Time course and predictors of symptoms after primary prostate cancer therapy.
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PURPOSE: Understanding the distinctive patterns of treatment-related dysfunction after alternative initial treatments for early prostate cancer (PC) may improve patients' choice of treatment and later help them adjust to its consequences. We characterized the time course of treatment complications while adjusting for potentially confounding pretreatment factors hindering other observational studies. PATIENTS AND METHODS: In a prospective cohort study of 417 men we assessed urinary, bowel, and sexual function from before primary treatment to 24 months after. To control for potential confounding, we measured sociodemographic and PC prognostic factors, medical comorbidity, and pretreatment function commonly affected by PC and its treatment. RESULTS: Patients who underwent external beam radiotherapy (EBRT), radical prostatectomy (RP), and brachytherapy (BT) differed significantly in sociodemographic factors, cancer prognostic factors, and pretreatment symptom status, especially sexual function. Urinary incontinence increased sharply after RP, while bowel problems and urinary irritation/obstruction rose after EBRT and BT. Sexual dysfunction increased in all patients, particularly after radical prostatectomy, and nerve-sparing surgical technique had little apparent benefit. There was no change in urinary function and little change in overall bowel function after 12 months, but the time course of sexual dysfunction varied by treatment and, for bowel function, by symptom. Multiple regression modeling confirmed that treatment influences all 24-month outcomes, but residual confounding persisted. CONCLUSION: Pretreatment function and the primary treatment modality for early stage PC strongly predict the affected organ systems and time course of dysfunction. With this information, patients and their physicians may refine their choice of treatment and better anticipate its consequences. (+info)
Endoanal sonography in assessment of fecal incontinence following obstetric trauma.
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OBJECTIVES: Fecal incontinence is a common, incapacitating and largely unrecognized medical problem and can be caused by various factors. Obstetric trauma is the most common cause of fecal incontinence secondary to trauma. We aimed to analyze the role of endoanal ultrasound in assessment of this type of fecal incontinence, and report the functional results of surgical treatment. METHODS: We reviewed the records of all 22 patients with fecal incontinence secondary to obstetric trauma who were evaluated by endoanal ultrasound and underwent surgical management in our department from April to 1997 to April 2002. Pre- and postoperative evaluation of the degree of incontinence was done using the incontinence score of Jorge and Wexner. RESULTS: The patients had a median age of 43 (range, 29-68) years. All had vaginal deliveries, five of which (22.7%) were instrumental. Most of the patients had total fecal incontinence (solids) with preoperative incontinence score values of 15-20 (median, 18). Endoanal ultrasound confirmed structural defects in the anterior external anal sphincter alone in 16 (72.7%) patients, and both anterior external and internal sphincter defects in six (27.3%) patients. A thinned perineal body was present in all patients. All patients received surgical treatment with overlapping sphincteroplasty and there was improvement of continence in 19 (86.4%) patients with postoperative incontinence score values between 4 and 0 (median, 2). CONCLUSIONS: Endoanal sonography is an accurate method for assessing sphincter anatomy, delineating both internal and external anal sphincters. Surgical treatment of sphincter defects is associated with good outcome. (+info)
Promoting continence: simple strategies with major impact.
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Urinary incontinence is a common problem, especially among women, yet it remains underreported and undertreated. This is partly due to patients' beliefs that little can be done and partly due to healthcare professionals' perception that treatment is limited to surgery, advanced behavioral strategies requiring specialized equipment, or containment devices. Nurses are in a strategic position to reduce the incidence of incontinence by teaching bladder health strategies (ie, fluid management, appropriate voiding intervals, constipation prevention, weight control, smoking cessation, and pelvic muscle exercises), actively assessing patients for incontinence, and initiating appropriate referrals and primary interventions. Patients with significant neurologic deficits, structural abnormalities such as pelvic organ prolapse, or urinary retention should be referred for further workup. However, most patients can be treated with primary continence restoration strategies, which include identifying and correcting reversible factors such as urinary tract infection or atrophic urethritis; instruction in pelvic floor muscle exercises; and instruction regarding urge inhibition strategies. Implementing these simple strategies can significantly improve bladder function and continence in the majority of patients. (+info)
The pathophysiology of faecal spotting in obese subjects during treatment with orlistat.
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BACKGROUND: The intermittent loss of oil or liquid faeces ('spotting') is an adverse effect that occurs in obese patients during treatment with the lipase inhibitor orlistat; the pathophysiology is unknown. AIM: To investigate the effects of orlistat on anorectal sensorimotor function and continence. METHODS: Obese subjects susceptible to spotting were identified by an unblind trial of orlistat. Obese spotters (n = 15) and non-spotters (n = 16) completed a randomized, double-blind, cross-over trial of orlistat and placebo. Anorectal function was assessed by rectal barostat and anal manometry, together with a novel stool substitute retention test, a quantitative measurement of faecal continence. RESULTS: Orlistat increased stool volume and raised faecal fat and water. Treatment had no effect on anorectal motor function, but rectal sensation was reduced; on retention testing, the volume retained was increased. Subjects susceptible to spotting had lower rectal compliance, heightened rectal sensitivity and weaker resting sphincter pressure than non-spotters. On retention testing, gross continence was maintained; however, spotters lost small volumes of rectal contents during rectal filling. CONCLUSION: Treatment with orlistat has no direct adverse effects on anorectal function or continence. Spotting occurs during treatment with orlistat when patients with sub-clinical anorectal dysfunction are exposed to increased stool volume and altered stool composition. (+info)
Review article: the management of pelvic floor disorders.
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Anorectal disorders, such as faecal incontinence, defecation difficulty and conditions associated with anorectal pain, are commonly encountered in the practices of gastroenterologists, urogynaecologists and colorectal surgeons. The evaluation of these disorders has been very much improved by the development and wider availability of diagnostic tests, such as manometry, endo-anal ultrasound, static and dynamic pelvic magnetic resonance imaging and electromyography. After briefly reviewing the normal anatomy and physiology of the anorectum, the pathophysiology and diagnostic approaches to faecal incontinence, defecation disorders and functional anorectal pain are discussed. Until recently, the management of these disorders has been largely anecdotal. However, our therapeutic armamentarium has been expanded by pharmacological agents, such as nitrates, calcium channel blockers and botulinum toxin, as well as the development of novel techniques, such as sacral nerve stimulation. These and other pharmacological, behavioural and surgical approaches are reviewed with respect to the robustness of evidence to support their efficacy in patients with these disorders. (+info)
Risk factors in acquired faecal incontinence.
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Acquired faecal incontinence arising in the non-elderly population is a common and often devastating condition. We conducted a retrospective cohort analysis in 629 patients (475 female) referred to a tertiary centre, to determine the relative importance of individual risk factors in the development of faecal incontinence, as demonstrated by abnormal results on physiological testing. Potential risk factors were identified in all but 6% of patients (7 female, 32 male). In women, the principal risk factor was childbirth (91%), and in most cases at least one vaginal delivery had met with complications such as perineal injury or the need for forceps delivery. Of the males, half had undergone anal surgery and this was the only identified risk factor in 59%. In many instances, assignment of cause was hampered by a long interval between the supposed precipitating event and the development of symptoms. Abnormalities of anorectal physiology were identified in 76% of males and 96% of females (in whom they were more commonly multiple). These findings add to evidence that occult damage to the continence mechanism, especially through vaginal delivery and anal surgery, can result in subsequent faecal incontinence, sometimes after an interval of many years. (+info)
Impact of anal incontinence and chronic constipation on quality of life.
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AIM: To determine the impact of symptoms related to chronic constipation and fecal incontinence on quality of life. PATIENTS AND METHODS: This prospective study included 173 consecutive patients who referred addressed to our laboratory for anorectal manometry. Quality of life was evaluated using the GIQLI questionnaire, and severity of symptoms using the Cleveland Clinic scores for constipation and fecal incontinence. A correlation study was performed between the quality of life and symptoms scores. RESULTS: The GIQLI questionnaire was correctly completed by 157 patients (90.7%). The mean GIQLI score was 89 +/- 24, without any significant difference between constipated and incontinent patients. The mean constipation score was 15.7/30 (range: 6-25). The mean fecal incontinence score was 10.5/20 (range: 3-16). Correlation between quality of life and symptom scores was poor. Thus, a significant threshold value for symptom scores corresponding to major alteration of quality of life could not be determined. CONCLUSIONS: Quality of life is profoundly altered both in patients with chronic constipated and incontinence. Symptom scores do not allow satisfactory evaluation of the impact of chronic constipation or fecal incontinence on patients' quality of life. These results confirm the need for systematic exploration of quality of life in these patients, to correctly address the severity of functional diseases, and the influence of therapy. (+info)
Applied electrophysiology of transposed muscle stimulation: practical considerations and surgical experience on graciloplasty for faecal incontinence.
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Dynamic Graciloplasty has demonstrated to be a reliable option in the treatment of end-stage Faecal Incontinence with stable results after long-term evaluation studies. Continence restoration varies from 40 to 65% depending on incontinence etiology and surgical experience. In spite of that mechanisms of chronic electrostimulation, necessary to obtain muscular fiber conversion and increase contractile resistance to a prolonged stimulation still remains unfriendly to many colorectal surgeons. On the basis of pioneering experience on this field we examine the main critical aspects of electrostimulation, ranging from neurovascular bundle preparation to electrodes insertion and stimulation protocol application. The experience in the last 36 dynamic graciloplasties performed for Faecal Incontinence treatment is presented. A long-term success rate of 75% was achieved. Key features for a good postoperative contractile response were identified in a careful gracilis mobilization, in a meticulous identification of nervous pedicle and in the prudent early p.o. stimulation. Fibers conversion was obtained after a 10-11 weeks of training period with on/off stimulation in the majority of patients and battery life was significantly prolonged with a meticulous search of the lowest intraoperative stimulation thresholds. Early failures demonstrated to be linked mainly to postoperative septic complications, while long-term results were significantly related to the efficacy of muscular recruitment and in preoperative phase, to a careful patients selection. (+info)