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Stimulation for Faecal
Incontinence
Stimulation for Faecal
Incontinence
PhD Thesis by
Jonas Worsøe
Center for Sensory-Motor Interaction (SMI),
Department of Health Science and Technology,
Aalborg University, Aalborg, Denmark
ISBN 978-87-92329-53-0 (e-book)
Published, sold and distributed by:
River Publishers
P.O. Box 1657
Algade 42
9000 Aalborg
Denmark
Tel.: +45369953197
www.riverpublishers.com
Copyright for this work belongs to the author, River Publishers have the sole
right to distribute this work commercially.
All rights reservedc 2012 Jonas Worsøe.
No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying,
microfilming, recording or otherwise, without prior written permission from
the Publisher.
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Table of Contents
Preface xi
Abstract xiii
Dansk resume xvii
Abbreviations xxi
Chapter 1: Introduction 1
1.1 Background 1
1.2 Aims 2
1.3 Anatomy 3
1.3.1 Stomach 3
1.3.2 Small intestine 4
1.3.3 Rectum 4
1.3.4 The anal canal 4
1.3.5 The pelvic floor 5
1.3.6 Control of gastrointestinal motility 6
1.4 Normal gastrointestinal motility 8
1.4.1 Physiology of gastrointestinal motility 8
1.4.2 Motility of the stomach and the small intestine 8
1.4.3 Ano-rectal motor activity 9
1.5 Fecal incontinence 10
1.5.1 Factors important for fecal continence 10
1.5.2 Epidemiology of FI 10
1.5.3 Etiology of FI 10
1.5.4 Idiopathic FI 12
1.5.5 Patophysiology of idiophatic FI 12
1.6 Neurogenic bowel dysfunction 12
1.6.1 Bowel symptoms in spinal cord injury patients 12
1.6.2 Patophysiology of neurogenic bowel dysfunction 13
1.6.3 Autonomic dysreflexia 14
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1.7 Some important methods for assessment of gastric emptying and
small intestinal motility 14
1.7.1 Scintigraphy 14
1.7.2 Manometry 15
1.7.3 Wireless motility capsule 15
1.8 Methods for evaluation of FI 15
1.8.1 Assessments of FI 15
1.8.2 Bowel habit diary 16
1.8.3 Wexner score 16
1.8.4 St. Marks score 16
1.8.5 The Fecal Incontinence Quality of Life Scale (FIQL,
Rockwood score) 16
1.8.6 Neurogenic bowel dysfunction score 17
1.9 Routine methods for assessment of ano-rectal function 17
1.9.1 Endoanal ultrasound 17
1.9.2 Anal manometry 17
1.9.3 Rectal sensation 17
1.9.4 Pudental nerve terminal motor latency 18
1.9.5 Anal sensibility 18
1.9.6 Colorectal transit time 18
1.10 Methods for investigation of rectal wall properties and
Rectalmotility 18
1.10.1 Manometric measurements of rectal motility 19
1.10.2 Pressure-volume measurements with a balloon 19
1.10.3 Pressure-volume measurements with a non-compliant bag 19
1.10.4 Pressure-CSA measurements with impedance planimetry 20
1.10.5 Probes for recording of rectal phasic activity and wall
Properties 21
1.10.6 Calibration procedure 22
1.10.7 Validity of the impedance planimetry probe used for
Distension 23
1.11 Current treatment options for FI 25
1.11.1 Conservative treatment 25
1.11.2 Biofeedback 26
1.11.3 Transanal irrigation 26
1.11.4 Surgery (Malone, levatorplasty, postanal repair, neo sphincter, magnet-sphincter) 26
1.12 Electric stimulation in the management of FI 27
1.12.1 Sacral nerve stimulation 27
1.12.2 Peripheral electrical nerve stimulation 28
1.12.3 Other stimulation methods 30
References 32
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Chapter 2: Electrical stimulation of the dorsal cliteral nerve reduces
incontinence episodes in idiopathic faecal incontent patients: A pilot
study 53
2.1 Introduction 53
2.2 Methods 54
2.2.1 Patients 54
2.2.2 Stimulation 54
2.2.3 Protocol 55
2.2.4 Analysis 56
2.3 Results 56
2.4 Discussion 59
2.5 Conclusion 62
References 62
Chapter 3: The acute effect of dorsal genital nerve stimulation on rectal
wall properties in patients with idiopathic faecal incontinency 65
3.1 Introduction 65
3.2 Methods 66
3.2.1 Subjects 66
3.2.2 Stimulation 67
3.2.3 Impedance planimetry 67
3.2.4 Distension protocol 68
3.2.5 Analysis 69
3.2.6 Statistics 69
3.3 Results 70
3.3.1 Phasic distension 71
3.3.2 Stepwise distension 74
3.4 Discussion 74
3.5 Conclusion 77
References 77
Chapter 4: Acute effect of electrical stimulation of the dorsal genital
nerve on rectal capacity in patients with spinal cord injury 81
4.1 Introduction 81
4.2 Methods 82
4.2.1 Subjects 82
4.2.2 Stimulation 83
4.2.3 Impedance planimetry 83
4.2.4 Distension protocol 84
4.2.5 Analysis 85
4.2.6 Statistics 86
4.3 Results 86
4.4 Discussion 89
4.5 Conclusion 91
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References 91
Chapter 5: Gastric transit and small intestinal transit time and motility
assessed by a magnet tracking system 95
5.1 Introduction 95
5.2 Methods 97
5.2.1 Subjects 97
5.2.2 Magnet Tracking System, MTS-1 97
5.2.3 MTS-1 combined with PillCam 99
5.2.4 Protocol 99
5.2.5 Analysis 100
5.2.6 Statistics 102
5.3 Results 102
5.3.1 Inter observer variation 102
5.3.2 Validation of gastric transit and small intestinal transit
data determined with MTS-1 103
5.3.3 Fasting and postprandial propagation velocities in the
small intestine 104
5.3.4 Transit and small intestinal motility patterns of magnetic
pill versus magnet-PillCam unit 105
5.3.5 Frequency of contractions 105
5.4 Discussion 105
5.5 Conclusion 108
References 108
Chapter 6: Sacral nerve stimulation for faecal incontinence does not
affect gastric contraction and small intestinal motility 113
6.1 Introduction 113
6.2 Methods 114
6.2.1 Patients and efficacy of SNS 114
6.2.2 Magnet Tracking System, MTS-1 114
6.2.3 Protocol 115
6.2.4 Analysis and statistics 115
6.3 Results 116
6.3.1 Gastric contraction frequency and gastric emptying 116
6.3.2 Propagation velocities in the small intestine during
SNS and without SNS 116
6.3.3 Small intestinal contraction frequency 116
6.3.4 Bowel habit diary 118
6.4 Discussion 118
6.5 Conclusion 120
References 120
Chapter 7: Discussion 125
7.1 Discussion 125
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7.2 Conclusion 128
7.3 Perspectives 129
References 129
About the Author 135
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