Ambulatory patients with spina bifida are 50% more likely to be fecally continent than non-ambulatory patients, particularly after a MACE procedure.
BACKGROUND
While fecal incontinence (FI) affects many patients with spina bifida (SB), it is unclear if it is associated with ambulatory status.


OBJECTIVE
To determine if ambulatory status is associated with FI, and a potential confounding variable, in patients with and without a Malone antegrade continence enema (MACE).


METHODS
This study retrospectively reviewed of patients aged ≥8 years with SB who were enrolled in an international quality of life study at outpatient visits (January 2013 to September 2015). Patients reported FI over the last 4 weeks (strict criteria: any FI/accidents vs no FI). Patients unable to self-report FI due to developmental delay were excluded. Those who were ambulating outdoors with/without braces/crutches were considered community ambulators. Non-parametric tests and logistic regression were used for analysis.


RESULTS
A total of 115 patients with a MACE and 57 without a MACE were similar in gender (P = 0.99), ventriculoperitoneal status (P = 0.15) and age (16.0 vs 15.4 years, P = 0.11). Median ages at MACE procedure and follow-up were 7.0 and 8.2 years, respectively, and all used the MACE ≥3x/week. They were less likely to be ambulators (54.8 vs 71.9%, P = 0.03). In patients with a MACE, 64 (55.7%) had total fecal continence, compared with 29 (50.9%) without a MACE (P = 0.62). In the MACE group, ambulators were more likely to be continent compared with non-ambulatory patients (65.1 vs 44.2%, P = 0.04) (Table). Although not statistically significant, a similar difference was observed in the non-MACE group (56.1 vs 37.5%, P = 0.25). In the MACE group, continent and incontinent patients, regardless of ambulatory status, had similar rates of MACE use, additive use and time for MACE completion (P ≥ 0.43). MACE ambulators were more likely to be continent than MACE non-ambulators on multivariate analysis (OR 3.26, P = 0.01).


CONCLUSIONS
This study reported higher than typical FI rates since: (1) it used a stringent definition of total fecal continence; (2) patients without FI were perhaps less likely to participate; and (3) it relied on patient-reported rather than clinician-reported outcomes. This cross-sectional study should not be interpreted as "MACE procedure is ineffective;" this would require a longitudinal study. The present findings may not apply to young children or those with significant developmental delay (patients excluded from the study).


CONCLUSIONS
Ambulatory patients with SB are 50% more likely to have total fecal continence on long-term follow-up, particularly after a MACE procedure. Ambulatory status is a significant confounder of FI and should be considered in future analyses.
Division of Pediatric Urology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA.
T
T
Large
Division of Pediatric Urology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA. Electronic address: szymanko@iupui.edu.
K M
KM
Szymanski
Division of Pediatric Urology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA.
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B
Whittam
Division of Pediatric Urology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA.
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R
Misseri
Division of Pediatric Urology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA.
K H
KH
Chan
Division of Pediatric Urology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA.
M
M
Kaefer
Division of Pediatric Urology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA.
R C
RC
Rink
Division of Pediatric Urology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA.
M P
MP
Cain
D000293:Adolescent; D002431:Cecostomy / Q000379:methods*; D002648:Child; D003430:Cross-Sectional Studies; D005242:Fecal Incontinence / Q000453:epidemiology / Q000209:etiology* / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D055496:Neurogenic Bowel / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment; D016135:Spinal Dysraphism / Q000150:complications* / Q000175:diagnosis* / Q000601:surgery; D018709:Statistics, Nonparametric; D016896:Treatment Outcome; D016138:Walking / Q000502:physiology*
Ambulation; Fecal incontinence; Malone antegrade continence enema; Spina bifida