Diagnosis and Treatment of Dyssynergic Defecation

Biofeedback Treatment Can Improve Clinical Condition and Quality of Life in Patients with Pelvic Floor Dyssynergy with Irritable Bowel Syndrome: A Prospective Cohort Study

Background: Chronic constipation is a common health concern. Defecatory disorders are considered one of the mechanisms of chronic idiopathic constipation. This study aimed to evaluate the effect of concurrent irritable bowel syndrome (IBS) on the success rate and response to biofeedback therapy in patients with chronic constipation and pelvic floor dyssynergia (PFD). Methods: This prospective cohort study was performed at the Imam Khomeini Hospital Complex in Tehran from October 2020 to July 2021. Patients aged 18-70 years with chronic constipation and PFD confirmed by clinical examination, anorectal manometry, balloon expulsion test, and/or defecography were included. All patients failed to respond to treatment with lifestyle modifications and laxative use. The diagnosis of IBS was based on the ROME IV criteria. Biofeedback was educated and recommended to all patients. We used three different metrics to assess the patient's response to biofeedback: 1) constipation score (questionnaire), 2) lifestyle score (questionnaire), and 3) manometry findings (gastroenterologist report). Results: Forty patients were included in the final analysis, of which 7 men (17.5%) and 21 (52.2%) had IBS. The mean age of the study population was 37.7 ± 11.4. The average resting pressure decreased in response to treatment; however, this decrease was statistically significant only in non-IBS patients (P = 0.007). Patients with and without IBS showed an increase in the percentage of anal sphincter relaxation in response to treatment, but this difference was not statistically significant. Although the first sensation decreased in both groups, this decrease was not statistically significant. Overall, the clinical response was the same across IBS and non-IBS patients, but constipation and lifestyle scores decreased significantly in both groups of patients with and without IBS (P < 0.001). Conclusion: Biofeedback treatment appears to improve the clinical condition and quality of life of patients with PFD. Considering that a better effect of biofeedback in correcting some manometric parameters has been seen in patients with IBS, it seems that paying attention to the association between these two diseases can be helpful in deciding on treatment.

Anorectal manometry for the diagnosis of pelvic floor disorders in patients with hypermobility spectrum disorders and hypermobile Ehlers-Danlos syndrome

INTRODUCTION

Functional gastrointestinal disorders (FGID) including impaired rectal evacuation are common in patients with Hypermobility Spectrum Disorder (HSD) or Hypermobile Ehlers-Danlos Syndrome (hEDS). The effect of connective tissue pathologies on pelvic floor function in HSD/hEDS remains unclear. We aimed to compare clinical characteristics and anorectal pressure profile in patients with HSD/hEDS to those of age and sex matched controls.

METHODS

We conducted a retrospective review of all FGID patients who underwent high resolution anorectal manometry (HR-ARM) and balloon expulsion test (BET) for evaluation of impaired rectal evacuation. Patients with HSD/hEDS were age and sex matched to a randomly selected cohort of control patients without HSD/hEDS. An abnormal BET was defined as the inability to expel a rectal balloon within 2 minutes. Wilcoxon rank sum test and Fisher's exact test were used to make comparisons and logistic regression model for predictive factors for abnormal evacuation.

RESULTS

A total of 144 patients (72 with HSD/hEDS and 72 controls) were analyzed. HSD/hEDS patients were more likely to be Caucasian (p < 0.001) and nulliparous. Concurrent psychiatric disorders; depression, and anxiety (p < 0.05), and somatic syndromes; fibromyalgia, migraine and sleep disorders (p < 0.001) were more common in these patients. Rate of abnormal BET were comparable among the groups. HDS/hEDS patients had significantly less anal relaxation and higher residual anal pressures during simulated defecation, resulting in significantly more negative rectoanal pressure gradient. The remaining anorectal pressure profile and sensory levels were comparable between the groups. While diminished rectoanal pressure gradient was the determinant of abnormal balloon evacuation in non HSD/hEDS patients, increased anal resting tone and maximum volume tolerated were independent factors associated with an abnormal BET in HSD/hEDS patients. Review of defecography data from a subset of patients showed no significant differences in structural pathologies between HSD/hEDS and non HSD/hEDS patients.

CONCLUSIONS

These results suggest anorectal pressure profile is not compromised by connective tissue pathologies in HSD patients. Whether concurrent psychosomatic disorders or musculoskeletal involvement impact the pelvic floor function in these patients needs further investigation.

Biofeedback pelvic floor muscle training versus posterior tibial nerve electrostimulation in treatment of functional obstructed defecation: a prospective randomized clinical trial

Background

Functional obstructed defecation is a common anorectal problem among adult population. The objective was to compare the short-term efficacy of biofeedback pelvic floor muscle training versus transcutaneous posterior tibial nerve electrostimulation in treatment of patients with functional obstructed defecation.

Results

There were 41 patients completed the study. There were no statistical significant differences between biofeedback pelvic floor muscle training group and transcutaneous posterior tibial nerve electrostimulation group regarding different clinical characteristics, as well as, electrophysiological findings. There was statistically significant reduction in all outcome measures after intervention in both groups. The primary outcome measure was Modified obstructed defecation score. Secondary outcome measures were Patient Assessment of Constipation-Quality of Life questionnaire, time of toileting, and maximum anal pressure during straining to evacuate. No significant differences were present between both groups regarding different outcome measures in the pretreatment and post-treatment assessments. Successful outcome was reported in 81% of patients in biofeedback pelvic floor muscle training group in comparison to 40% of patients in the posterior tibial nerve electrostimulation group according to the Modified obstructed defecation score which was the primary outcome measure.

Conclusions

Both biofeedback pelvic floor muscle training and posterior tibial nerve electrostimulation are considered effective methods in the treatment of functional obstructed defecation. However, biofeedback pelvic floor muscle training seems to be more effective and superior in comparison to posterior tibial nerve electrostimulation. Posterior tibial nerve electrostimulation could be combined with biofeedback pelvic floor muscle training or considered as a second line therapy after failure of biofeedback pelvic floor muscle training.

Trial registration

Pan African Clinical Trials Registry, PACTR202009762113535. Registered 2 September 2020—retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12321.

Dietary management of adults with IBD - the emerging role of dietary therapy

Historically, dietitians played a minor part in the management of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. Patients were commonly referred for consequences of uncontrolled disease, such as malnutrition and bowel obstruction risk. Today, dietitians are fundamental members of the multidisciplinary IBD team, from educating on the role of diet at diagnosis and throughout the lifespan of a patient with IBD to guiding primary induction therapy. This aspect is reflected in published guidelines for IBD management, which previously placed diet as only a minor factor, but now have diet-specific publications. This Review describes a four-step approach in a dietitian's assessment and management of diet in patients with IBD: (1) identifying and correcting nutritional gaps and dietary imbalances; (2) considering diet to treat active disease with the use of exclusive enteral nutrition (EEN) or emerging diets that could replace EEN; (3) using therapeutic diets to control existing complications of IBD, such as reduced fibre to prevent bowel obstruction in stricturing disease or a fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet to manage co-existing functional gut symptoms; and (4) considering the role of diet in preventing IBD development in high-risk populations.

Intra- and inter-observer agreement in the classification of dyssynergic defecation on high-resolution anorectal manometry using water-perfusion system

BACKGROUND AND AIMS

Dyssynergic defecation (DD) classified on anorectal manometry is based on variations in anal sphincter pressures and rectal pressure generated during bearing down. There is a paucity of data on intra- and inter-observer agreement in the classification of DD on high-resolution anorectal manometry (HRAM) using a water-perfusion system.

METHODS

This cross-sectional observational study was conducted between June 2014 and May 2016 on 70 adult patients with DD. Observer 1 did the baseline analysis and reanalyzed the readings at least 6 months later, blinded to the initial analysis results (intra-observer variability). Four other blinded observers (5-25 years in anorectal manometry and minimum 5 years of experience in HRAM) then individually analyzed the manometry data (inter-observer variability).

RESULTS

Intra-observer agreement was excellent (kappa 0.862) for classifying DD. Agreement between the six observations (i.e. two from observer 1 and four from independent observers) was also good (kappa 0.632). The highest agreement was for type 4 DD (kappa 0.738), followed by type 1 (0.680), type 2 (0.664), and type 3 (0.537). Cronbach's alpha value was 0.93, suggesting excellent internal consistency.

CONCLUSION

The diagnosis of the types of DD on anorectal manometry using a water-perfusion system has excellent intra-observer and good inter-observer agreement .

Antegrade continence enemas in children with functional constipation and dyssynergic defecation: Go or no go?

OBJECTIVE

To assess outcomes of children with functional constipation after antegrade continence enemas (ACEs) and determine if pre operative anorectal manometry (AMAN) findings, including dyssynergic defecation, are associated with outcomes.

METHODS

A retrospective review of pediatric patients with functional constipation who received a Malone appendicostomy or cecostomy after failed medical management was conducted. Patients were included if they had AMAN data prior to their operation. Patients that underwent colonic resection were excluded. Demographics, clinical characteristics, manometry results, and post ACE outcomes were obtained. Descriptive statistics were performed.

RESULTS

Thirty-nine patients were identified with median age at ACE of 8.9 years (IQR: 7.2-12.6) and median follow-up of 2.5 years (IQR: 1.8-3.2 years). Twenty patients (51%) were female and most (35, 92%) were White. All patients had severe constipation prior to ACE and 59% had fecal incontinence. Thirty-four patients (87%) received a Malone and 5 (13%) received a cecostomy. Post ACE, 35 (90%) were clean with daily flushes and 6 (15%) eventually successfully transitioned to laxatives only. Awake AMAN and balloon expulsion test were performed in 15 patients, with 14 (93%) displaying evidence of dyssynergic defecation. Twelve of 14 of patients (86%) with dyssynergia were clean with ACE at follow-up. because of the majority of patients being clean post ACE, there was limited power to detect predictors of poor outcomes.

CONCLUSIONS

ACEs are successful treatment options for patients with severe constipation and fecal incontinence, including those with dyssynergic defecation. Larger studies are needed to identify factors predictive of poor outcomes.

LEVEL OF EVIDENCE

III.

The Effects of Cognitive Behavioral Therapy with Biofeedback Therapy on the Quality of Life, Anxiety, Depression and Somatic Symptoms in Patients with Dyssynergic Defecation: A Randomized Controlled Trial

Background: Dyssynergic defecation (DD) is a major cause of chronic functional constipation. Patients with DD have greater psychological distress and impaired health-related quality of life compared with the general population. This study aimed to evaluate the effectiveness of cognitive-behavioral therapy (CBT) combined with biofeedback therapy (BFT) on the quality of life, anxiety, depression and physical symptoms in patients with DD.

Methods: This randomized controlled trial (IRCT20141115019957N2) was conducted on 45DD patients who were referred to the Rehabilitation Clinic of Iran University of Medical Sciences in 2017. The convenience sampling method was used to select the participants and then they were randomly allocated into three equal groups using RANDBETWEEN function in Excel. The first group received a combination of BFT&CBT and also standard-of-care therapy (SoCT). The second group was treated with BFT and SoCT, and the third group received only SoCT. The patients were assessed by digital rectal examination and the Short Form-36, Spielberger Anxiety, Beck Depression and Constipation Scoring System questionnaires before and after the treatment.The data were analyzed by SPSS-22, ANOVA, ANCOVA and Chi-Square tests.

Results: Patients who received both CBT&BFT had significant improvement in symptoms of constipation, depression, and anxiety.Furthermore, BFT and CBT&BFT groups are valued equivalent only on the mental component of SF36 and the total SF36 questionnaire. But the physical component was significantly different, favoring CBT&BFT (p< 0.001). In CBT&BFT group,67%of patients reached the relaxed stage. In contrast, no patient reached the relaxed neither in BFT nor in SoCT.

Conclusion: According to our study, patients with unfavorable responses to BFT may become better if CBT is added to their treatment plan.

Clinical value of positive BET and pelvic floor dyssynergia in Chinese patients with functional defecation disorder

BACKGROUND

Functional defecation disorder (FDD) is a common subtype of functional constipation (FC). Balloon expulsion test (BET) and high resolution anorectal manometry (HR-ARM) are significant tools but their results are not always consistent.

AIMS

To investigate the characteristics of patients with positive BET and pelvic floor dyssynergia (PFD) and explore the value of both positive results in FDD diagnosis.

METHODS

We retrospectively diagnosed FC subtypes and enrolled FDD patients based on Rome-IV criteria. They underwent HR-ARM, BET and CTT tests. Then they were classified to two groups and further stratified by FDD subtypes. Validated questionnaires were applied to investigate patients' constipation, anxiety/depression and quality of life.

RESULTS

335 FDD patients were finally enrolled. They were classified into two groups according to whether BET and PFD were both positive (consistent or not). 84.48% showed consistent results. These patients had significantly higher anal residual pressure, lower anal relaxation rate, manometric defecation index (MDI) and a more negative rectoanal pressure gradient (RAPG) (Ps < .05). The specific distribution of FDD phenotypes in two groups showed significant difference (p = .021). Males suffered a more negative RAPG (p < .001) and age was correlated with anal relaxation rate (p < .001). A subset (177 individuals) was investigated with validated questionnaires. Scores for Defecation Symptoms, Physical Discomfort and GAD-7 score were significantly high in Consistent Group (Ps < .05). GAD-7 score was associated with Defecation Symptoms (p < .001) while anal residual pressure, GAD-7 and Defecation Symptoms score were linked to Physical Discomfort (Ps < .05). The diagnostic specificity and PPV for FDD rose significantly with positive BET and PFD.

CONCLUSION

FDD patients with positive BET and PFD suffered from severe defecation symptoms, anxiety and impaired QOL. Positive BET and PFD could be an ideal tool for screening FDD.

Kilohertz alternating current neuromodulation of the pudendal nerves: effects on the anal canal and anal sphincter in rats

The first two objectives were to establish which stimulation parameters of kilohertz frequency alternating current (KHFAC) neuromodulation influence the effectiveness of pudendal nerve block and its safety. The third aim was to determine whether KHFAC neuromodulation of the pudendal nerve can relax the pelvic musculature, including the anal sphincter. Simulation experiments were conducted to establish which parameters can be adjusted to improve the effectiveness and safety of the nerve block. The outcome measures were block threshold (measure of effectiveness) and block threshold charge per phase (measure of safety). In vivo, the pudendal nerves in 11 male and 2 female anesthetized Sprague Dawley rats were stimulated in the range of 10 Hz to 40 kHz, and the effect on anal pressure was measured. The simulations showed that block threshold and block threshold charge per phase depend on waveform, interphase delay, electrode-to-axon distance, interpolar distance, and electrode array orientation. In vivo, the average anal pressure during unilateral KHFAC stimulation was significantly lower than the average peak anal pressure during low-frequency stimulation (p < 0.001). Stimulation with 20 kHz and 40 kHz (square wave, 10 V amplitude, 50% duty cycle, no interphase delay) induced the largest anal pressure decrease during both unilateral and bilateral stimulation. However, no statistically significant differences were detected between the different frequencies. This study showed that waveform, interphase delay and the alignment of the electrode along the nerve affect the effectiveness and safety of KHFAC stimulation. Additionally, we showed that KHFAC neuromodulation of the pudendal nerves with an electrode array effectively reduces anal pressure in rats.

Organizing and Developing a GI Motility Lab in Community Practice: Challenges and Rewards

PURPOSE OF REVIEW

Neurogastroenterology and motility is a rapidly evolving subspecialty that encompasses over 33% of gastroenterological disorders, and up to 50% of referrals to gastroenterology practice. It includes common problems such as dysphagia, gastroesophageal reflux disease, irritable bowel syndrome, chronic constipation, gastroparesis, functional dyspepsia, gas/bloating, small intestinal bacterial overgrowth, food intolerance and fecal incontinence Standard diagnostic tests such as endoscopy or imaging are normal in these conditions. To define the underlying mechanism(s)/etiology of these disorders, diagnostic motility tests are often required. These are best performed by well-trained personnel in a dedicated motility laboratory. Our purpose is to provide an up-to-date overview on how to organize and develop a motility laboratory based on our collective experiences in setting up such facilities in academia and community practice.

RECENT FINDINGS

A lack of knowledge, training and facilities for providing diagnostic motility tests has led to suboptimal patient care. A motility laboratory is the hub for diagnostic and therapeutic motility procedures. Common procedures include esophageal function tests such as esophageal manometry and pH monitoring, anorectal function tests suchlike anorectal manometry, neurophysiology and balloon expulsion, dysbiosis and food intolerance tests such as hydrogen/methane breath tests, and gastrointestinal transit assessment. These tests provide an accurate diagnosis and guide clinical management including use of medications, biofeedback therapy, neuromodulation, behavioral therapies, evidence-based dietary interventions and endoscopic or surgical procedures. Further, there have been recent developments in billing and coding of motility procedures and training requirements that are not well known. This review provides a stepwise approach on how to set-up a motility laboratory in the community or academic practice and includes the rationale, infrastructure, staffing needs, commonly performed motility tests and their clinical utility, billing and coding strategies, training needs and economic considerations for setting up this service.

Rectal Evacuation Disorders are Associated With Poor Bowel Preparation in Patients With Chronic Constipation: Results From Two Centers

INTRODUCTION

We evaluated factors that can predict the adequacy of bowel preparation in patients with chronic constipation undergoing colonoscopy.

MATERIALS AND METHODS

We identified patients with chronic constipation who underwent anorectal manometry and at least 1 colonoscopy at 2 tertiary referral centers from 2003 to 2019. We also identified a subgroup of patients who underwent colonic transit testing through radiopaque marker testing. We determined demographic, medical, and constipation-related factors associated with poor bowel preparation and their effect on standardized quality metrics using univariate and multivariate analyses.

RESULTS

We identified 274 patients with chronic constipation who underwent anorectal manometry testing. Both outlet dysfunction (prolonged balloon expulsion) and slow-transit constipation were associated with suboptimal bowel preparation. Outlet dysfunction was also associated with decreased cecal intubation rates, adenoma detection rates, and sessile serrated polyp detection rates. In multivariable analyses controlling for demographics and known factors associated with poor bowel preparation, outlet dysfunction was associated with an almost 3-fold odds of suboptimal bowel preparation [odds ratio (OR): 2.9; 95% confidence interval (CI): 1.6-5.1] and a 3-fold reduction in cecal intubation rates (OR: 0.3; 95% CI: 0.1-0.8). Among those with radiopaque marker colonic transit testing available, slow-transit constipation was associated with a >2-fold odds of suboptimal bowel preparation (OR: 2.2; 95% CI: 1.1-4.4).

CONCLUSIONS

Among a cohort of patients with chronic constipation undergoing colonoscopy, outlet dysfunction was associated with suboptimal bowel preparation and other quality metrics. Constipated patients with a rectal evacuation disorder may represent a subgroup of patients that could benefit from individualized strategies for better bowel preparation.

Efficacy of a Modified Training Program of Adaptive Biofeedback Therapy for Dyssynergic Defecation in Patients with Chronic Constipation

BACKGROUND

Biofeedback therapy is highly effective and safe in treating dyssynergic defecation, which affects more than half of patients with chronic constipation. However, conventional biofeedback training has limitations.

AIMS

This study aims to modify the adaptive biofeedback (ABF) previously established by the investigators and evaluate its efficacy for dyssynergic defecation.

METHODS

A total of 42 constipation patients were enrolled and randomly assigned to receive either 4-week adaptive biofeedback (ABF) training (ABF group), or fixed biofeedback (FBF) training (FBF group). The ABF training program was modified, as follows: (1) the tailored training targets were set according to the ability of the individual subject, instead of the fixed values; (2) the outcome was scored on the basis of the rectal-anal pressure gradient; (3) the feedback information was delivered through multimedia. The outcomes were compared between the two groups.

RESULTS

The number of weekly bowel movements (BM) was significantly greater in the ABF group than in the FBF group. The improvement in dyssynergic defecation was also noted with the modified ABF training, which performed significantly better than the conventional training on incomplete defecation, bloating, defecation time, staining, and urgency. Notably, the use of medications was significantly reduced upon completion of the 4-week adaptive training, and this was significantly lesser than that in the fixed training. Furthermore, there was significantly better improvement on anorectal motility and rectal sensation in the ABF group vs. the FBF group.

CONCLUSION

The modified ABF training program significantly improves constipation-related symptoms, and its performance is superior to conventional FBF training for dyssynergic defecation.

Dyssynergic Defecation and Other Evacuation Disorders

Constipated patients are frequently referred to gastroenterologists for symptoms refractory to lifestyle modifications and laxatives. Dyssynergic defecation, the dyscoordination of rectoanal, abdominal, and pelvic floor muscles to facilitate defecation, is a major cause of refractory primary constipation. Understanding of the diagnosis, evaluation, and management of dyssynergic defecation and other evacuation disorders will allow providers to effectively manage these patients. This review focuses on the definition, pathophysiology, evaluation, and treatment of dyssynergic defecation and other evacuation disorders. Emerging treatments for these disorders include home biofeedback therapy for dyssynergic defecation and translumbosacral neuromodulation therapy for levator ani syndrome.

Psychological and Nutritional Factors in Pelvic Floor Disorders

This article discusses the role of psychological and nutritional factors in gastrointestinal pelvic floor disorders such as dyssynergic defection and explores the use of multidisciplinary strategies to enhance treatment.

The Efficacy of Biofeedback Therapy in Patients with Solitary Rectal Ulcer and Dyssynergic Defecation

BACKGROUND

The treatment of solitary rectal ulcer (SRU) is challenging and controversial; generally, no response to conventional treatments can be obtained, particularly in patients with dyssynergic defecation (DD). We assessed the efficiency of biofeedback therapy (BFT) in patients who did not respond to conservative treatments and had coexistence of SRU and DD.

METHODS

BFT responses, as well as anorectal manometry and rectoscopy results of 20 patients with the coexistence of SRU and DD, were assessed.

RESULTS

Mean age was 32.5 years. Of the patients, 12 were female, and 8 of them were male. An average of 12 sessions of BFT was performed on the patients. Ulcer disappeared in 11 patients (55%) after BFT, and the ulcer size decreased in 3 patients (15%). However, ulcers healed in 9 (90%) of 10 patients whose DD pattern disappeared following BFT, and ulcers healed in only 20% of patients whose DD pattern continued (p = 0.005). The change in anal resting pressure after BFT was significant (p = 0.016). Ulcers were healed in 87.5% (7/8) of the patients whose anal resting pressure decreased after BFT and whose DD disappeared, while ulcers remained untreated in 85.7% of the patients whose anal resting pressure decreased, but the DD pattern continued (p = 0.005).

CONCLUSIONS

SRU patients with DD are typically unresponsive to medical treatments. Ameliorating anorectal dyssynergia should be the priority of treatment in these patients. BFT is an effective treatment for DD. BFT enhances the healing of ulcers in patients with SRU by restoring coordination of the pelvic floor.

Pelvic floor dysfunction at transperineal ultrasound and chronic constipation in women with endometriosis

OBJECTIVE

To assess the association between sonographic findings at transperineal ultrasound (TPU) and chronic constipation (CC) in women with endometriosis.

METHODS

An observational prospective cohort study was performed by enrolling all endometriosis women scheduled for surgery between September 2019 and October 2020. Women underwent TPU at rest and during Valsalva maneuver evaluating levator-hiatal-area (LHA), antero-posterior diameter (APD), levator-ani muscle (LAM)-coactivation. Ultrasound findings were compared between women with and without CC in the whole study population, and subsequently in two subgroups [only ovarian and deep infiltrating endometriosis (DIE)].

RESULTS

87 women were enrolled: 29 (33%) with CC and 58 (67%) without CC. Women with endometriosis and CC showed a smaller LHA during Valsalva, less LHA and APD enlargement from rest to maximum Valsalva, a higher prevalence of LAM-coactivation compared to women without CC. In ovarian-subgroup, women with CC had smaller LHA at Valsalva, less enlargement of LHA and APD from rest to maximum Valsalva and higher prevalence of LAM-coactivation compared to non-CC patients. In DIE-subgroup, TPU did not significantly differ between CC and non-CC patients.

CONCLUSION

TPU signs of pelvic floor muscle hypertone are more frequent in endometriosis patients with CC compared to those without constipation, particularly in women affected by isolated ovarian endometriosis.

New developments in defecatory studies based on biomechatronics

Introduction

Defecation is a complex process that is difficult to study and analyze directly. In anorectal disease conditions, the defecation process may be disturbed, resulting in symptoms including fecal incontinence and constipation. Current state-of-the-art technology measures various aspects of anorectal function but detailed analysis is impossible because they are stand-alone tests rather than an integrated multi-dimensional test.

Objectives

The need for physiologically-relevant and easy-to-use diagnostic tests for identifying underlying mechanisms is substantial. We aimed to advance the field with integrated technology for anorectal function assessment.

Methods

We developed a simulated stool named Fecobionics that integrates several tests to assess defecation pressures, dimensions, shape, orientation and bending during evacuation. A novelty is that pressures are measured in axial direction, i.e. in the direction of the trajectory. Using this novel tool, we present new analytical methods to calculate physiologically relevant parameters during expulsion in normal human subjects.

Results

Data are reported from 28 human subjects with progressively more advanced versions of Fecobionics. A new concept utilizes the rear-front pressure (preload-afterload) diagram for computation of novel defecation indices. Fecobionics obtained physiological data that cannot be obtained with current state-of-the-art technologies.

Conclusion

Fecobionics measures well known parameters such as expulsion time and pressures as well as new metrics including defecation indices. The study suggests that Fecobionics is effective in evaluation of key defecatory parameters and well positioned as an integrated technology for assessment of anorectal function and dysfunction.

A systematic review of diagnostic tests to detect pelvic floor myofascial pain

INTRODUCTION AND HYPOTHESIS

Myofascial pain arising from pelvic floor muscles occurs in women with vaginismus, interstitial cystitis and endometriosis but is often overlooked. The aim is to examine alternative diagnostic tests to detect pelvic floor myofascial pain compared with standardized vaginal palpation of pelvic floor muscles as the reference test.

METHODS

A systematic review was prospectively conducted (PROSPERO-CRD42020183092) according to PRISMA guidelines. Databases searched included Ovid Medline 1946-, Embase 1957-, Scopus 1960-, Cochrane Combined, Clinical trials, Google Scholar (top 200 articles), Web of Science, TRIP, BIOSIS, DARE, CINHAL, EmCare, PEDro, ProQuest and EBSCOhost up to July 2020. Articles were independently screened by two authors and assessed for bias using QUASDAS-2 tool.

RESULTS

A total of 26,778 articles were screened and 177 were selected for full text review, of which 5 were selected for final analysis. Five studies included 9694 participants of which 1628 had pelvic floor myofascial pain. Only one study reported data to calculate sensitivities and specificities of the index test, which utilized a score of > 40 on the Central Sensitization Inventory to detect women with pelvic floor myofascial pain and revealed a sensitivity of 34.8% and a specificity of 84.9% compared to the reference test.

CONCLUSIONS

This systematic review did not reveal any diagnostic test superior to the pre-defined reference test. There is a lack of consensus on the definition of pelvic floor myofascial pain and a lack of a validated diagnostic criteria which must be addressed to progress with meaningful research in this field.

Pelvic floor physical therapy in the treatment of chronic anal fissure (PAF-study): Study protocol for a randomized controlled trial

BACKGROUND

Chronic anal fissure (CAF) is a common cause of severe anorectal pain with a high incidence rate. Currently, a wide range of treatment options are available with recurrence rates varying between 7 and 42%. Pelvic floor physical therapy (PFPT) is a treatment option for increased pelvic floor muscle tone and dyssynergia which often accompanies CAF. However, literature on this subject is scarce. The Pelvic Floor Anal Fissure (PAF)-study aims to determine the efficacy and effectiveness of PFPT on improvement on pelvic floor muscle tone and function, pain, healing of the fissure, quality of life and complaint reduction in patients with CAF.

METHODS

The PAF-study is a single-centre, two armed, randomized controlled trial. Patients with CAF and pelvic floor dysfunction are eligible for inclusion. Exclusion criteria include abscess, fistula, Crohn's disease, ulcerative colitis, anorectal malignancy, prior rectal radiation, and pregnancy. A total of 140 patients will be randomized for either PFPT or postponed treatment of PFPT.The primary outcome is tone at rest during electromyographic registration of the pelvic floor before and after therapy. Secondary outcomes consist of healing of the fissure, pain ratings, improvement of pelvic floor function, complaint reduction and quality of life. Primary and secondary endpoints are measured at 8 and 20 weeks and at 1-year follow-up.

DISCUSSION

Currently, there is a gap in treatment modalities between conservative management and surgery. This manuscript prescribes the rationale, design, and methodology of a randomized controlled trial investigating PFPT as a treatment option for patients with CAF.

Women with chronic constipation have more bothersome urogenital symptoms

BACKGROUND

The aim of our study was to characterize urogenital symptoms in women with and without constipation, and by severity of constipation.

METHODS

This was a retrospective cohort study conducted at a pelvic floor disorder center in a tertiary healthcare facility from May 2007 through August 2019 and completed an intake questionnaire were included. We collected demographic, physical exam data and quality of life outcomes. The Urinary Distress Inventory (UDI-6) was used to assess urogenital symptoms. Women with constipation completed the Constipation Severity Instrument (CSI). We excluded women with a history of a bowel resection, inflammatory bowel disease, or pelvic organ prolapse symptoms. The cohort was then divided into two groups, constipated and non-constipated, and the prevalence and severity of urogenital-associated symptoms were compared. A secondary analysis was made among constipated subjects stratified by constipation severity based on CSI scores.

RESULTS

During the study period, 875 women (59.5%) had chronic constipation. Women with chronic constipation were more likely to experience urogenital symptoms, such as dyspareunia, urinary hesitancy, and a sensation of incomplete bladder emptying (all p < 0.05). Moreover, on univariate analysis, women with high CSI scores (75 percentile or higher) were found to have higher UDI-6 scores, increased bladder splinting, pad use, urinary frequency and dyspareunia while on multivariate analysis higher UDI score, increased bladder splinting, urinary frequency and dyspareunia were significantly associated (p < 0.05).

CONCLUSION

We found that the presence and severity of chronic constipation worsened the degree of bother from urogenital symptoms. Given that chronic constipation can modulate urogenital symptoms, our study suggests that pelvic floor specialists should assess the presence and severity of urogenital and bowel symptoms to provide comprehensive care.

A novel wireless, smartphone-based biofeedback training device for functional defecatory disorders: a pilot study

BACKGROUND

Functional defecatory disorders (FDDs) are highly prevalent around the world. Biofeedback is an effective treatment for FDDs. Traditionally, this treatment is performed by clinicians in a limited number of hospitals because of procedure-related expenses and a need for a dedicated procedure room. To make the biofeedback therapy more widely available, we have designed a novel wireless, smartphone-based biofeedback device, with the ultimate goal of performing the therapy at home. The aim of this pilot study was to investigate whether the developed device can be employed to treat patients with FDDs in a clinical setting, prior to employing it in a home setting.

METHODS

From March 2018 to July 2018, we performed the biofeedback therapy using the newly developed wireless, smartphone-based device in patients with FDDs 30 min daily during weekdays for 2 weeks. A Visual Analogue Scale (VAS) for bowel satisfaction, Patient Assessment of Constipation-Symptoms (PAC-SYM), Patient Assessment of Constipation Quality of Life (PAC-QOL), and a balloon expulsion test were assessed at baseline and after the therapy.

RESULTS

Thirteen patients were recruited and ten of them (mean age 70.3 ± 8.9 years, female:male ratio: 3:7) completed the study. Spontaneous bowel movements, complete spontaneous bowel movements, and VAS were all significantly increased after the therapy compared with baseline, respectively (6.5 ± 4.3 vs. 1.5 ± 2.2, p = 0.006; 3.1 ± 2.2 vs. 0.2 ± 0.6, p = 0.002; 49.5 ± 31.0 vs. 12.0 ± 9.2, p = 0.003). There was a significant decrease in the PAC-SYM and PAC-QoL after the biofeedback therapy (0.7 ± 0.6 vs. 1.4 ± 0.3, p = 0.001; 0.7 ± 0. 6 vs. 1.5 ± 0.4, p = 0.001). The therapy reduced the balloon expulsion time significantly (83.9 ± 68.8 s vs. 160.0 ± 36.7 s, p = 0.002). No obvious adverse events related to the procedure itself occurred.

CONCLUSIONS

Biofeedback training using the newly developed wireless, smartphone-based device is feasible in the clinic setting, and it seems to be a promising method for improving constipation and related symptoms in patients with FDDs. These findings could be used to develop a much-needed, home-based, suitably powered, randomized, controlled clinical trial.

Understanding the physiology of human defaecation and disorders of continence and evacuation

The act of defaecation, although a ubiquitous human experience, requires the coordinated actions of the anorectum and colon, pelvic floor musculature, and the enteric, peripheral and central nervous systems. Defaecation is best appreciated through the description of four phases, which are, temporally and physiologically, reasonably discrete. However, given the complexity of this process, it is unsurprising that disorders of defaecation are both common and problematic; almost everyone will experience constipation at some time in their life and many will develop faecal incontinence. A detailed understanding of the normal physiology of defaecation and continence is critical to inform management of disorders of defaecation. During the past decade, there have been major advances in the investigative tools used to assess colonic and anorectal function. This Review details the current understanding of defaecation and continence. This includes an overview of the relevant anatomy and physiology, a description of the four phases of defaecation, and factors influencing defaecation (demographics, stool frequency/consistency, psychobehavioural factors, posture, circadian rhythm, dietary intake and medications). A summary of the known pathophysiology of defaecation disorders including constipation, faecal incontinence and irritable bowel syndrome is also included, as well as considerations for further research in this field.

Anorectal manometry to diagnose dyssynergic defecation: Systematic review and meta-analysis of diagnostic test accuracy

BACKGROUND

Chronic constipation is a common condition, and dyssynergic defecation underlies up to 40% of cases. Anorectal manometry is recommended to assess for dyssynergic defecation among chronically constipated patients but remains poorly standardized. We aimed to evaluate the diagnostic accuracy of anorectal manometry and determine optimal testing parameters.

METHODS

We performed a systematic review with meta-analysis of diagnostic test accuracy including cohort studies of chronically constipated patients and case-control studies of patients with dyssynergic defecation or healthy controls. Meta-analysis was performed to determine summary sensitivity, specificity, and area under the curve (AUC) with 95% confidence intervals (CI).

KEY RESULTS

A total of 15 studies comprising 2140 patients were included. Including all studies (estimating optimal diagnostic accuracy), the AUC was 0.78 [95% CI 0.72-0.82], summary sensitivity was 79% [61%-90%], and summary specificity was 64% [44%-79%] to diagnose dyssynergic defecation. In cohort studies only (estimating real-world diagnostic accuracy), the AUC was 0.72 [0.66-0.77], summary sensitivity was 86% [64%-95%], and summary specificity was 49% [30%-68%]. Employing three consecutive simulated defecation attempts improved sensitivity to 94%. A fourth simulated defecation maneuver with air insufflation may improve accuracy. Measuring anorectal pressures to identify complex dyssynergic patterns did not improve real-world diagnostic accuracy estimates over anal pressure measurement alone. Choice of manometry system did not impact diagnostic accuracy.

CONCLUSIONS & INFERENCES

Following the current iteration of the London consensus protocol (three simulated defecation attempts measuring anal relaxation), the role of anorectal manometry in evaluating dyssynergic defecation appears limited. Future iterations of this protocol may improve diagnostic accuracy.

Digital Rectal Examination Is a Valuable Bedside Tool for Detecting Dyssynergic Defecation: A Diagnostic Study and a Meta-Analysis

BACKGROUND

Accurate dyssynergic defecation (DD) diagnosis depends on anorectal physiological tests that are not widely available.

AIM

The purpose of this study is to evaluate the diagnostic yield of digital rectal examination (DRE) compared with anorectal physiological tests in diagnosing DD in patients with constipation.

METHODS

A total of 218 chronic constipation patients who fulfilled the Rome IV diagnostic criteria for functional constipation (FC) and underwent a standardized DRE and high-resolution anorectal manometry (HRAM) test were enrolled in this study. The diagnostic accuracy of DRE compared with HRAM was evaluated, and the agreement between DRE and HRAM was calculated. Furthermore, a comprehensive literature search on PubMed, Web of Science, Cochrane Library, and Embase database was conducted to further elucidate the pooled diagnostic accuracy of DRE in DD patients.

RESULTS

A total of 101 patients (46.33%) had a DD pattern using HRAM, while 117 patients (53.67%) were diagnosed without DD. The sensitivity of DRE in diagnosing dyssynergia was 71.3%, and the specificity was 76.1%. There was a moderate agreement between DRE and HRAM for diagnosing DD (κ-coefficient = 0.474, P < 0.001). Meanwhile, six studies (including our study) comprising 964 constipated patients were included in our meta-analysis. The outcomes demonstrated that the AUC was 0.85 (95% CI 0.82-0.88) with 77% summary sensitivity (95% CI 65-86) and 80% summary specificity (95% CI 71-86) to diagnose DD.

CONCLUSIONS

DRE could be a valuable tool for screening DD. Our study revealed acceptable sensitivity and specificity of DRE in detecting dyssynergia compared with the physiological tests. Meanwhile, our study highlights that DRE remains an important tool in clinical practice.

Diagnosis of Functional Gastrointestinal Disorders and Choice of Treatment Regimen in Constipation Patients

Aim. A practical review of functional gastrointestinal disorder diagnosis in constipation patients and the rationale for opting treatment.

Key points. Functional constipation commonly afflicts different ages and negatively impacts the quality of life. The current diagnostic algorithm in chronic constipation includes the disease identification according to Rome Criteria IV, red-flag symptom detection and instrumental laboratory examination. Functional constipation is notably often associated with anorectal abnormalities that bear a diagnostic value to elaborate an apt treatment strategy. Anorectal manometry, rectal sensation and balloon expulsion tests are the well-studied and significant probing techniques for objective anorectal zone sensorimotor function assessment in patients with functional constipation. The article reviews modern diagnostic methods in functional defecation disorders.

Conclusion. The examination and treatment algorithms presented will help improve diagnosis and apply the most suitable management in a constipation-associated functional digestive pathology.

Diagnostics of functional disorders of the gastrointestinal tract in patients with constipation

The purpose of the review is to acquaint general practitioners, therapists, gastroenterologists with the possibilities of diagnosing functional disorders of the gastrointestinal tract associated with constipation, as well as to draw attention to the need for additional examination methods for a comprehensive assessment of functional disorders of the gastrointestinal tract in patients with constipation on pathogenesis.

Functional constipation is an urgent problem today due to its prevalence among different age groups, a negative impact on the quality of life, as well as the variability of the clinical forms of diseases associated with this symptom. The modern diagnostic algorithm for chronic constipation consists of several stages, including the identification of signs of the disease, according to the Rome criteria of the IV revision (2016), the identification of symptoms of “red flags” and laboratory and instrumental research. It should be borne in mind that functional constipation is often based on the pathology of the anorectal zone, which is an important factor in the diagnosis and development of further therapeutic strategies. The article provides an overview of modern and promising methods for diagnosing functional disorders of defecation, taking into account functional disorders of the anorectal zone associated with constipation.

Functional methods such as anorectal manometry, rectal sensory test and balloon expulsion test are the  most studied and obligatory tests for an objective assessment of the sensorimotor function of the anorectal zone. In Russia, these methods are used very little, which requires extensive familiarization of practitioners with the advantages of these techniques. Knowledge and application of the presented examination algorithms will help the clinician to increase the overall diagnostic efficiency and apply the most justified tactics of managing patients with functional pathology of the digestive system associated with constipation. 

Rectosigmoid Localization of Radiopaque Markers for Identifying Defecation Disorders in Patients With Chronic Constipation: A Retrospective Cohort Study

BACKGROUND/AIMS

Defecation disorders (DD) are part of the spectrum of chronic constipation with outlet obstruction. Although anorectal physiologic tests are required for the diagnosis of DD, these tests are not available in many institutions. This study aims to investigate the predictivity of DD using rectosigmoid localization of radiopaque markers in a colonic transit study.

METHODS

A total of 169 patients with refractory constipation with a mean age of 67 years were studied. All patients underwent anorectal manometry, a balloon expulsion test, and a colonic transit study. Barium defecography was performed if needed. The relationship between DD diagnosed by these anorectal tests and the rectosigmoid accumulation of markers was examined.

RESULTS

Seventy-nine (46.7%) patients were identified to have DD based on anorectal test combinations. Rectosigmoid accumulation of markers was observed in 39 (23.1%) patients. The sensitivity and positive predictive value of rectosigmoid accumulation for identifying DD were 31.6% and 64.1%, respectively. Rectosigmoid accumulation provided poor discrimination of DD from normal transit constipation, at a specificity of 82.1% but with a sensitivity of only 10.6%. In discriminating DD from slow transit constipation, rectosigmoid accumulation was found to be useful with a positive likelihood ratio of 5.3.

CONCLUSION

s Rectosigmoid accumulation of markers can differentiate DD from slow transit constipation. However, non-rectosigmoid accumulation does not exclude the presence of DD.

The role of neuromodulation in chronic functional constipation: a systematic review

BACKGROUND

Chronic functional constipation is a highly prevalent disorder in which, when conservative measures fail to relieve symptoms, surgical interventions are sometimes indicated. In recent years, neuromodulation for the treatment of functional constipation has gained interest but its role and effectiveness are still unclear. The purpose of this review is to provide a systematic overview on the current literature on the different modalities of neurostimulation and their effect on chronic functional constipation in adults as reported in the literature.

METHODS

A search in the literature for articles concerning the effect of different types of neuromodulation on constipation was performed in PubMed using extensive search terms for the different modalities of neuromodulation. Studies and trials were checked for eligibility. For all types of neuromodulation together, 27 articles were included.

RESULTS

17 studies were included on SNM (sacral nerve modulation). Although multiple studies show positive results on the effect of SNM in constipation, double-blind crossover RCT's (randomised controlled trials) showed no significant effect. 3 studies were included for tSNS (transcutaneous sacral nerve stimulation), 2 for PTNS (percutaneous tibial nerve stimulation) and 2 for TTNS (transcutaneous tibial nerve stimulation). Studies and trials on these modalities of neuromodulation reported ambiguous results on statistical significance of the effect. For transcutaneous IFC (interferential current therapy) 2 studies were included, which both reported a statistically significant effect on all outcomes.

CONCLUSION

The beneficial effect of neuromodulation in chronic functional constipation remains questionable. However, neuro-modulation might be worth considering in patients refractory to treatment before turning to more invasive measures. Future research should shed more light on the effects of neuromodulation in constipation.

Botulinum toxin type-A infiltration of the external anal sphincter to treat outlet constipation in motor incomplete spinal cord injury: pilot cohort study

BACKGROUND

Outlet constipation is a major problem in spinal cord injury (SCI) patients. We aimed to study the efficacy of external anal sphincter (EAS) infiltration with type-A botulinum toxin (BTX-A) in motor incomplete SCI patients with outlet constipation.

METHODS

Double blind, randomized, placebo controlled, comparative study in 16 motor incomplete SCI subjects. Patients were randomly assigned toreceive100 UI of BTX-A (n = 9) or physiologic serum infiltration (n = 7) in the EAS under electromyographic guidance. Outcome measures included a questionnaire for clinical bowel function evaluation, colonic transit time and anorectal manometry. All assessments were done at baseline, 1 and 3 months after treatment.

RESULTS

Fourteen patients completed the study. In the BTX-A group we observed an improvement of subjective perception of bowel function (p = 0.01), constipation (p = 0.02) and neurogenic bowel dysfunction score (p = 0.02). The anorectal manometry revealed are duction of EAS voluntary contraction pressure (p = 0.01). No changes were observed in the placebo group. No significant side effects were observed in none of the groups.

CONCLUSION

BTX-A infiltration of the EAS is a safe technique that in motor incomplete SCI, decreases the EAS contraction and the anal canal pressure during straining, and improves outlet constipation symptoms. Future studies in larger populations are needed.

Novel bionics developments in gastroenterology: fecobionics assessment of lower GI tract function

Biomechatronics (bionics) is an applied science that is interdisciplinary between biology and engineering (mechanical, electrical and electronics engineering). Biomechatronics covers a wide area and is probably best known in development of prosthetic limbs, vision aids, robotics and neuroscience. Although the gastrointestinal tract is difficult to study, it is particularly suited for a bionics approach as demonstrated by recent developments. Ingestible capsules that travel the tract and record physiological variables have been used in the clinic. Other examples include sacral nerve stimulators that seek to restore normal anorectal function. Recently, we developed a simulated stool termed fecobionics. It has the shape of normal stool and records a variety of parameters including pressures, bending (anorectal angle) and shape changes during colonic transit and defecation, i.e. it integrates several current tests. Fecobionics has been used to study defecation patterns in large animals as well as in humans (normal subjects and patient groups including patients with symptoms of obstructed defecation and fecal incontinence). Recently, it was applied in a canine colon model where it revealed patterns consistent with shallow waves originating from slow waves generated by the interstitial cells of Cajal. Furthermore, novel analysis such as the rear-front pressure (preload-afterload) diagram and quantification of defecation indices have been developed that enable mechanistic insight. This paper reviews the fecobionics technology and outlines perspectives for future applications.

Anorectal Manometry on Children: A Moroccan Series and Literature Review

Introduction and objectives: Anorectal manometry is a test that evaluates the function of the rectum,but also the anus. It is useful for the diagnosis of several conditions like fecal incontinence and constipation.In children these tests are being increasingly used for all ages.The aim of this study was to determine the benefit of anorectal manometry in children and to report our experience. Material and Methods:Over a period of four years, 273children that underwent anorectal manometry were included in the study,their data and tests results were analyzed. Results:Out of 273 patients included,68,5% were boys and 31,5% were girls.The mean age was 9 years.154patients(51,6%) had Fecal incontinence(Group1),75children(27,5%) had chronic constipation(Group2),and both of them(Group3) were reported in 37children(13,6%).An awake manometry was  performed in 248children(91%) however this test under sedation allowed us the exclusion of Hirschsprung’s disease in 21children(84%).In group1, 25%patients had bad anal contraction.In groupe3, 21,6%children had bad anal contraction.The statistical analysis showed a significant difference in age(p=0.022) and resting pressure(p=0.050) between the three groups.Children with fecal incontinence had a higher rate of dyssynergy,80.2% and 83.8% in groups 1 and 3 respectively compared to 60.4% in patients with chronic constipation(p=0,852) Conclusion:The gold standard for the exploration of children’s terminal constipation and encopresis is the anorectal manometry.It is an important tool to establish diagnosis.In our study, this test allow the exclusion of Hirschsprung’s disease in infants with constipation,  in other hand we found a higher rate of dyssynergy in children with fecal incontinence(80%) which had allow us to propose a biofeedback therapy.

Physiotherapy and pelvic floor health within a contemporary biopsychosocial model of care: From research to education and clinical practice

Background

Pelvic floor dysfunction (PFD) is a common problem in both men and women. Despite the high prevalence and negative effects on quality of life, there is still a lack of research in this area which translates into clinical practice and education.

Objectives

My study discusses how gaps and controversies in current research and evidence on PFD might be addressed by positioning PFD within a contemporary biopsychosocial model of care (BPSM).

Method

Various databases were searched for relevant studies published between 2010 and 2020 to support hypotheses and statements.

Results

My study focuses on the available evidence of PFD in both men and women as related to the themes and sub-themes of the BPSM, and how this available evidence might translate into education and clinical practice. It highlights areas of research, education and clinical practice that need to be explored and how the different components of healthcare may influence one another.

Conclusion

Biomedical aspects regarding pelvic health are mostly investigated and taught, whilst psychological, cognitive, behavioural, social and occupational factors, individualised care, communication and therapeutic alliances are still under-investigated and not integrated or translated at a sufficient level into research, education and clinical practice.

Clinical implications

Incorporating the integration of all factors of the BPSM into research is important for effective knowledge translation and enhancement of a de-compartmentalised approach to management. The interaction between the different components of the BPSM should be investigated especially in a South African population.

The Effect of Biofeedback Therapy Combined with Comprehensive Nursing Intervention on the Quality of Life of Patients with Functional Constipation Based on Dynamic Magnetic Resonance Defecation

In order to study the quality of life of patients with functional constipation based on dynamic magnetic resonance defecation, the biofeedback therapy combined with comprehensive nursing intervention was used to diagnose and treat the patients, so as to explore its clinical efficacy and its impact on patients' quality of life. The obstructed defecation surgical treatment carries frequent recurrences, and dynamic magnetic resonance imaging defecography evaluated and elucidated the underlying anatomic features. This research selected 80 patients who came to our hospital for treatment of functional constipation and evaluated and recorded various clinical indicators before and after treatment in the form of questionnaire survey. The results showed that the clinical symptom scores of patients with functional constipation before and after treatment were greatly different (P < 0.05). Thus, the biofeedback therapy combined with comprehensive nursing intervention showed a good clinical effect in the treatment of patients with functional constipation and significantly improved the quality of life of patients, showing high clinical application and promotion value. A convenient diagnostic procedure is represented by the dynamic magnetic resonance imaging in females, especially pelvic floor organs dynamic imaging during defecation.

Prevalence and Clinical Characteristics of Dyssynergic Defecation and Slow Transit Constipation in Patients with Chronic Constipation

Patients with chronic constipation who do not respond to initial treatments often need further evaluation for dyssynergic defecation (DD) and slow transit constipation (STC). The aims of this study are to characterize the prevalence of DD and STC in patients referred to a motility center with chronic constipation and correlate diagnoses of DD and STC to patient demographics, medical history, and symptoms. High-resolution ARM (HR-ARM), balloon expulsion testing (BET) and whole gut transit scintigraphy (WGTS) of consecutive patients with chronic constipation were reviewed. Patients completed questionnaires describing their medical history and symptoms at the time of testing. A total of 230 patients completed HR-ARM, BET, and WGTS. Fifty (22%) patients had DD, and 127 (55%) patients had STC. Thirty patients (13%) had both DD and STC. There were no symptoms that were suggestive of STC vs. DD; however, patients with STC and DD reported more severe constipation than patients with normal transit and anorectal function. Patients with chronic constipation often need evaluation for both DD and STC to better understand their pathophysiology of symptoms and help direct treatment.

Characterization of Patients With Obstructed Defecation and Slow Transit Constipation With a Simulated Stool

INTRODUCTION

Defecatory disorders including obstructed defecation (OD) are currently diagnosed using specialized investigations including anorectal manometry and the balloon expulsion test. Recently, we developed a simulated stool named Fecobionics that provides a novel type of pressure measurements and analysis. The aim was to study OD phenotypes compared with slow transit constipation (STC) patients and normal subjects (NS).

METHODS

Fecobionics expulsion parameters were assessed in an interventional study design. The Fecobionics device contained pressure sensors at the front, rear, and inside a bag. All constipation patients had colon transit study, defecography, anorectal manometry, and balloon expulsion test performed. The Fecobionics bag was distended in the rectum until desire-to-defecate in 26 OD compared with 8 STC patients and 10 NS. Rear-front pressures (preload-afterload parameters) and defecation indices (DIs) were compared between groups.

RESULTS

The Wexner constipation scoring system score was 13.8 ± 0.9 and 14.6 ± 1.5 in the OD and STC patients (P > 0.5). The median desire-to-defecate volume was 80 (quartiles 56-80), 60 (54-80), and 45 (23-60) mL in OD, STC, and NS, respectively (P < 0.01). The median expulsion duration was 37 (quartiles 15-120), 6 (3-11), and 11 (8-11) seconds for the 3 groups (P < 0.03). Fecobionics rear-front pressure diagrams demonstrated clockwise loops with distinct phenotype differences between OD and the other groups. Most DIs differed between OD and the other groups, especially those based on the anal afterload reflecting the nature of OD constipation. Several OD subtypes were identified.

DISCUSSION

Fecobionics obtained novel pressure phenotypes in OD patients. DIs showed pronounced differences between groups. Larger studies are needed on OD subtyping.

Severe gastroparesis is associated with an increased incidence of slow-transit constipation as measured by wireless motility capsule

BACKGROUND

Dysmotility in one region of the gastrointestinal tract has been found to predispose patients to developing motility disorders in other gastrointestinal segments. However, few studies have evaluated the relationship between gastroparesis and constipation.

METHODS

Retrospective review of 224 patients who completed 4-hour, solid-phase gastric emptying scintigraphy (GES), and wireless motility capsule (WMC) testing to evaluate for gastroparesis and slow-transit constipation, respectively. When available, anorectal manometry data were reviewed to evaluate for dyssynergic defecation. Patients were divided into two groups based on the results of the GES: 101 patients with normal gastric emptying and 123 patients with gastroparesis (stratified by severity). Differences in constipation rates were compared between the groups.

KEY RESULTS

Slow-transit constipation was more common in the gastroparesis group, but statistical significance was not reached (42.3% vs 34.7%, p = 0.304). Univariate logistical regression analysis found no association between slow-transit constipation and gastroparesis (OR 1.38, 95% CI 0.80-2.38, p = 0.245) nor dyssynergic defecation and gastroparesis (OR 0.88, 95% CI 0.29-2.70, p = 0.822). However, when stratifying gastroparesis based on severity, slow-transit constipation was found to be associated with severe gastroparesis (OR 2.45, 95% CI 1.20-5.00, p = 0.014). This association was strengthened with the exclusion of patients with diabetes mellitus (OR 3.5, 95% CI 1.39-8.83, p = 0.008) - a potential confounder.

CONCLUSIONS & INFERENCES

Patients with severe gastroparesis (>35% gastric retention at the 4-hour mark on solid-phase GES) have an increased likelihood of having underlying slow-transit constipation. Dyssynergic defecation does not appear to be associated with gastroparesis (of any severity).

An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment

INTRODUCTION

The terminology for female and male pelvic floor muscle (PFM) assessment has expanded considerably since the first PFM function and dysfunction standardization of terminology document in 2005. New terms have entered assessment reports, and new investigations to measure PFM function and dysfunction have been developed. An update of this terminology was required to comprehensively document the terms and their definitions, and to describe the assessment method and interpretation of the finding, to standardize assessment procedures and aid diagnostic decision making.

METHODS

This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) Working Group 16, with contributions from recognized experts in the field and external referees. A logical, sequential, clinically directed assessment framework was created against which the assessment process was mapped. Within categories and subclassifications, each term was assigned a numeric coding. A transparent process of 12 rounds of full working group and external review was undertaken to exhaustively examine each definition, plus additional extensive internal development, with decision making by collective opinion (consensus).

RESULTS

A Terminology Report for the symptoms, signs, investigations, and diagnoses associated with PFM function and dysfunction, encompassing 185 separate definitions/descriptors, has been developed. It is clinically based with the most common assessment processes defined. Clarity and user-friendliness have been key aims to make it interpretable by clinicians and researchers of different disciplines.

CONCLUSION

A consensus-based Terminology Report for assessment of PFM function and dysfunction has been produced to aid clinical practice and be a stimulus for research.

Risk of COVID-19 transmission in esophageal, anorectal manometry and 24-hour impedance-pH monitoring

BACKGROUND

the impact of the COVID-19 pandemic has led to the interruption of most manometry or impedance-pH monitoring studies. The risk of restarting activities is unknown.

OBJECTIVE

assess the risk of SARS-CoV-2 virus infection, both to patients and healthcare workers, in relation to esophageal and anorectal functional tests during the pandemic without protective measures.

METHOD

a questionnaire was designed to determine whether patients and healthcare workers had COVID-19, confirmed by either a test or compatible symptoms, after functional studies were performed from January until March 2020.

RESULTS

the survey was answered by 263 (92.9 %) patients. Four (1.52 %) patients had confirmed COVID-19 in the two weeks after the functional test (adjusted rate 8.34 cases per 1,000 [95 % CI -0.06-16.74], OR 0.84 [95 % CI: 0.83-0.85], p < 0.001) and no patient after anorectal manometry. Another five had only compatible symptoms, for a total of nine patients (3.42 %) (adjusted rate 27.50 cases/1,000 [95 % CI: 7.27-47.74], OR 2.84 [95 % CI: 2.81-2.87]). In the total study period, 18.25 % had confirmed COVID-19 or compatible symptoms. The average number of days between the procedure and the first day of symptoms was progressively shortened (January: 56 days, February: 33 days, March: 10.5 days). Two of ten healthcare workers (20 %) had confirmed COVID-19.

CONCLUSIONS

the risk of COVID-19 infection when performing functional tests is low and more related to the evolution of the pandemic rather than to the procedure itself. The small number of healthcare workers included in the study does not allow a definitive conclusion to be drawn on their risk of infection.