Needs Assessment for Treatment of Fecal Incontinence
In this issue of the Diseases of the Colon & Rectum, Helewa and colleagues3 highlight the lack of awareness of fecal incontinence as a health issue and the barriers that exist to access to treatment. The qualitative research techniques used are unfamiliar to many surgeons used to more measurable outcomes. Yet the message is powerful, illustrated by selected patient narratives that resonate with those who treat patients with incontinence. Patient perspectives are paramount and “empower decisions based on their values.”4
There has undoubtedly been considerable progress in treating obstetric anal sphincter injuries (OASIS) now recognized as a major cause of incontinence following childbirth. Guidelines from the American College of Obstetricians and Gynecologists,5 the Society of Obstetricians and Gynecologists of Canada,6 and the British Royal College of Obstetricians7 now mandate adequate assessment of the perineum and anal sphincters following vaginal delivery. Anatomical repair under optimum conditions and follow-up in specialized clinics offer the best outcome for those recognized as having sustained OASIS.8 However, OASIS and cumulative injury to the endopelvic fascia and pudendal nerves during subsequent vaginal deliveries coupled with menopause9 often insidiously lead to continence difficulties in middle years. It is this cohort of women who are least well served.
Helewa et al3 have found that improved quality of life and not absolute number of incontinence episodes is the most important treatment end point from the patient’s perspective. The widely used Cleveland Clinic and St Mark scores focus on number and severity of episodes, whereas the Fecal Incontinence Quality of Life,10 the colorectal functional outcome11 questionnaires, and the recently developed International Consultation on Incontinence Questionnaire-Bowel questionnaire12 offer more comprehensive assessment of the effects of incontinence on quality of life. Future research focusing on outcomes assessment must take account of these metrics.
Not all patients with fecal incontinence need a surgical procedure; indeed, the majority can be successfully managed with dietary and lifestyle advice coupled with loperamide or similar pharmacological manipulation. A key intervention, however, is the opportunity to interact with an interested and knowledgeable health care professional. Often, a continence nurse or physiotherapist is best suited rather than a clinician, because time and empathy are essential to the process, in particular, when self-esteem needs to be reestablished. Multiple visits are often required to reinform and reinforce treatment advice given. Helewa et al3 used posterior tibial nerve stimulation (PTNS) to treat their patients, because they did not have funded access to sacral nerve stimulation. As in the recent CONFIDeNT trial13 that compared PTNS with sham transcutaneous electrical stimulation, Helewa et al3 found quality-of-life benefit that may reflect 12 weeks of patient interaction with a health care professional rather than the actual effect of the PTNS itself. This finding highlights both the importance of professional engagement and the need to adequately assess quality-of-life outcomes.
Finally, Helewa et al3 highlight the difficulty of accessing appropriate care for patients with fecal incontinence in the Canadian health care system.