To investigate the aetiological importance of bowel dysfunction in patients with uterovaginal prolapse and urinary stress incontinence.Observational study using a questionnaire about obstetric history and bowel function, and anorectal physiological studies.Physiology unit and gynaecological outpatients departments of two teaching hospitals.Twenty-three women with uterovaginal prolapse (mean age 57 years), 23 women with urinary stress incontinence (mean age 52 years) and 27 control women (mean age 52 years).There was no statistically significant difference between the three groups in their parity, age or birthweight of their children. However, straining at stool as a young adult prior to the development of urogynaecological symptoms was significantly more common in women with uterovaginal prolapse (61% vs 4%, P < 0.001) and women with urinary stress incontinence (30% vs 4%, P < 0.05), compared with controls. A bowel frequency of less than twice per week as a young adult was also more common in women with uterovaginal prolapse than in control women (48% vs 8%, P < 0.001). At the time of consultation, 95% of the women with uterovaginal prolapse were constipated, compared with only 11% of control women. Many of these women also needed to digitate to achieve rectal evacuation. Compared with controls, women with uterovaginal prolapse had a prolonged pudendal nerve terminal motor latency (1.9 ms vs 2.2 ms, respectively, P = 0.003). Women with stress incontinence of urine had a normal pudendal nerve latency (2.0 ms). Other tests of anorectal function were normal.Constipation, in addition to obstetric history, appears to be an important factor in the pathogenesis of uterovaginal prolapse.
For patients with mild-to-moderate ulcerative colitis (UC), 5-aminosalicylic acid (5-ASA) represents the mainstay of their therapy. However, many of the current 5-ASA formulations require multiple-daily dosing, which can lead to poor adherence, particularly among those with quiescent disease, and increased risk of disease exacerbation. MMX mesalamine (LialdaTM [MezavantTM XL in the UK and Ireland; MezavantTM elsewhere]) is a novel, oral formulation of 5-ASA designed for once-daily (QD) dosing. During a 12-month maintenance study (SPD476-303) among patients with mild-to-moderate UC, patient satisfaction with MMX mesalamine treatment was assessed. Patients with mild-to-moderate UC who attained remission following MMX mesalamine treatment (2.4g/day given QD or as 1.2g twice daily [BID], or 4.8g/day given QD) in either of two, 8-week, phase III studies (SPD476-301 and -302), or an 8-week extension study (in which patients received MMX mesalamine 4.8g/day [given as 2.4g BID] as part of study SPD476-303), could enter a 12-month maintenance phase of study SPD476-303. Patients entering the maintenance phase of this open-label study were randomized to MMX mesalamine 2.4g/day given QD or as 1.2g BID. Patients completed a voluntary treatment satisfaction questionnaire after 6 months or at study withdrawal. Satisfaction was assessed using a 5-grade scale ranging from extremely satisfied to extremely dissatisfied. The satisfaction questionnaire was completed by 79/225 patients who received the QD regimen and by 73/234 patients who received the BID regimen. 96.2% of patients in the QD group and 91.8% in the BID group reported being somewhat/extremely satisfied with the number of times per day they were required to take medication. Values for overall satisfaction were 98.7% and 95.9%, respectively. The majority of patients receiving MMX mesalamine 2.4g/d (whether given QD or BID) maintenance therapy were satisfied with their treatment. Satisfaction with MMX mesalamine, particularly if given QD, is expected to improve adherence rates and thus overall treatment success.
Anorectal physiology and continence were assessed prospectively before and after surgery in 50 patients with chronic perianal sepsis. Functional and physiological parameters were unchanged after surgery in 13 control patients who had sepsis but who did not undergo division of the anal sphincter. Group 1 comprised 22 patients with internal sphincter division alone (15 intersphincteric, seven trans-sphincteric treated by a loose seton technique) and group 2 consisted of 15 patients with a trans-sphincteric fistula laid completely open. In group 1 the median (interquartile range (i.q.r.)) resting pressure in the distal 1 cm of the anal canal was reduced from 68 (60-90) cmH2O before surgery to 44 (35-60) cmH2O after operation (P < 0.001); squeeze pressure was less affected, but function deteriorated in 11 of the 22 patients. The median (i.q.r.) resting pressure in group 2 patients also fell, from 68 (34-84) cmH2O before operation to 28 (20-54) cmH2O afterwards (P = 0.003); median (i.q.r.) maximum squeeze pressure decreased more, from 124 (76-170) cmH2O to 72 (48-112) cmH2O (P = 0.002). Functional deficit occurred in eight of the 15 patients. Incontinence was related to low resting pressure, reflecting internal sphincter integrity, and to local epithelial electrosensitivity (reflecting scarring), but not to squeeze pressure, fistula type or surgical treatment.
Abstract Background and method This systematic review assesses the efficacy and safety of sacral nerve stimulation (SNS) for faecal incontinence and constipation. Electronic databases and selected websites were searched for studies evaluating SNS in the treatment of faecal incontinence or constipation. Primary outcome measures included episodes of faecal incontinence per week (faecal incontinence studies) and number of evacuations per week (constipation studies). Results From 106 potentially relevant reports, six patient series and one crossover study of SNS for faecal incontinence, and four patient series and one crossover study of SNS for constipation, were included. After implantation, 41–75 per cent of patients achieved complete faecal continence and 75–100 per cent experienced improvement in episodes of incontinence. There were 19 adverse events among 149 patients. The small crossover study reported increased episodes of faecal incontinence when the implanted pulse generator was switched off. Case series of SNS for constipation reported an increased frequency of evacuation. There were four adverse events among the 20 patients with a permanent implant. The small crossover study reported a reduced number of evacuations when the pulse generator was switched off. Conclusion SNS results in significant improvement in faecal incontinence in patients resistant to conservative treatment. Early data also suggest benefit in the treatment of constipation.
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