Conservative Management of Functional Bowel & Pelvic Floor Disorders Kathy Davis PhD BSc(Hons)SRN Specialist Nurse Consultant Parkside Hospital & Minerva Medical Clinic
Overview Burden of disease Aims Assessment Management & new technologies in FI
PFD is common (prev. 14-46%) Affects 1/3 rd of all women Affects bladder, bowel & sexual function >60% PF problems can be managed conservatively
Health burden and costs High level of unmet service need Significant costs- NHS bill for UI & FI estimated at 500 million PA on par with gynae ca, osteoporosis, pneumonia, flu, OA (Turner al BJU 2004) USA - PFD adult OPD visit = 0.9% of > women over 60 years (Sung et al 2009) Future demand for services over next 30 years expected to rise by 50% (Luber et al 2001)
AIMS OF TREATMENT Symptom improvement (primary outcome) Restoration of physiological function Correction of anatomical defect Improvement in QoL & social confidence
Challenge of Faecal Incontinence Multifactorial Pathophyisological mechanisms overlap Majority of patients (80%) have 1 or more underlying abnormalities (structure, function, stool characteristics)
Assessment Patients reluctant to discuss details specific questioning needed Onset Precipitating events Duration Severity History of constipation/ impaction Stool volume/consistency/urgency Ability to distinguish flatus, formed/unformed stool Coexisting medical conditions Medications, prescription/otc Diet/lifestyle -smoking, EtoH, caffeine Determine clinical subtype
Sub types of Faecal Incontinence Passive incontinence the involuntary discharge of feacal matter or flatus without any awareness. Urge incontinence the discharge of faecal matter or flatus despite active attempts to retain these contents Faecal seepage undesired leakage of stool often after a bowel movement with otherwise normal continence and evacuation
Treatments: overview Focus on containment : Pads/Anal plugs Focus on function: Dietary & lifestyle modification Pharmacological Bowel retraining /ASM/PFME +-biofeedback/anal irrigation, SNS, PTNS Focus on structure: Direct anal sphincter repair with levatorplasty Sphincter bulking/implants Artificial anal sphincter
Modifiable risk factors Smoking - effect of nicotine on colonic transit & rectal compliance, 5 fold increase in FI among smokers (Bharucha et al 2012) Obesity - multiple health problems, increased intra abdominal pressure/ PF weakness (Halland & Talley 2012) Diet - role in stool volume & consistency, sources of food intolerance (lactose or gluten), soluble v insoluble fibre, caffeine, alcohol, citrus Lifestyle and toileting behaviour - ameliorate / attenuate IBS
Trans Anal Irrigation system (Peristeen) Qufora Mini system
Neuromodulation Fast growing area of medicine Technology that impacts upon neural interfaces to produce benefit 1 Inherently non-destructive, reversible & adjustable First applied medicinally in 1909: stereotactic brain surgery 2 1. Krames et al., Neuromodulation 2009, Elselvier 2. Horsley V, BMJ 1909 & Cushing H, Brain 1909
Neuromuscular Modulation SNS & PTNS Both effective for FI & UI - SNS associated with complications Advantages of peripheral NM via PN: - indirect stimulation is inherently safe - application can be removed - dose can be adjusted - minimally invasive & well tolerated - potential effect on multiple pelvic organs - cost effective compared to SNS - NICE approved
Sacral Nerve Stimulation Some long term data, N of SN s believed to act at level of efferent motor neuron increased contraction, ASM/PFM pressure Complete continence 41-75% 50% decrease in FI episodes & improved QoL in 75-100%, Invasive, 2-stage procedure, pts must undergo PNE prior to permanent neuro- stimulator implant in upper buttock Expensive, not routinely recommended, requires individual funding application 10 yr cost approx. 19,800 Jarrett et al., Br J Surg 2004, Hetzer et al., Arch Surg 2007, Dudding et al., Br J Surg 2008, Matzel et al., Lancet 2004, Wexner et al., Ann Surg 2010
Pathway of the Tibial Nerve PTNS delivers retrograde access to SN plexus
Urgent PC Neuromodulation System Less invasive NM, alt option to SNS Involves a battery powered, external electrical pulse generator & acupuncture type needle electrode lead set. Total cost approx. 1740.00 (Yr 1 x 15 ) av. 4 top ups (approx. 464.00 Yr 2/3 (exclusive of facilities, clinical & admin support )
Procedure Patient sat comfortably, support treatment leg, insertion site is easily accessible, 3 finger breadths above medial malleolus, 1 finger breadth posterior to tibia 30 minute treatments
Contraindications Urgent PC Pregnant or planning to become pregnant Pacemakers or implantable defibrillators Those prone to excessive bleeding Patients with nerve damage that could impact either percutaneous tibial nerve or pelvic floor function
Treatment Frequency 12 treatments- typically 1 x pw top up to maintain symptom improvement If symptoms reappear or increase in severity, return to treatment frequency providing efficacy Improvement after 6 to 8 treatments Complete 12 sessions before determining effectiveness Measure baseline for comparison (bowel diary, FI score, QOL) Continue with dietary/pharmacological measures
Outcomes Success rate 55-65% Safe & well tolerated Reduced toilet frequency Reduced faecal urgency Greater deferment time Low patient drop out High levels of patient acceptability, satisfaction & dignity Cost effective v containment pads (Hotouras et al Int J colorectal dis ( 2012)
Take home message PTNS treatment well tolerated buys time perception of greater bodily function control emotional benefits- reduces anxiety & frustration- less dependence on locating toilets liberation from pads feels clean more normal lifestyle
Proposed Model for Management Refer all patients to a CNC led clinic Assess and treat Still symptomatic PFD MDT Individualize conservative treatment plan Optimise bladder & bowel function Improve -- discharge Colorectal investigations corrective surgery Urogynaecology investigation corrective surgery 22
Summary FB/PFD has many unmet clinical needs Allow sufficient consultation time Most patients can be effectively managed conservatively Judicial use of range of Tx modalities (TAI, B& B retraining, PFMT +-biofeedback, NM & PTNS Form an important adjunct & may even avoid need for surgery
Thank you