That women suffering from anal incontinence (AI) will reduce their symptoms through conservative management in a group-based educational course given by nurses and physical therapists.

This pilot study is a mixed methods study, and this abstract presents the quantitative outcome. The study started in January 2020 and was completed in June 2020.
Forty-two women, aged 31-83, participated and the average age of the participants was 72 years old. Participants were women over 18 years of age, had not given birth within the last 6 months and suffering from AI. AI is defined as complaint of involuntary loss of flatus or feces (1).
Participants were recruited through advertisements in the local newspaper as well pamphlets located in libraries and medical offices (primarily primary care physicians and gynecologists). Interested participants contacted the nurse directly via email or telephone and were then screened for red flags and participation suitability. If included the St. Marks Incontinence Score (SMIS) was conducted (2).
The group-based educational course was based at a local health care center in collaboration with a gastroenterology unit at a local hospital. The instructors were nurses and physical therapists, specializing in incontinence. A total of five groups completed the course with an average of eight women in each group. The education course consisted of three modules of two hours duration each (Figure 1). 

Modules 1 and 2 were one week apart, and modules 2 and 3 were two weeks apart. This provided the participants with the opportunity to test and try conservative management methods and techniques in real life situations over the duration of a month. 
The conservative management approach consisted of simple methods and techniques, which the women could easily incorporate into their AI management. The participants were educated on the following topics with the aim to attain a soft and solid stool as well as a complete rectal defecation:
-	Bowel function and anatomy
-	The use of Psyllium Husks
-	Glycerin suppository and testing of rectal irrigation.
-	Anal plugs and constipation medicines 
-	Pelvic floor function and exercises
The participants received assistive devices and assistance as needed to adjust the types of management techniques according to their individual needs. 
The women completed an evaluation questionnaire after module 3, exploring the women’s experiences with the course, intervention outcomes, and the topics most important to the individual participant. 
The nurse evaluated the SMIS with each of the participants at the preliminary interview (baseline) and four-weeks (follow up) after completion of the course. SMIS was used to determine the degree of AI symptom intensity reduction.

40 of the 42 women participated in the four-week SMIS follow-up. The highest score on the preliminary SMIS was 17 and the lowest was 3. The median value was 10. At the four-week follow-up the highest score was 12 and the lowest 0 with a median score of 5 (Figure 2). A p-value less than 0,05 is considered statistically significant. The result of this study carries a p-value, p= 0,000000000001, p<0.0001, thus significant. 

The women’s evaluation of the educational course revealed that 72.5% of the 42 participants experienced the course as coherent and felt an improvement in their symptoms after the three modules. According to 87.5% of the participants, was acquiring practical techniques to handle their symptoms an important part of the course. Other topics showed that 90% considered meeting other women with the same issues to be an important part of the course, and 72.5% of the participants considered receiving instruction in pelvic floor exercises as valuable.

The results suggest that regardless of whether the participants had a low or high score on SMIS, they reported experiencing an improvement at the third module and the improvement persisted at the four-week follow-up. The significant reduction in SMIS suggests that the participants had a high degree of adherence of self-management based on the knowledge they acquired during the course. Furthermore, participation in a self-referred educational course may indicate motivation to prevent and alleviate symptoms. The participants responded that it was very important for them to meet other women with AI. This might be because of the opportunity to share their thoughts, inspire and support each other during the course.

A group-based education course, facilitated by nurses and physical therapists, including education and guidance in conservative management methods can reduce the degree of AI. This study suggests that women with AI benefit from meeting others with AI, and that group-based education can be recommended.

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Roos A-M, Sultan AH, Thakar R. St. Mark’s incontinence score for assessment of anal incontinence following obstetric anal sphincter injuries (OASIS). Int Urogynecol J Pelvic Floor Dysfunct. 2009 Apr;20(4):407–10.