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Background. Conflicting results are reported about the contribution of maternal, obstetric and fetal characteristics to postpartum fecal incontinence (FI), which is hampering prevention and management of FI. Objective. To perform a systematic review identifying delivery-related etiological factors for postpartum FI. Search strategy. Literature searches of PubMed, EMBASE, CINAHL, DocOnline and reference lists from 1980 up to 2009 were conducted. Selection criteria. Prospective cohort studies evaluating maternal, obstetric or fetal risk factors for postpartum FI, with a follow-up period of at least three months, were assessed. We reviewed full reports in English, German or Dutch, with anal incontinence (AI), FI, flatus incontinence, soiling, urgency and FI severity scores as reported outcomes. Data collection and analysis. Data on study characteristics, methodological quality and outcome were extracted from 31 studies according to a standardized protocol. Clinical and methodological sources of heterogeneity permitted only a qualitative analysis. Main results. A third- or fourth-degree sphincter rupture was the only etiological factor strongly (AI) or moderately (flatus incontinence) associated with postpartum FI. No association with other postulated risk factors was found, for example, birth weight or instrumental delivery. The potential co-existence of different risk factors impedes the interpretation of the influence of a single delivery-related risk factor. Conclusions. This systematic review, including only longitudinal studies and recognizing the importance of separating results for different outcomes, identifies that a third- or fourth-degree sphincter rupture is the only factor that is strongly (AI) or moderately (flatus incontinence) associated with postpartum FI.

BackgroundVarious guidelines for the management of low back pain have been developed to enhance the effectiveness and efficiency of care. Evidence that guideline-adherent care results in better health outcomes, however, is not conclusive.ObjectiveThe main objective of this study was to assess whether a higher percentage of adherence to the Dutch physical and manual therapy guidelines for low back pain is related to improved outcomes. The study further explored whether this relationship differs for the individual steps of the process of care and for distinct subgroups of patients.DesignThis was an observational prospective cohort study (2005–2006) in the Netherlands that included a sample of 61 private practice therapists and 145 patients.MethodsTherapists recorded the process of care and the number of treatment sessions in Web-based patient files. Guideline adherence was assessed using quality indicators. Physical functioning was measured by the Dutch version of the Quebec Back Pain and Disability Scale, and average pain was measured with a visual analog scale. Relationships between the percentage of guideline adherence and outcomes of care were evaluated with regression analyses.ResultsHigher percentages of adherence were associated with fewer functional limitations (β=−0.21, P=.023) and fewer treatment sessions (β=−0.27, P=.005).LimitationsThe relatively small self-selected sample might limit external validity, but it is not expected that the small sample greatly influenced the internal validity of the study. Larger samples are required to enable adequate subgroup analyses.ConclusionsThe results indicate that higher percentages of guideline adherence are related to better improvement of physical functioning and to a lower utilization of care. A proper assessment of the relationship between the process of physical therapy care and outcomes may require a comprehensive set of process indicators to measure guideline adherence.

Aims To determine the psychometric properties of the (5-item) total PRAFAB-questionnaire score in a group of patients with stress or predominant urgency urinary incontinence (UI) to justify its use in clinical practice and research. Methods Psychometric properties were assessed in a prospective cohort of patients with primary or recurrent UI referred for physiotherapy treatment. Results In total, 99 women enrolled the cohort study, of whom 87 were classified as stable (“about the same” on the global rating scale [GRS]) and included for analyses. Factor analysis resulted in a single underlying factor in both UI groups. The PRAFAB-questionnaire scores demonstrated excellent test–retest reliability (high ICCsagreement [0.93–0.95] and kappa scores for individual items) and excellent internal consistency (Cronbach's alpha's of 0.82). The PRAFAB-questionnaire was able to discriminate among different patient groups indicating good construct validity. Responsiveness to clinical improvement for both groups was shown to be excellent with large effect size statistics and high correlations (0.79–0.89) with patients' perceived benefit on the GRS indicating excellent longitudinal validity. The minimally important change stratified for non-severe and severe classified patients were estimated between −2.5 to −4.6 and −4.5 to −7.0 points, respectively for the stress UI group and −2.5 to −3.4 points and −4.0 to −4.4, respectively for the urgency UI group. Conclusions The brief and simple PRAFAB-questionnaire demonstrated good psychometric properties for use in clinical practice and research to evaluate treatment effects for UI in women. Future research will be necessary to replicate these findings and further explore its psychometric properties. Neurourol. Urodynam. 26:998–1007, 2007. © 2007 Wiley-Liss, Inc.

Aims It is unclear which patients with fecal incontinence (FI) are likely to benefit from physiotherapy treatment, which is relevant for medical decision making and patient counseling. This study aimed to identify patient characteristics predicting a favorable outcome of physiotherapy. Methods Eighty patients with FI, with a mean age of 59.3 (SD ± 11.9), were recruited at the Maastricht University Medical Centre and enrolled in a randomized controlled trial, which assessed the effect of adding rectal balloon training to pelvic floor muscle training. Treatment groups were combined for prediction modeling. Candidate predictors were obtained from demographics, medical history, physical examination, baseline tests, questionnaires, and physiotherapy diagnostics. Favorable outcome was defined as a combination of: (i) Vaizey score reduction ≥5 points, and (ii) “slightly” to “very much improved” on the nine-point global perceived effect score. Predictors were identified by univariable and multivariable logistic regression analysis. Results Thirty-seven patients (46.3%) had a favorable outcome. Multivariable analysis showed that longer time since FI onset appeared to be associated with an unfavorable outcome (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.47–1.00; P = 0.05), whereas the use of constipating medication (OR, 3.79; CI, 0.99–14.51; P = 0.05), any obstetric factor (OR, 2.15; CI, 0.94–4.89; P = 0.07), and experiencing minor embarrassment (OR, 2.12; CI, 1.10–4.09; P = 0.03) predicted a favorable outcome. Conclusions The small subset of identified predictors for a favorable outcome may be relevant in patient counseling and targeting physiotherapy treatment more efficiently, especially as they are available early in the diagnostic process. Neurourol. Urodynam. 31:1156–1160, 2012. © 2011 Wiley Periodicals, Inc.

Fecal incontinence (FI) is embarrassing, resulting in poor quality of life. Rectal sensation may be more important than sphincter strength to relieve symptoms. A single-blind, randomized controlled trial among adults with FI compared the effectiveness of rectal balloon training (RBT) and pelvic floor muscle training (PFMT) versus PFMT alone.We randomized 80 patients, recruited from the Maastricht University Medical Centre. Primary outcome was based on the Vaizey score. Secondary outcomes were the Fecal Incontinence Quality of Life Scale (FIQL), 9-point global perceived effect (GPE) score, anorectal manometry, rectal distension volumes, and thresholds of anorectal sensation. Analyses were by intention-to-treat.Forty patients were assigned to combined RBT with PFMT and 40 to PFMT alone. Adding RBT did not result in a significant improvement in the Vaizey score [mean difference: -1.19; 95% confidence interval (CI): -3.79 to 1.42; P = 0.37]. Secondary outcomes favoring RBT were: Lifestyle subscale of the FIQL (0.37; 95% CI: 0.02-0.73; P = 0.04), GPE (-1.01; 95% CI: -1.75 to -0.27; P = 0.008), maximum tolerable volume (49.35; 95% CI: 13.26-85.44; P = 0.009), and external anal sphincter fatigue (0.65; 95% CI: 0.26-1.04; P = 0.001). Overall, 50% of patients were considered improved according to the estimated minimally important change (Vaizey change ≥-5).RBT with PFMT was equally effective as PFMT alone. Secondary outcomes show beneficial effects of RBT on urgency control, GPE, and lifestyle adaptations. Characteristics of patients who benefit most from RBT remain to be confirmed.

Aim To determine the psychometric properties of the total Vaizey score and its individual items. Methods The study was conducted as part of a prospective cohort study assessing the outcome of pelvic floor rehabilitation in patients with fecal incontinence. Results One hundred ninety-four patients were analyzed, 53 of whom provided data on the global perceived effect (GPE) score. Pelvic floor rehabilitation resulted in a significant reduction of the total Vaizey score and most individual items. The total Vaizey scores changed in agreement with the GPE scores. The total Vaizey score was responsive, but some individual items yielded inconsistent results for three different measures. The test–retest reliability was adequate or excellent for six individual items and the total Vaizey score. The internal consistency was low for the total Vaizey score at baseline, in contrast to the follow-up and change scores. The estimates for the minimally important change (MIC) and smallest detectable change yielded moderately consistent results. An MIC of −5 points seemed preferable and yielded the lowest misclassification rate. Conclusions More research is required to confirm conclusions on the psychometric properties of the total Vaizey score and its individual items, and to justify its use in research and routine clinical practice. Neurourol. Urodynam. 29:370–377, 2010. © 2009 Wiley-Liss, Inc.