This Month in Gastroenterology

We compared the prevalence of fecal incontinence between constipated and nonconstipated women and correlated its prevalence with the number of Rome III constipation symptoms. We performed a cross-sectional survey to evaluate the prevalence of fecal incontinence and constipation among women who presented to two gynecologic clinics for routine care over a 24-month period. Fecal incontinence was defined as loss of well-formed and/or loose stool beyond the patient's control that occurred at least once in the last 4 weeks, was bothersome, had been present for the past 3 or more months, and had affected the person's activities, relationships, or feelings. Constipation was diagnosed using the Rome III criteria. Our study was exempt from institutional review board approval because it was a survey and did not ask for information that could be used to identify the participant. Mean age of the 2,319 participants was 50.1 ± 15 years and mean body mass index (BMI) was 28.7 ± 7. Seven hundred and twenty-five (31 %) women had constipation, and 233 (10 %) had fecal incontinence. One hundred and one (43 %) incontinent women had coexisting constipation. Logistic regression analysis identified white race (p = .013), menopause (p = .010), and constipation (p = .004) as risk factors for fecal incontinence. After controlling for these risk factors, constipated women were more likely to have fecal incontinence than nonconstipated women [relative risk (RR) 1.60, 95 % confidence interval (CI) 1.26-2.05]. In addition, the prevalence of fecal incontinence was strongly associated with the number of Rome III constipation symptoms (p < .001). Constipation is an important risk factor for fecal incontinence.

Fecal incontinence has a great impact on daily life, and many patients are reluctant to report it. The purpose of this study was to estimate the prevalence of fecal incontinence in patients with Crohn's disease, validate risk factors, and relate outcome with quality of life. The design was cross-sectional. The study was conducted at an academic tertiary center. Consecutive patients with Crohn's disease treated between 2003 and 2013 were included in this study. A questionnaire was sent out in October 2013 to evaluate perianal disease, current symptoms of fecal incontinence, and its impact on quality of life (Fecal Incontinence Quality of Life questionnaire). Risk factors were validated with univariate and multivariate analyses. The questionnaire was responded by 325 (62%) of 528 patients. Median age was 42 years (range, 18-91 y), 215 (66%) were women, and a diagnosis of Crohn's disease was established for a median period of 12 years (interquartile range, 6-21 y). Fecal incontinence was reported by 65 patients (20%). Fecal incontinence was associated with liquid stools (p = 0.0001), previous IBD-related bowel resections (p = 0.001), stricturing behavior of disease (p = 0.02), and perianal disease (p = 0.03). Quality of life (lifestyle, coping, depression, and embarrassment) was poor in patients with fecal incontinence, particularly in patients with more frequent episodes of incontinence. There was no correction for disease activity in the multivariate regression analysis. The prevalence of fecal incontinence in a tertiary population with Crohn's disease is substantially higher than in the community-dwelling population. Considering the reduced quality of life in incontinent patients, active questioning to identify fecal incontinence is recommended in those with liquid stools, perianal disease, or previous (intestinal or perianal) surgery. See Video Abstract at http://journals.lww.com/dcrjournal/Pages/videogallery.aspx.

To determine the prevalence of faecal incontinence in the community and evaluate identifiable risk factors. Cross-sectional survey using a validated questionnaire. A short version of the questionnaire was sent to 220 subjects and a long version to 770 subjects, randomly selected from western Sydney, Australia. Self-reported faecal incontinence, defined as involuntary loss of anal sphincteric control leading to unwanted release of liquid or solid faeces (not flatus) at an inappropriate time or in an inappropriate place, within the past 12 months. The long questionnaire also sought information on bowel habit and potential risk factors for faecal incontinence. The response rate was 66%. The prevalence of solid or liquid faecal incontinence was 2% and 9%, respectively. The mean age of subjects with faecal incontinence was 53 years; 55% were women. After adjusting for age and sex, there was a significant association between faecal incontinence and perianal injury (P = 0.03), perianal surgery (P < 0.001), feelings of incomplete defecation (P < 0.0001), loose or watery motions (P < 0.0001) and urgency (P < 0.0001). Seven of 48 subjects with faecal incontinence reported being asked by their physician about faecal incontinence and nine of 33 reported seeking medical advice for their incontinence. Subjects with faecal incontinence perceived their health to be significantly poorer than did other subjects (P = 0.02). There is a high burden of faecal incontinence in the community, and the prevalence in men may be greater than is usually appreciated. Despite significant associated morbidity, most cases of faecal incontinence were unrecognised by doctors.

Objectives: The present systematic review focused on the prevention or treatment of three main types of pelvic floor dysfunctions (PFDs) specifically pelvic organ prolapse (POP), urinary incontinence (UI), and fecal incontinence (FI) using physiotherapy and pelvic floor muscle exercises (PFMEs). With regard to the breadth of the problem, there is not much evidence grounded on the best management. The main purpose of this systematic review was to evaluate the effects of physiotherapy and PFMEs on the prevention and treatment of pregnancy-related PFDs; namely, POP, FI, and UI. Therefore, this review incorporated studies comparing the use of physiotherapy and PFMEs with every other existing interventions. Methods: This systematic review and meta-analysis was conducted on randomized-controlled-trial (RCT) articles and quasi-RCT designs through a search in the studies published with no time limits until December 2017 in the databases of PubMed (Medline), Web of Science, Scopus, Embase, Cochrane Library, and ProQuest. The meta-analysis was also applied for data synthesis. Moreover, heterogeneity was assessed using Cochran’s Q test and I2 index. Results: A total number of 26 RCTs were examined in this review in which the outcome variables were related to POP, UI, and FI prevalence; POP, UI, and FI severity, as well as pelvic floor muscle (PFM) strength and endurance. In most articles, UI prevalence or severity in intervention groups had significantly improved compared with those in controls. The number of studies examining POP and FI was also relatively low. In two studies, FI severity or prevalence in intervention groups had significantly enhanced in comparison with those in control groups; however, FI prevalence in two articles had been reported lower in intervention groups than that in control groups although no significant difference had been observed. There was also no significant improvement in intervention groups in two other studies in this respect. Besides, three articles had not reported traces of improvement in POP, as well as a significant difference between intervention and control groups. Nevertheless, two studies had found a significant improvement in POP in this regard. Based on meta-analysis results for the variable of PFM strength, Cochran’s Q test (P&lt;0.001) and I2 index (90.02) indicated heterogeneity between studies; so, a random-effect meta-analysis was applied to estimate overall effect sizes. The overall mean differences following intervention between the study groups were also equal to 6.94, with a 95% CI (1.36 to 12.52). Conclusions: It was concluded that physiotherapy and PFMEs might have effects on pregnancy-related UI, but they had not consistently reduced FI severity or prevalence and failed to constantly improve POP.

Prevalence of and Factors Associated With Fecal Incontinence: Results From a Population-Based Survey

Re: Transobturator Vaginal Tape for the Treatment of Stress Urinary Incontinence in Elderly Women without Concomitant Pelvic Organ Prolapse: Is it Effective and Safe?

Prevalence studies of faecal incontinence in the general population are rare and the impact of faecal incontinence on quality of life has not been previously addressed. To establish the prevalence of faecal incontinence in adults in terms of frequency of leakage, degree of soiling, and level of impact on quality of life. In a cross sectional postal survey, 15 904 adults aged 40 years or more (excluding residents of nursing and residential homes) were selected randomly by household from the Leicestershire Health Authority patient register. Participants were asked to complete a confidential health questionnaire. Major faecal incontinence was defined as soiling of underwear or worse with a frequency of several times a month or more. Respondents were also asked if bowel symptoms had an impact on their quality of life. From a total sample of 10 116 respondents, 1.4% reported major faecal incontinence and 0.7% major faecal incontinence with bowel symptoms that had an impact on quality of life. Major faecal incontinence was significantly associated with a lot of impact on quality of life (odds ratio 12.4, 95% confidence interval 7.5-20.6). Incontinence was more prevalent and more severe in older people but there was no significant difference between men and women. This study has confirmed that faecal incontinence is a fairly common symptom, particularly in older people. Faecal incontinence in men has received little attention in the past and the results from this study indicate that it is as much of a problem in men as it is in women while the level of unmet need in this group is high. Estimates of need for health care for this symptom should be multidimensional and assess both the severity of symptoms and the impact it has on quality of life.

Little is known about faecal incontinence (FI) in individuals with irritable bowel syndrome (IBS). To compare characteristics of people with IBS reporting FI, compared with people with IBS who do not report FI. We collected demographic, gastrointestinal and psychological symptoms, healthcare usage, direct healthcare costs, impact on work and activities of daily living, and quality of life data from individuals with Rome IV-defined IBS. We asked participants about FI, assigning presence or absence according to Rome-IV criteria. Of 752 participants with Rome IV IBS, 202 (26.9%) met Rome IV criteria for FI. Individuals with FI were older (p< 0.001), more likely to have IBS-D (47.0% vs. 39.0%, p= 0.008), and less likely to have attained a university or postgraduate level of education (31.2% vs. 45.6%, p< 0.001), or to have an annual income of ≥£30,000 (18.2% vs. 32.9%, p< 0.001). They were more likely to report urgency (44.6% vs. 19.1%, p< 0.001) as their most troublesome symptom and a greater proportion had severe IBS symptom scores, abnormal depression scores, higher somatic symptom-reporting scores or higher gastrointestinal symptom-specific anxiety scores (p< 0.01 for trend for all analyses). Mean health-related quality of life scores were significantly lower among those with, compared with those without, FI (p< 0.001). Finally, FI was associated with higher IBS-related direct healthcare costs (p= 0.002). Among individuals with Rome IV IBS, one-in-four repo rted FI according to Rome IV criteria. Physicians should ask patients with IBS about FI routinely.

Fecal disorders have a relevant social impact because they impair the quality of life of the patient and add to the cost of healthcare. In order to shed light on the pathophysiology of fecal disorders it is helpful to consider the progression of obstructed defecation to fecal incontinence which occurs in women without anal sphincter defects who have descending perineum syndrome. The overall prevalence of chronic constipation in the general population is about 15 %, and the most common subtype among women is obstructed defecation. Obstructed defecation occurs in 47.7 % of Italian patients affected by chronic constipation. Dyssynergia alone is present in young women (median age 38 ± 14 years), whereas dyssynergia plus structural diseases, such as rectocele, rectal intussusception, mucosal prolapse and perineal descent materialize in middle-aged women (median age 52 ± 14 years) [1]. Therefore there is no doubt that ageing is implicated in the evolution from functional to anatomic pelvic floor disorders. In parallel, excessive abdominal straining at stool evacuation causes progressive perineal descent: the recurrent straining against defecatory outlet obstruction impairs pelvic floor muscle tone until it disappears completely. In this way descending perineum overlaps with pelvic floor dyssynergia [2]. Older age is correlated with both dynamic and fixed descending perineum [3], and excessive perineal descent is found in 78 % of elderly patients with evacuation disorders [4]. The organic descent of the hypotonic pelvic floor combined with pudendal neuropathy explains the appearance of fecal incontinence. Perineal descent involves the anterior, middle and posterior pelviperineal areas in women. Uro-gynecological structures and proctologic segments are all implicated and thus pelvic organ prolapse may coexist with rectoanal intussusception, rectal prolapse and rectocele [5]. Fecal incontinence is a physically and psychologically disabling condition which has a negative impact on the quality of life of the patient. The prevalence of fecal incontinence in community-dwelling women in the USA varies considerably depending on the population studied, ranging from 2.2 to 17 % of women housed in communities and up to almost half of all nursing home residents. Fecal incontinence is often related to several specific diseases, such as diabetes mellitus, dementia, irritable bowel syndrome, cerebrovascular disease, pelvic-anal surgery, traumatic sphincter lesions and post-partum incontinence. Even when excluding the presence of these cases, women over 65 years often have combined chronic constipation and fecal incontinence (32.7 % of constipated women) and women with anal incontinence have greater values of descending perineum measures than those without anal incontinence [6]. Therefore, these last epidemiological data support the hypothesis of a link between obstructed and fecal incontinence via descending perineum syndrome. Obstructed defecation can be caused by organic or functional diseases which are difficult to untangle. Mechanical causes include rectocele, rectoanal intussusception, descending perineum syndrome, solitary rectal ulcer syndrome, mucosal rectal prolapse, enterocele and sigmoidocele. Disorders of rectal sensation and pelvic floor dyssynergia are the functional diseases. Patients with rectal hyposensitivity have most commonly constipation (48 %), combined constipation and incontinence (27 %), or fecal incontinence (20 %). Obstructed defecation patients have a & F. Pucciani pucciani@unifi.it

Fecal incontinence (FI) is a debilitating condition defined as recurrent uncontrolled passage of fecal material according to Rome IV. Although FI greatly impacts patients' health-related quality of life (HRQOL), there have been few studies about the prevalence of FI in the Japanese general population. The aim of this study was to investigate the epidemiology of FI using Rome IV criteria in Japan. This was a cross-sectional internet survey for Japanese individuals aged 18 to 79 years using a questionnaire about demographics, comorbidities, lifestyle, abdominal symptoms, bowel habits, HRQOL, and disorders of gut-brain interaction according to Rome IV diagnostic criteria. Multivariate linear regression analysis identified factors associated with FI fulfilling Rome IV criteria (Rome IV FI). Overall, 9995 subjects were analyzed. Of which, 9.5% of the participants had at least one episode of FI in the last 3 months, and the prevalence of Rome IV FI was 1.2%. HRQOL was significantly impaired in patients with Rome IV FI compared to continent individuals. Major functional bowel disorders overlapped with 39.5% of Rome IV FI where functional diarrhea (25.8%) was the most predominant. The overlap further impaired HRQOL in Rome IV FI patients. Alcohol consumption (odds ratio 1.82, 95% CI 1.24-2.66, p = 0.002) was independently related to Rome IV FI apart from gastroesophageal reflux disease, irritable bowel syndrome, functional abdominal bloating/distension, and functional diarrhea. The prevalence of Rome IV FI was 1.2% in Japan. Further study is warranted to investigate the effect of lifestyle modification on the management of FI.

Incontinence is a common and distressing condition of later life. Prevalence studies have reported rates of urinary incontinence from about 3% to 60%, depending on how incontinence is defined and the type of population studied. There is much less information about the prevalence of faecal incontinence. However, some studies have found approximately 2% of the general population and about 60% of the nursing home population to be incontinent of faeces. Although some studies have examined the impact of urinary incontinence on health status, the impact of faecal incontinence has not been investigated previously. Quantification of the prevalence and specific impact on health of common disorders such as incontinence will help commissioners and providers in the prioritization of diagnostic and therapeutic services for this distressing condition. With this in mind, we report the relevant results of the Tipping the Balance Survey, which quantified the prevalence and impact on self-perceived health, anxiety and depression of both faecal and urinary incontinence.

PurposeNumerous studies have investigated the prevalence of constipation and fecal incontinence (FI) in the general population and, even though these disorders are known to co-occur, they were studied independently of each other. Our aim was to investigate the prevalence of constipation and FI, and their co-occurrence, in the general population in the Netherlands.MethodsWe studied a cross-section of the Dutch population (N = 1259). All respondents completed the Groningen Defecation & Fecal Continence checklist. We defined constipation and FI in accordance with the Rome III criteria.ResultsWe found that 24.5% (95% CI, 22.1–26.8) suffered from constipation, 7.9% (95% CI, 6.4–9.4) suffered from FI, and 3.5% (95% CI, 2.5–4.5) suffered from both disorders. Constipated respondents were 2.7 times more likely to suffer from FI than non-constipated respondents (95% CI, 1.8–4.0). Moreover, 48.7% of the respondents with constipation, 35.0% with FI, and 38.6% in whom the disorders co-occurred qualified their bowel habits as either “good” or “very good”. We found that 49.4% of the respondents with constipation and 48.0% with FI had not discussed their complaints with anyone.ConclusionsConstipation and FI, isolated or co-occurring, are common disorders in the general population, even in young and healthy respondents. Since constipation and FI often co-occur, we recommend that patients who seek medical attention for either disorder should be examined for both. Moreover, constipation and/or FI are not always identified appropriately by patients. Therefore, physicians should take the initiative to diagnose and treat these disorders.

State of Research in Pediatric Gastroenterology, Hepatology, and Nutrition: 2010 and Beyond

This is the first reported prospective study comparing outcome and cost in patients undergoing sphincteroplasty for anal incontinence vs. sphincteroplasty performed in combination with one or more procedures for urinary incontinence and/or pelvic organ prolapse. We analyzed 44 patients with fecal incontinence who underwent anal sphincter repair alone (20 patients) or in combination with procedures for urinary incontinence or pelvic organ prolapse (24 patients). Information regarding risk factors for fecal incontinence, the degree of incontinence, and the extent that incontinence limited social, physical, and sexual activity was prospectively obtained from questionnaires. Clinic chart reviews and follow-up telephone interviews provided additional data. A cohort of case-matched patients who underwent only urogynecologic procedures was compared retrospectively for operative time, hospital cost, length of stay, and postoperative complications. There were no major complications in any group. The functional outcomes, physical, social, and sexual activity were similar in all three groups. Twenty-two of 24 patients who underwent the combined procedures were glad that they had both procedures concomitantly. Combination pelvic floor surgery provides good outcomes and is cost effective. This approach should be offered to women with concurrent problems of fecal and urinary incontinence and/or pelvic organ prolapse.

Proton-pump inhibitor-responsive esophageal eosinophilia is a newly recognized entity with an unclear prevalence in children, as only retrospective data are available. The aim of this study was to determine the prevalence and clinical features of proton-pump inhibitor-responsive esophageal eosinophilia in children. This prospective study enrolled patients with esophageal symptoms and esophageal eosinophilic counts as 15 or more than 15 eos/hpf (eosinophils per high-power field). Children received treatment with esomeprazole 1 mg · kg per dose twice daily for 8 weeks and the endoscopy was repeated. Complete response to proton-pump inhibitor (PPI) was defined as 5 or less than 5 eos/hpf, and a partial response as >5 and <15 eos/hpf in post-treatment biopsies. Fifty-one children (74.5% boys) were included. Histological response was observed in 35 children (68.6%): 24 children (47%) had a complete response and 11 children (21.6%) had a partial response. Only 16 children (31.4%) were diagnosed with eosinophilic esophagitis (EoE). There were no differences in history of atopy, allergy tests, pH study results, and endoscopic scores. Clinical symptoms were similar, with the exception of food impaction, which was more frequent in children with EoE (56.2% vs 20%, P = 0.01). The mean pretreatment peak eosinophil count was higher in patients with EoE (74.8 ± 36.2 vs 46.3 ± 30.7, P = 0.007). Eleven of the 14 patients (78.6%) on a lower PPI treatment maintenance dose remained in clinicopathologic remission at 1-year follow-up. A significant proportion of children with esophageal eosinophilia responded to high dose PPI treatment. Clinical, endoscopic, and pH study results were similar, with exception of patients with EoE, who were more likely to experience food impaction and have higher esophageal eosinophil counts.