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Measurement challenges in fecal incontinence
EDITORIAL Measurement Challenges in Fecal Incontinence
T
his issue of Journal of WOCN offers readers 4 high-quality articles. Barbara Pieper and Ellen DiNardo offer us an insightful look at health maintenance in a primary care clinic for urban indigent adults. Pat Bonham provides a review of the literature on the antibiotic treatment of osteomyelitis in patients with diabetes and foot ulcers, and Vicki Johnson examines the influence of the principles of exercise physiology on pelvic floor muscle training. Of particular interest to the WOC nurse is the article by Norton and Chelvanayagam on the measurement challenges in fecal incontinence. The challenges in nursing research are many, with none more perhaps than in the treatment of people with fecal incontinence. Whereas measurement of urinary incontinence has been refined and is generally accepted to be both objective, with pad tests and diaries, and subjective, with quality of life measures, the quantification of fecal incontinence is far more complicated. Indeed, people with fecal incontinence may control stool leakage through constipation; keeping a stool leakage/defecation diary may show no episodes of soiling because of gross constipation. Initial treatment, as Norton and Chelvanayagam point out, includes diet changes and stool consistency regulation. To submit to this treatment puts the person at great risk of fecal soiling, something he or she controls by being constipated. Thus the ability to adhere to an initial protocol is challenged before the practitioner even starts. It takes great courage for a person to admit to fecal incontinence and possibly even more to undergo therapy that initially may make the problem far more severe. Yet, over the long term, chronic constipation has its own set of associated problems. A growing body of evidence exists that links urinary incontinence, fecal incontinence, and pelvic organ prolapse to each other and each of these conditions in turn to pelvic floor denervation and pudendal neuropathy.1,2 Stretching of the pudendal nerve is believed to be the major cause of nerve stretch. Although vaginal delivery has been implicated as a major contributing event for urinary incontinence and pelvic neuropathy,
chronic constipation with repeated prolonged straining may also contribute to progressive neuropathy and dysfunction.3 Thus women who are at risk for fecal and urinary incontinence because of delivery trauma walk a tightrope because lack of treatment of chronic constipation puts them at high risk for ensuing problems. Although effective therapy for urinary incontinence has evolved slowly, the evolution of treatment of fecal incontinence has been even slower. In 2 Cochrane Systematic reviews,4,5 the authors identified only 5 randomized or quasi-randomized trials using biofeedback and/or sphincter exercises and only 1 trial of electrical stimulation. The methodologic weaknesses of the studies prevented any opinions about the effectiveness of these treatments. In their article, Norton and Chelvanayagam have placed the current knowledge of conservative management of fecal incontinence far beyond what urinary incontinence knowledge was at the same stage of development. Such a foundation will further the efforts of the many researchers who tackle this as yet unchartered area of nursing research. This study and others forthcoming in this Journal are huge steps forward in the resolution of a most debilitating and humiliating problem.
Katherine Moore, RN, PhD
REFERENCES 1. Pannek J, Haupt G, Sommerfeld, HJ, Schulze H, Senge T. Urodynamic and rectomanometric findings in urinary incontinence. Scand J Urol Nephrol 1996;30:457-60. 2. Smith ARB, Hosker GL, Warrell DW. The role of pudendal nerve damage in the aetiology of genuine stress incontinence in women. Br J Obstet Gynaecol 1989;96:29-32. 3. Lubowski DZ, Swash M, Nichols J, Henry MM. Increase in pudendal nerve terminal motor latency with defecation straining. Br J Surg 1988;75: 1095-7. 4. Hosker G, Norton C, Brazzelli M. Electrical stimulation for faecal incontinence in adults. Cochrane Database Syst Rev 2000;(2):CD001310. 5. Norton C, Hosker G, Brazzelli M. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev 2000;(2):CD002111.
J WOCN 2001;28:121. Copyright © 2001 by the Wound, Ostomy and Continence Nurses Society. 1071-5754/2001/$35.00 + 0 21/9/115331 doi:10.1067/mjw.2001.115331
121
T
his issue of Journal of WOCN offers readers 4 high-quality articles. Barbara Pieper and Ellen DiNardo offer us an insightful look at health maintenance in a primary care clinic for urban indigent adults. Pat Bonham provides a review of the literature on the antibiotic treatment of osteomyelitis in patients with diabetes and foot ulcers, and Vicki Johnson examines the influence of the principles of exercise physiology on pelvic floor muscle training. Of particular interest to the WOC nurse is the article by Norton and Chelvanayagam on the measurement challenges in fecal incontinence. The challenges in nursing research are many, with none more perhaps than in the treatment of people with fecal incontinence. Whereas measurement of urinary incontinence has been refined and is generally accepted to be both objective, with pad tests and diaries, and subjective, with quality of life measures, the quantification of fecal incontinence is far more complicated. Indeed, people with fecal incontinence may control stool leakage through constipation; keeping a stool leakage/defecation diary may show no episodes of soiling because of gross constipation. Initial treatment, as Norton and Chelvanayagam point out, includes diet changes and stool consistency regulation. To submit to this treatment puts the person at great risk of fecal soiling, something he or she controls by being constipated. Thus the ability to adhere to an initial protocol is challenged before the practitioner even starts. It takes great courage for a person to admit to fecal incontinence and possibly even more to undergo therapy that initially may make the problem far more severe. Yet, over the long term, chronic constipation has its own set of associated problems. A growing body of evidence exists that links urinary incontinence, fecal incontinence, and pelvic organ prolapse to each other and each of these conditions in turn to pelvic floor denervation and pudendal neuropathy.1,2 Stretching of the pudendal nerve is believed to be the major cause of nerve stretch. Although vaginal delivery has been implicated as a major contributing event for urinary incontinence and pelvic neuropathy,
chronic constipation with repeated prolonged straining may also contribute to progressive neuropathy and dysfunction.3 Thus women who are at risk for fecal and urinary incontinence because of delivery trauma walk a tightrope because lack of treatment of chronic constipation puts them at high risk for ensuing problems. Although effective therapy for urinary incontinence has evolved slowly, the evolution of treatment of fecal incontinence has been even slower. In 2 Cochrane Systematic reviews,4,5 the authors identified only 5 randomized or quasi-randomized trials using biofeedback and/or sphincter exercises and only 1 trial of electrical stimulation. The methodologic weaknesses of the studies prevented any opinions about the effectiveness of these treatments. In their article, Norton and Chelvanayagam have placed the current knowledge of conservative management of fecal incontinence far beyond what urinary incontinence knowledge was at the same stage of development. Such a foundation will further the efforts of the many researchers who tackle this as yet unchartered area of nursing research. This study and others forthcoming in this Journal are huge steps forward in the resolution of a most debilitating and humiliating problem.
Katherine Moore, RN, PhD
REFERENCES 1. Pannek J, Haupt G, Sommerfeld, HJ, Schulze H, Senge T. Urodynamic and rectomanometric findings in urinary incontinence. Scand J Urol Nephrol 1996;30:457-60. 2. Smith ARB, Hosker GL, Warrell DW. The role of pudendal nerve damage in the aetiology of genuine stress incontinence in women. Br J Obstet Gynaecol 1989;96:29-32. 3. Lubowski DZ, Swash M, Nichols J, Henry MM. Increase in pudendal nerve terminal motor latency with defecation straining. Br J Surg 1988;75: 1095-7. 4. Hosker G, Norton C, Brazzelli M. Electrical stimulation for faecal incontinence in adults. Cochrane Database Syst Rev 2000;(2):CD001310. 5. Norton C, Hosker G, Brazzelli M. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev 2000;(2):CD002111.
J WOCN 2001;28:121. Copyright © 2001 by the Wound, Ostomy and Continence Nurses Society. 1071-5754/2001/$35.00 + 0 21/9/115331 doi:10.1067/mjw.2001.115331
121