ADVANCING THE TREATMENT OF FECAL AND URINARY INCONTINENCE THROUGH RESEARCH:

Trial Design, Outcome Measures, and Research Priorities

BACKGROUND:

This was, in effect, the Second International Conference on Encopresis sponsored by the International Foundation for Functional Gastrointestinal Disorders (www.iffgd.org) with the University of Wisconsin Medical School held at the Pfister Hotel in Milwaukee, Wisconsin from November 3-5, 2002. This location was a wonderful convenience for yours truly who lives on the other side of Lake Michigan on the lakeshore of Western Michigan. My only regret was having to drive 285 miles around the bottom of the lake and through Chicago because the car ferry had already stopped service due to the very unpredictable weather at this time of year. As you can probably already tell, this will be a highly personalized set of my impressions of the conference. It should in no way be viewed as "official" or a product of the conference organizers.

The conference was attended by about 170 professionals, which included mainly physicians followed by nurses and psychologists. The medical specialty most represented was Gastroenterology (GI), but there was quite a mix of others with surgery and OB-GYN represented as well. I overheard many comments from the specialists about how unusual it was for them to be attending a conference with other specialties. The cross-fertilization and stimulation was very evident from the animated exchanges during coffee breaks and at the lunches and dinners provided at the conference. The dinners on Sunday and Monday evenings were well attended and people virtually collapsed with exhaustion after long exchanges before going back to their rooms!

The international representation was not as high as I recall at prior conferences, but there were representatives from the Netherlands, the United Kingdom, Israel, and Canada. I met them all and had special fun with the "Hollanders" because I live just 25 miles North of Holland, Michigan where a national tulip festival is held every early Spring. Western Michigan with its high Dutch immigrant population is highly conservative and religious by contrast to their own "homeland", which really surprised them.

One of these gentlemen (M.A. Benninga-- Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands) presented a paper citing a lack of any large randomized controlled therapeutic trials for constipation in children, despite its high prevalence. He concluded that, "The treatment of constipation is, therefore, mainly based on experience rather that evidence". I certainly agree with him. He cited as Priority 1: "Double-blind randomized controlled trials in which different laxative regimens should be compared, with larger samples and long term follow up in children with mild and severed constipation". His Priority 2 is a "Large randomized controlled trial in which the additional effect of a prolonged enema program should be compared with an intensive oral laxative regimen". For Priority 3 he recommended, a "Large randomized controlled trial in which the additional effect of a prolonged enema program has to be compared to an intensive toilet training program". I talked to Dr Benninga after his presentation, but I have no idea if my ideas will influence him at all. Now, in April 2004 as I am reviewing this page, I have heard nothing further and doubt that I had any impact whatsoever. Actually, this is my typical experience at conferences and I am now increasingly relying on my clients to report back to their GI docs about their experience with my treatment protocol for encopresis. I am hopeful that this will be more persuasive over time, but will continue to write and to try and influence gastroenterologists and psychologists to consider trials of my treatment program both clinically and in large scale randomized controlled trials.

This conference was "pricey", but well justified and worth it with physicians paying fees of $500 and other professions paying $350. They gave the Psychologists a break this year with the lower fee. Moreover, the hotel rooms at the elegant Pfister Hotel were also pricey, but there were more reasonably priced hotels within 5-7 blocks of the conference site--a Best Western and a Howard Johnson's at least. I enjoyed my walks to and from the Pfister from the Best Western!!!

The highly professional, technical nature of this conference would not be appealing to laypersons and there would have been great disappointment for parents of encopretic or enuretic children since there was very little emphasis on these populations.

A recent communication from the sponsoring organization for this conference announced that the proceedings of this November 2002 Consensus Conference on Advancing the Treatment of Fecal and Urinary Incontinence Through Research was just published as a supplement in the journal, GASTROENTEROLOGY, in January, 2004. This 185 page supplement will be a key resource for researchers, but note that this is primarily for problems in adults as I earlier noted above. The table of contents is available on-line by going to www.aboutincontinence.org and clicking on the Gastroenterology supplement link. The co-director of this conference, William E. Whitehead, PhD, notes that this supplement is available on line and can be downloaded in PDF format. The internet address is www2.gastrojournal.org.

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