|560||Hyperbaric Oxygen in the Treatment of Fecal Incontinence Secondary to Pudendal Neuropathy [2003년 11월 DCR]||2011-12-23||1604|
J. D. Cundall, M.R.C.S.,* A. Gardiner, M.S.C.,* K. Chin, F.R.C.S.,* G. Laden, B.S.C.,†P. Grout, F.R.C.S.,† G. S. Duthie, M.D.*
From the *Academic Surgical Unit, Castle Hill Hospital, Cottingham, East Yorkshire, United Kingdom, and the †North East England Hyperbaric Unit, Hull, United Kingdom
PURPOSE: Hyperbaric oxygen therapy has several physiologic effects on damaged nerves in animal models, which lead to an improvement in neurologic function. Idiopathic fecal incontinence secondary to pudendal neuropathy is usually treated with biofeedback, which shows improvement in only 50 percent of patients.
METHODS: Thirteen patients (12 females, age range, 40–75 years) with chronic pudendal neuropathy and fecal incontinence were identified. They received 30 treatments of hyperbaric oxygen during a period of 6 weeks. Each treatment was at 2.4 atmospheres breathing pure oxygen for 90 minutes. Pudendal latencies were performed sequentially throughout the treatment and one and six months after it had finished. Questionnaires were used to assess improvements in symptoms and quality of life (Wexner fecal incontinence quality of life score).
RESULTS: All patients completed the treatment without major complications. There was a consistent
improvement of the latencies (on the left 2.36 msec initially, reduced to 2.08 msec at 6-month follow-up and on the right 2.23 msec, on the left reduced to 2.07 msec at 6 months). These improvements were significant (Wilcoxon’s two-tailed, asymptomatic significance, comparing pretreatment to 6-month follow-up, left 0.005, right 0.003). Incontinence sores also improved (12.08 initially to 11.64 at the end of treatment, 10.55 at 1-month follow-up, and 10.45 at 6-month follow-up). Using the same test, the improvement in incontinence scores also was significant when comparing pre-end (0.05) and pre-one month (0.011) but not pre-six month (0.054).
CONCLUSIONS: Hyperbaric oxygen therapy has improved pudendal nerve function and continence in
this group of patients. The cause for this improvement in latencies is unclear at present but may be because of a direct effect on the nerve or an improvement in blood flow to the nerve through angiogenesis. However, these results are good enough to schedule further trials.
Neuropathic incontinence (also referred to as idiopathic incontinence) was first described by Snooks
et al. They noted that 75 percent of women with idiopathic anorectal incontinence had histologic evidence of denervation of the pelvic floor sphincter muscles. This damage was associated with a
prolonged second stage of labor and the use of instruments, such as forceps and episiotomies.
The condition may result from direct nerve damage or damage to its surroundings. Snooks thought that it
was a direct stretching injury to the nerve, which lead to a prolongation of the latency. However, an alternative explanation has been postulated by Shafik and Doss, who described the canal as acting as a pulley for the pudendal neurovascular bundle, fixing the bundle in place and preventing it from being traumatized by the continuous movement of the anorectal muscles. They suggest that disruption of this “pulley” system during childbirth can lead to fecal incontinence and describe a decompression operation for the pudendal canal, which improves continence.
Currently, there are no adequate therapies for patients with neurogenic FI. The first-line treatment, in
the acute or chronic setting, is biofeedback. However, in many units results are no better than 50
percent at one year.
If conservative measures fail, the next stage is usually complex reconstructive surgery such as a dynamic graciloplasty or artificial sphincter placement. Recently the use of sacral nerve stimulators has
shown benefit for these patients, although there are no large series published yet.
Oxygen at pressure acts like a drug. It has many effects on damaged nerves in animal settings. Hyperbaric oxygen (HBO) has been shown to aid the regeneration of nerves that have been damaged by
crush injuries, ischemia, and after transected nerves have been repaired. Other effects that may be useful in the treatment of nerve damage are promotion of angiogenesis and a reduction in edema.
Because of these effects, it was postulated that hyperbaric oxygen might enhance nerve conduction in pudendal neuropathy and thus ameliorate the incontinence. We therefore designed a prospective trial
to determine whether HBO therapy is safe in this condition, whether there is any physiologic effect,
and whether there are any effects to be able then to set up an adequately powered, randomized, controlled trial.