examination to identify any readily reversible or malignant causes. A colonoscopy is recommended for individuals who meet screening criteria or present with a change in bowel symptoms, such as diarrhea, bleeding, or obstruction.^13,14

Fecal incontinence treatments include a range of approaches categorized from conservative, or first-line therapy, to fourth-line surgical managements (FIGURE 1).^1,10,13,14In this Update, we review the results of 3 well-designed trials that enrolled women with frequent nonneurogenic FI.

Common first- and second-line treatments produce equivalent improvements in FI symptoms at
6 months

Jelovsek JE, Markland AD, Whitehead WE, et al; National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Controlling faecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomized clinical trial. Lancet Gastroenterol Hepatol. 2019;4:698-710.

In a multicenter, randomized trial of first- and second-line treatments for FI, Jelovsek and colleagues evaluated the efficacy of oral placebo, loperamide, pelvic floor physical therapy (PFPT) with biofeedback using anorectal manometry, or combination therapy over a 24-week period.

Continue to: Four treatments compared...

References

Sultan AH, Monga A, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction. Neurourol Urodyn. 2017;36:10-34.
Bharucha AE, Dunivan G, Goode PS, et al. Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol. 2015;110:127-136.
Bharucha AE, Zinsmeister AR, Locke GR, et al. Symptoms and quality of life in community women with fecal incontinence. Clin Gastroenterol Hepatol. 2006;4:1004-1008.
Perry S, Shaw C, McGrother C, et al; Leicestershire MRC Incontinence Study Team. Prevalence of faecal incontinence in adults aged 40 years or more living in the community. Gut. 2002;50:480-484.
Ditah I, Devaki P, Luma HN, et al. Prevalence, trends, and risk factors for fecal incontinence in United States adults, 2005-2010. Clin Gastroenterol Hepatol. 2014;12:636-643.e1-2.
Brown HW, Wexner SD, Lukacz ES. Factors associated with care seeking among women with accidental bowel leakage. Female Pelvic Med Reconstr Surg. 2013;19:66-71.
Norton NJ. The perspective of the patient. Gastroenterology. 2004;126(1 suppl 1):S175-S179.
Guan W, Schmuhl NB, Brown HW. Response re: If we don't ask, they won't tell: screening for urinary and fecal incontinence by primary care providers. J Am Board Fam Med. 2019;32:119.3-120.
Whitehead WE, Borrud L, Goode PS, et al; Pelvic Floor Disorders Network. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology. 2009;137:512-517.
Wald A, Bharucha AE, Cosman BC, et al. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. 2014;109:1141-1157.
Bharucha AE, Zinsmeister AR, Schleck CD, et al. Bowel disturbances are the most important risk factors for late onset fecal incontinence: a population-based case-control study in women. Gastroenterology. 2010;139:1559-1566.
Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997;32:920-924.
Paquette IM, Varma MG, Kaiser AM, et al. The American Society of Colon and Rectal Surgeons' clinical practice guideline for the treatment of fecal incontinence. Dis Colon Rectum. 2015;58:623-636.
American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 210: Fecal incontinence. Obstet Gynecol. 2019;133:e260-e273.
Heymen S, Scarlett Y, Jones K, et al. Randomized controlled trial shows biofeedback to be superior to pelvic floor exercises for fecal incontinence. Dis Colon Rectum. 2009;52:1730-1737.
Wexner SD, Coller JA, Devroede G, et al. Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study. Ann Surg. 2010;251:441-449.
Leroi AM, Parc Y, Lehur PA, et al. Efficacy of sacral nerve stimulation for fecal incontinence: results of a multicenter double-blind crossover study. Ann Surg. 2005;242:662-669.

2019 Update on pelvic floor dysfunction

References

Common first- and second-line treatments produce equivalent improvements in FI symptoms at6 months

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Common first- and second-line treatments produce equivalent improvements in FI symptoms at
6 months