An Interview with Paola de Nardi.
Vittoria Bellato (left) recently interviewed Paola de Nardi (right), a highly experienced colorectal surgeon at the San Raffaele University Hospital in Milan, Italy. She has extensive expertise in the field of anorectal disorders, including fecal incontinence. Her dedication to advancing knowledge and improving patient care has led to numerous publications and presentations at national and international conferences. Today, we have the opportunity to speak with her about fecal incontinence, its diagnosis, and treatment options.
Vittoria Bellato (VB): What is the role of pelvic floor rehabilitation and biofeedback in the treatment of fecal incontinence, and how effective are these interventions?
Paola de Nardi (PdN): The initial treatment of FI should always be directed towards conservative measures including lifestyle changes, dietary and medical management based on patient's characteristics, such as high fiber diet, fiber supplements, and/or antidiarrheal agents. For patients not responding to simpler supportive measures, I suggest pelvic floor rehabilitation with or without biofeedback. Rehabilitation techniques act on strength, endurance, tension, co-ordination and sensory activity of anal sphincter muscles, as well as on sensory function and compliance of the rectum. These treatments should always be individually tailored and a combination of different techniques is recommended in order to obtain the best results. Additionally motivation and cognitive ability of the patient are essential and they may not be appropriate for patients with neurological diseases. As far as effectiveness, I strongly believe in the rehabilitation programs which I propose to the majority of my patients; however this treatment is time consuming, it is not broadly available and well trained physiotherapists are lacking. It should be noted that in the literature the results vary widely and there is a lack of well-designed studies.
VB: What is the role of sacral nerve stimulation in the treatment of fecal incontinence?
PdN: Sacral neuromodulation was once reserved for patients with intact sphincters and idiopathic incontinence. Nowadays it is considered as first line surgical option in patients with weak/atrophic sphincter, sphincter defect or disruption, or neuropathy, by many guidelines. This technique has many advantages: the possibility to test the efficacy before a permanent implant, the potential to benefit patients with both urinary and fecal incontinence, a low complication rate. We know that SNS acts on different pathologic mechanisms, however the exact mode of action is not fully understood. SNS has been shown to reduce the number of episodes of incontinence, improve the incontinence scores, the ability to defer defecation and quality of life; according to a systematic review the rate of patients with permanent implant who reach complete continence was 41-75%.
VB: What is the efficacy of transanal irrigation in patients with fecal incontinence?
PdN: Transanal irrigation is an interesting option for patients with FI. It is safe and inexpensive, and effectively reduces the episodes of incontinence by promoting complete bowel clearing. It is mostly employed for patients with overflow incontinence and fecal impaction or neurogenic bowel dysfunctions. One of the more recent application of TAI is in patients with low anterior resection syndrome with main complain of fecal incontinence or frequency. The irrigation is usually well tolerated and the patients are trained to perform TAI at home thus improving the compliance. Although there are only few studies on this topic, they demonstrated a significant improvement in LARS score and quality of life.
VB: Can anal sphincter repair improve fecal incontinence in patients with obstetric anal sphincter injury (OASIS)?
PdN: The overall risk of obstetric anal sphincter injuries, also defined as 3rd or 4th degree perineal lacerations, is approximately 6%, and is associated with increased risk of fecal incontinence in women. OASIS can be recognized at the time of delivery, in the post-partum, or after a long time. The diagnosis of a sphincter laceration at the time of delivery can be missed by a less experienced provider. In my experience adequate training of obstetricians and/or the availability of a colorectal surgeon familiar with acute OASIS, at the time of delivery are of pivotal importance to recognize OASIS, avoid misdiagnosis, and to assure a competent repair. Indeed OASIS can be repaired either immediately or it can be delayed up to 12 hours, when human or logistic resources can be available. Studies demonstrated that the majority of symptoms and QoL significantly improve following restoring sphincter integrity, unless there is a persistent anal sphincter defect; this underlines the importance of adequate assessment and repair.
VB: I noticed that the possible benefit of first line treatment (for example pelvic floor muscle exercise +/- biofeedback) after surgical treatment is not frequently discussed in guidelines. Do you advocate the use of such treatment post-surgery?
PdN: I agree with you that guidelines do not adequately address some aspect of pelvic floor muscle training. For instance the possibility to implement pelvic floor physiotherapy during pregnancy to prevent perineal injuries and FI in the postnatal period. Physiotherapy as an adjuvant treatment or in combination with surgery is another neglected topic. As far as I know, there are few trials on the association of pelvic floor muscle training or biofeedback and surgery. Nevertheless, my personal opinion is that, being continence a complex interaction between multiples anatomical structures and physiological mechanisms, physical therapy could play a role by improving several aspects that are not affect by sphyncteroplasty, such as muscle strength, rectal sensation or rectal compliance. Therefore, I personally encourage my patients to undergo pelvic floor exercise after surgery, also considering that the benefit of sphyncteroplasty deteriorates over time
VB: Do you have any messages to convey to the ESCP audience regarding diagnosis or treatment of patients with FI?
PdN: I would like to underline that the prevalence of fecal incontinence is underestimate and the physician should actively seek it since many patients may not voluntarily report this information. The treatment should follow a sequential approach from conservative measures to different and more complex surgical interventions. Nowadays there are many treatment options that should be individualized based on the severity of Fi and the characteristics of the patient, and new technologies are being developed to treat this disabling condition.
