Background
About one‐third of women have urinary incontinence (UI) and up to one‐tenth have faecal incontinence (FI) after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended ...during pregnancy and after birth for both preventing and treating incontinence.
This is an update of a Cochrane Review previously published in 2017.
Objectives
To assess the effects of PFMT for preventing or treating urinary and faecal incontinence in pregnant or postnatal women, and summarise the principal findings of relevant economic evaluations.
Search methods
We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearched journals and conference proceedings (searched 7 August 2019), and the reference lists of retrieved studies.
Selection criteria
We included randomised or quasi‐randomised trials in which one arm included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention.
Populations included women who, at randomisation, were continent (PFMT for prevention) or incontinent (PFMT for treatment), and a mixed population of women who were one or the other (PFMT for prevention or treatment).
Data collection and analysis
We independently assessed trials for inclusion and risk of bias. We extracted data and assessed the quality of evidence using GRADE.
Main results
We included 46 trials involving 10,832 women from 21 countries. Overall, trials were small to moderately‐sized. The PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Two participants in a study of 43 pregnant women performing PFMT for prevention of incontinence withdrew due to pelvic floor pain. No other trials reported any adverse effects of PFMT.
Prevention of UI: compared with usual care, continent pregnant women performing antenatal PFMT probably have a lower risk of reporting UI in late pregnancy (62% less; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; moderate‐quality evidence). Antenatal PFMT slightly decreased the risk of UI in the mid‐postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; high‐quality evidence). There was insufficient information available for the late postnatal period (more than six to 12 months) to determine effects at this time point (RR 1.20, 95% CI 0.65 to 2.21; 1 trial, 44 women; low‐quality evidence).
Treatment of UI: compared with usual care, there is no evidence that antenatal PFMT in incontinent women decreases incontinence in late pregnancy (very low‐quality evidence), or in the mid‐(RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; low‐quality evidence), or late postnatal periods (very low‐quality evidence). Similarly, in postnatal women with persistent UI, there is no evidence that PFMT results in a difference in UI at more than six to 12 months postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; low‐quality evidence).
Mixed prevention and treatment approach to UI: antenatal PFMT in women with or without UI probably decreases UI risk in late pregnancy (22% less; RR 0.78, 95% CI 0.64 to 0.94; 11 trials, 3307 women; moderate‐quality evidence), and may reduce the risk slightly in the mid‐postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; low‐quality evidence). There was no evidence that antenatal PFMT reduces the risk of UI at late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; moderate‐quality evidence). For PFMT started after delivery, there was uncertainty about the effect on UI risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; moderate‐quality evidence).
Faecal incontinence: eight trials reported FI outcomes. In postnatal women with persistent FI, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (very low‐quality evidence). In women with or without FI, there was no evidence that antenatal PFMT led to a difference in the prevalence of FI in late pregnancy (RR 0.64, 95% CI 0.36 to 1.14; 3 trials, 910 women; moderate‐quality evidence). Similarly, for postnatal PFMT in a mixed population, there was no evidence that PFMT reduces the risk of FI in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, low‐quality evidence).
There was little evidence about effects on UI or FI beyond 12 months' postpartum. There were few incontinence‐specific quality of life data and little consensus on how to measure it.
Authors' conclusions
This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on UI, although the reasons for this are unclear. A population‐based approach for delivering postnatal PFMT is not likely to reduce UI. Uncertainty surrounds the effects of PFMT as a treatment for UI in antenatal and postnatal women, which contrasts with the more established effectiveness in mid‐life women.
It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches, and in certain groups of women. Hypothetically, for instance, women with a high body mass index (BMI) are at risk of UI. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups, and how much PFMT women in both groups do, to increase understanding of what works and for whom.
Few data exist on FI and it is important that this is included in any future trials. It is essential that future trials use valid measures of incontinence‐specific quality of life for both urinary and faecal incontinence. In addition to further clinical studies, economic evaluations assessing the cost‐effectiveness of different management strategies for FI and UI are needed.
In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and ...to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, and pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, passive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.
Fecal incontinence is not a diagnosis but a frequent and debilitating common final pathway symptom resulting from numerous different causes. Incontinence not only impacts the patient’s self-esteem ...and quality of life but may result in significant secondary morbidity, disability, and cost. Treatment is difficult without any panacea and an individualized approach should be chosen that frequently combines different modalities. Several new technologies have been developed and their specific roles will have to be defined. The scope of this review is outline the evaluation and treatment of patients with fecal incontinence.
Inflammatory bowel diseases (IBD), Crohn`s disease and ulcerative colitis, are chronic conditions associated with high morbidity and healthcare costs. The natural history of IBD is variable and ...marked by alternating periods of flare and remission. Even though the use of newer therapeutic targets has been associated with higher rates of mucosal healing, a great proportion of IBD patients remain symptomatic despite effective control of inflammation. These symptoms may include but not limited to abdominal pain, dyspepsia, diarrhea, urgency, fecal incontinence, constipation or bloating. In this setting, commonly there is an overlap with gastrointestinal (GI) motility and absorptive disorders. Early recognition of these conditions greatly improves patient care and may decrease the risk of mistreatment. Therefore, in this review we describe the prevalence, diagnosis and treatment of GI motility and absorptive disorders that commonly affect patients with IBD.
Anterior resection syndrome Bryant, Catherine LC, MRCS; Lunniss, Peter J, FRCS; Knowles, Charles H, Prof ...
The lancet oncology,
09/2012, Letnik:
13, Številka:
9
Journal Article
Recenzirano
Summary Up to 80% of patients with rectal cancer undergo sphincter-preserving surgery. It is widely accepted that up to 90% of such patients will subsequently have a change in bowel habit, ranging ...from increased bowel frequency to faecal incontinence or evacuatory dysfunction. This wide spectrum of symptoms after resection and reconstruction of the rectum has been termed anterior resection syndrome. Currently, no precise definition or causal mechanisms have been established. This disordered bowel function has a substantial negative effect on quality of life. Previous reviews have mainly focused on different colonic reconstructive configurations and their comparative effects on daily function and quality of life. The present Review explores the potential mechanisms underlying disturbed functions, as well as current, novel, and future treatment options.
Our understanding of human colonic motility, and autonomic reflexes that generate motor patterns, has increased markedly through high-resolution manometry. Details of the motor patterns are emerging ...related to frequency and propagation characteristics that allow linkage to interstitial cells of Cajal (ICC) networks. In studies on colonic motor dysfunction requiring surgery, ICC are almost always abnormal or significantly reduced. However, there are still gaps in our knowledge about the role of ICC in the control of colonic motility and there is little understanding of a mechanistic link between ICC abnormalities and colonic motor dysfunction. This review will outline the various ICC networks in the human colon and their proven and likely associations with the enteric and extrinsic autonomic nervous systems. Based on our extensive knowledge of the role of ICC in the control of gastrointestinal motility of animal models and the human stomach and small intestine, we propose how ICC networks are underlying the motor patterns of the human colon. The role of ICC will be reviewed in the autonomic neural reflexes that evoke essential motor patterns for transit and defecation. Mechanisms underlying ICC injury, maintenance, and repair will be discussed. Hypotheses are formulated as to how ICC dysfunction can lead to motor abnormalities in slow transit constipation, chronic idiopathic pseudo-obstruction, Hirschsprung's disease, fecal incontinence, diverticular disease, and inflammatory conditions. Recent studies on ICC repair after injury hold promise for future therapies.
Objectives
To estimate the prevalence of constipation, fecal incontinence (FI), and combined symptoms and to identify shared factors associated with bowel symptoms in older U.S. men and women
Design
...Population‐based cross‐sectional study.
Setting
National Health and Nutrition Examination Survey (2005–2010).
Participants
Women and men aged 50 and older.
Measurements
Constipation was defined as hard stool consistency on the validated Bristol Stool Form Scale or stool frequency of fewer than three bowel movements per week. FI was defined as at least monthly loss of solid, liquid, or mucus stool. Combined symptoms was defined as constipation and FI. Multinomial multivarible models adjusted for age, race, socioeconomic status, education, self‐rated health, depression, impairments in activities of daily living, and number of comorbidities.
Results
Women (n = 3,078) reported higher prevalence of bowel symptoms than men (constipation 11.8% vs 4.7%%, FI 11.2% vs 8.6%, combined symptoms 1.4% vs 0.4%). In adjusted models, women had greater odds of having constipation (odds ratio (OR) = 3.0, 95% confidence interval (CI) = 2.3–3.8), FI (OR = 1.4, 95% CI = 1.1–1.8), and combined symptoms (OR = 4.6, 95% CI = 2.0–10.2) than men. Shared risk factors included poor self‐rated health and depression symptoms (constipation: OR = 1.8, 95% CI = 1.4–2.4 and OR = 1.8, 95% CI = 1.0–3.2; FI: OR = 1.6, 95% CI = 1.2–2.2 and OR = 2.3 95% CI = 1.4–3.6; combined symptoms: OR = 2.6 95% CI = 1.5–4.8 and OR = 4.6, 95% CI = 1.3–16.4).
Conclusion
When defining constipation and FI using validated instruments, women had a much higher prevalence of constipation than men, whereas men had a higher prevalence of FI than constipation. Shared risk factors reflect the negative effect that bowel symptoms have on quality of life.
Aim
There is increasing awareness of the poor functional outcome suffered by many patients after sphincter‐preserving rectal resection, termed ‘low anterior resection syndrome’ (LARS). There is no ...consensus definition of LARS and varying instruments have been employed to measure functional outcome, complicating research into prevalence, contributing factors and potential therapies. We therefore aimed to describe the instruments and outcome measures used in studies of bowel dysfunction after low anterior resection and identify major themes used in the assessment of LARS.
Method
A systematic review of the literature was performed for studies published between 1986 and 2016. The instruments and outcome measures used to report bowel function after low anterior resection were extracted and their frequency of use calculated.
Results
The search revealed 128 eligible studies. These employed 18 instruments, over 30 symptoms, and follow‐up time periods from 4 weeks to 14.6 years. The most frequent follow‐up period was 12 months (48%). The most frequently reported outcomes were incontinence (97%), stool frequency (80%), urgency (67%), evacuatory dysfunction (47%), gas–stool discrimination (34%) and a measure of quality of life (80%). Faecal incontinence scoring systems were used frequently. The LARS score and the Bowel Function Instrument (BFI) were used in only nine studies.
Conclusion
LARS is common, but there is substantial variation in the reporting of functional outcomes after low anterior resection. Most studies have focused on incontinence, omitting other symptoms that correlate with patients’ quality of life. To improve and standardize research into LARS, a consensus definition should be developed, and these findings should inform this goal.
Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and ...aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.
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