Faecal incontinence has detrimental social, psychological, physical and economic impact and significantly impairs quality of life. Recently, new guidelines were published with the collaboration of European Society of Coloproctology, United European Gastroenterology, European Society of Neurogastroenterology and the European Society for Primary Care Gastroenterology.
Dr Stéphanie Breukink (top left), Associate Professor of Colorectal Surgery and Colorectal consultant at Maastricht University Medical Center in the Netherlands and Sadé Assmann (top right), the first author of the new faecal incontinence guidelines speak to Vittoria Bellato (bottom right) and Zoe Garoufalia (bottom left) to update us on the recently published Joint European Clinical Practice Guideline for Fecal Incontinence – a UEG/ESCP/ESNM/ESPCG guideline.
Zoe Garoufalia (ZG) and Vittoria Bellato (VB): Stéphanie and Sadé, thank you very much for agreeing to this interview. Fecal incontinence is devastating situation for the patient and unfortunately has been poorly addressed up until now. How did you decide on this new collaboration?
Stéphanie Breukink (SB) and Sadé Assmann (SA): The UEG offers a great platform for young professionals from different societies to collaborate and to develop guidelines. Often a patient with fecal incontinence is seen by different doctors varying from GPs, gastroenterologists and surgeons, therefore this guideline was a perfect fit in this set up offered by the UEG.
ZG & VB: What is different from previous NICE guidelines published in 2007?
SB & SA: A more up-to-date guideline was necessary as a large number of studies have been published related to the treatment and diagnosis of faecal incontinence since 2007. Furthermore, we followed the GRADE methodology which gives a transparent framework for presenting evidence and provides a systematic approach for making clinical practice recommendations. Finally, the voice of the patients, who experience the burden of faecal incontinence every day, was imperative for the quality of these guidelines.
ZG & VB: Could you briefly introduce us to these new guidelines and the methodology used?
SB & SA: We have created an up-to-date, multidisciplinary, European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI) in adult patients. These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was involved in this project from start to finish to provide their invaluable perspective and to ensure issues important to this patient group were covered.
For the methodology of the guidelines, the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used.
To ensure user-friendliness, we came up with a treatment algorithm which summarizes the most important recommendations and steps which can be followed when treating a patient with FI. This treatment algorithm, along with the 45 recommendations can be found at the start of the manuscript. Its intended use is in combination with the main text.
ZG & VB: Is evidence-based medicine feasible for these patients?
SB & SA: As is the case with most guidelines, the overall level of evidence for the recommendations were relatively low. However, the recommendations in this guideline were based on the highest available evidence in literature, which can be seen in the wording used in the recommendations. In case of 'moderate' quality of evidence the word 'should' is used in the recommendation, in case of 'low' quality of evidence 'could' is used and in case of 'very low' quality of evidence the wording 'can be considered' is used in the recommendation. This is in accordance with the GRADE approach.
These guidelines offer several solutions at all treatment stages to facilitate shared decision making, and to ensure patient and caregiver can choose the proper treatment for her/his condition at each stage taking into account patient preferences, availability of procedures and fitness for procedures.
ZG & VB: Where can these guidelines be accessed?
SB & SA: These guidelines have been published in the UEG journal. It is open access and can be accessed using the following citation: Assmann SL, Keszthelyi D, Kleijnen J, Anastasiou F, Bradshaw E, Brannigan AE, et al. Guideline for the diagnosis and treatment of Faecal Incontinence - A UEG/ ESCP/ESNM/ESPCG collaboration. United European Gastroenterol J. 2022;1–36. https://doi.org/10.1002/ueg2.12213
ZG & VB: A patient advisory board was successfully created to comment on the guidelines throughout the whole process. What was the most impactful insight from this board in your opinion?
SB & SA: We are very thankful that the patient advisory board, which consisted of seven patients from the UK and the Netherlands were involved throughout the entire project. Prior to each GDG meeting, a PAB meeting took place to reflect on the guidelines and to make any improvements from a patient perspective. The patient representative of this PAB put forward any points discussed during the PAB meetings at the GDG meetings.
One of the problems which came forward during these PAB meetings is that the patients were unaware of the large amount of different available treatment options for faecal incontinence. A number of patients mentioned that when a treatment option would fail or not sufficiently reduce symptoms, that they would feel anxious as they thought there were no options left for them to try. To minimize this feeling, we created a patient information pamphlet (included as appendix in the guideline) which includes a list of different available treatment options accompanied by a short description of each treatment option.
Another problem many patients came across is that they felt doctors didn't sufficiently focus on all of the problems surrounding FI. Together with the PAB, we created a figure in the patient pamphlet which lists some of the: anatomical/functional factors, the problems related to pelvic floor- and gastrointestinal dysfunction and the psychological and social impact FI can have on a patient.
Finally, several patients mentioned that they would have appreciated it if their doctors would have actively asked them about their faecal incontinence when they carefully broached the subject at the doctor's office. Due to the embarrassing nature of the condition, a lot of people don't feel comfortable discussing the issue, especially if they feel the doctor doesn't seem comfortable discussing the issue.
ZG & VB: To improve strength of evidence, and thus strength of recommendations, more high quality randomized controlled trials should be performed which all should assess the same outcomes, facilitating comparison and evidence synthesis. Which is the next most needed trial on FI in your opinion?
SB & SA: As you may have seen scanning through these guidelines, the level of evidence is relatively low for each treatment option and diagnostic tool. This suggests that for all of these treatment options and diagnostic tools, additional high-quality trials would improve the strength of evidence. Additionally, as you have mentioned in your question; strength of evidence could greatly improve if everyone who conducts FI related research would use the same outcomes, so that multiple studies could be compared. We are currently working on the creation of a Core Outcome Set to help ensure uniformity in outcome measures being used among different trials in the future. For this project we are also prioritizing patient involvement.
ZG & VB: We noticed that the possible benefit of first line treatment (for example pelvic floor muscle exercised +/- biofeedback) after surgical treatment is not discussed in the guidelines. Do you advocate the use of such treatment post-surgery?
SB & SA: If surgery has not resulted in acceptable symptom reduction, we would definitely recommend continuing one or multiple treatment options. The treatment algorithm is intended to be used as a buildup schedule where combination of multiple treatment options can be applied.
ZG & VB: Do you have any messages to convey to the ESCP audience regarding diagnosis or treatment of patients with FI?
SB & SA: If you suspect that your patient may suffer from faecal incontinence, be sure to actively ask the patient about their problem and make them feel at ease. Many patients with faecal incontinence feel embarrassed about their condition. If you feel like this condition is out of your area of expertise, be sure to refer the patient to another health care professional who is able to help the patient further. If Faecal incontinence is within your comfort zone, you can use the treatment algorithm along with the rest of the guidelines to help you in which steps should be taken when treating a patient with faecal incontinence.
ZG & VB: Thank you for your time and insights.
Watch here a brief introduction of the new guideline by the experts.