Diagnosis and Treatment of Dyssynergic Defecation

Review article: dyssynergic defaecation and biofeedback therapy in the pathophysiology and management of functional constipation

BACKGROUND

Functional constipation is a common clinical presentation in primary care. Functional defaecation disorders are defined as the paradoxical contraction or inadequate relaxation of the pelvic floor muscles during attempted defaecation (dyssynergic defaecation) and/or inadequate propulsive forces during attempted defaecation. Prompt diagnosis and management of dyssynergic defaecation is hindered by uncertainty regarding nomenclature, diagnostic criteria, pathophysiology and efficacy of management options such as biofeedback therapy.

AIM

To review the evidence pertaining to the pathophysiology of functional defaecation disorders and the efficacy of biofeedback therapy in the management of patients with dyssynergic defaecation and functional constipation.

METHODS

Relevant articles addressing functional defaecation disorders and the efficacy of biofeedback therapy in the management of dyssynergic defaecation and functional constipation were identified from a search of Pubmed, MEDLINE Ovid and the Cochrane Library.

RESULTS

The prevalence of dyssynergic defaecation in patients investigated for chronic constipation is as many as 40%. Randomised controlled trials have demonstrated major symptom improvement in 70%-80% of patients undergoing biofeedback therapy for chronic constipation resistant to standard medical therapy and have determined it to be superior to polyethylene glycol laxatives, diazepam or sham therapy. Long-term studies have shown 55%-82% of patients maintain symptom improvement.

CONCLUSIONS

Dyssynergic defaecation is a common clinical condition in patients with chronic constipation not responding to conservative management. Biofeedback therapy appears to be a safe, successful treatment with sustained results for patients with dyssynergic defaecation. Further studies are required to standardise the diagnosis of dyssynergic defaecation in addition to employing systematic protocols for biofeedback therapy.

Gastrointestinal manifestations of pelvic floor disorders in adolescents: a diagnostic framework for the general practitioner

PURPOSE OF REVIEW

Pelvic floor disorders (PFDs) can present with gastrointestinal complaints in the adolescent patient, and identification of PFDs is aided by clues in the history and physical examination apparent to the knowledgeable clinician. The aim of this article is to provide a framework for the diagnostic evaluation of the adolescent patient with a PFD and introduce management strategies.

RECENT FINDINGS

Patients with PFDs can present with gastrointestinal symptoms, including abdominal pain, constipation, incomplete evacuation, and fecal incontinence or nongastrointestinal complaints around genitourinary symptoms or sexual health. Although such symptoms can be attributed to a variety of diagnoses, PFDs should be considered in the adolescent patient based on history and physical examination findings, including a careful digital rectal examination. Adolescent patients in high-risk groups may be especially susceptible to PFDs. Such groups include postpartum women, victims of sexual abuse, those with congenital anorectal malformations, or acquired spinal cord or pelvic floor injuries. Biofeedback can be beneficial in patients with PFDs.

SUMMARY

PFDs may present with a spectrum of symptoms, but a familiarity with the clinical characteristics and understanding of the digital rectal examination may guide the skillful clinician in diagnosis, initial management, and subspecialist referral if needed.

Balloon Expulsion Test Does Not Seem to Be Useful for Screening or Exclusion of Dyssynergic Defecation as a Single Test

Background/Aims

Balloon expulsion test (BET) is regarded as a screening tool of dyssynergic defecation (DD). However, some patients with normal BET results may be treated effectively by biofeedback training. This study aims to validate BET as a single screening test.

Methods

Two hundred and thirty-two patients who were diagnosed with functional constipation or irritable bowel syndrome with constipation who underwent anorectal manometry (ARM) and BET at Seoul National University Hospital were enrolled. We evaluated the validity of BET based on ARM and electromyography (EMG) during biofeedback training.

Results

If BET ≤ 1 minute was defined as normal, sensitivity and negative predictive value (NPV) of BET in predicting paradoxical contraction based on ARM findings were 71.4% and 13.9%. If BET ≤ 3 minutes was defined as normal, sensitivity and NPV were 35.2% and 6.6%. Specificity and positive predictive value (PPV) of BET ≤ 3 minutes criteria were 84.8% and 93.3%. Same analysis was conducted in 107 patients who underwent EMG during biofeedback training. With 1-minute criteria, sensitivity and NPV of BET were 70.3% and 14.3%. With 3 minutes criteria, sensitivity and NPV of BET was 38.6% and 8.8%. Specificity and positive predictive values were both 100.0%.

Conclusions

Based on either ARM or EMG during biofeedback training, sensitivity was at most 71.4% and NPV was less than 15.0% irrespective of whether BET was within 1minute or within 3 minutes. BET seems to have a limitation as both a screening test for dyssynergic defecation and a simple assessment to rule out the necessity of biofeedback training.

Age and Dyssynergia Subtypes Associated With Normal Sphincter Pressures in Women With Fecal Incontinence

OBJECTIVES

Fecal incontinence (FI) is frequently associated with low sphincter pressures, sensory abnormalities, and advanced age. Twenty-three percent of patients with FI and 22% of healthy patients demonstrate dyssynergic defecation (DD) on high-resolution anorectal manometry. Overflow incontinence occurs in some DD patients with normal resting and squeeze anal sphincter pressures. Our aim was to identify factors associated with normal sphincter pressures in women with FI.

METHODS

We reviewed medical records of 134 women with FI. Patients with normal resting and squeeze anal pressures were compared with those with abnormal pressures using Wilcoxon rank sum test and Fisher exact. Multivariable logistic regression was performed to identify factors associated with normal resting and squeeze anal pressures.

RESULTS

Among 134 women, abnormal resting and/or squeeze pressures were identified in 113 and normal pressures were identified in 21. Women with normal sphincter pressures were younger (mean age 52.7 ± 10.8 years vs 59.0 ± 14.0 years, P = 0.036), more often had abnormal defecation indices (100% vs 83.2%, P = 0.043) and higher rectal defecation pressures (30.8 ± 18.8 mm Hg vs 50.8 ± 22.6 mm Hg, P < 0.001). There was an overall association between DD subtype and normal and abnormal sphincter pressure groups (P = 0.021). Dyssynergia subtypes I or III (odds ratio, 7.2; 95% confidence interval, 1.8-28.8) and age younger than 67 years (odds ratio, 8.5; 95% confidence interval, 1.5-48.6) were associated with greater odds of having normal sphincter pressures.

CONCLUSIONS

Female FI patients with normal anal sphincter pressures are younger, have higher rectal defecation pressures, and more often have type I or type III DD.

Utility of high-resolution anorectal manometry and wireless motility capsule in the evaluation of patients with Parkinson's disease and chronic constipation

BACKGROUND

The aetiology of constipation in Parkinson's disease remains poorly understood. Defaecatory dyssynergia, anal sphincter spasticity and slow transit constipation may, individually or collectively, play a role.

AIMS

In this retrospective cohort analysis of patients with Parkinson's disease and chronic constipation, we determined the utility of high-resolution anorectal manometry, balloon expulsion and wireless motility capsule testing in defining the underlying aetiology for constipation.

METHODS

In this retrospective cohort study, consecutive patients with Parkinson's disease and chronic constipation underwent clinical assessment, manometry with balloon expulsion and wireless motility capsule testing using standard protocols.

RESULTS

We studied 66 patients fulfilling Rome IV criteria for functional constipation. Most patients (89%) had abnormal manometry, exhibiting various types of defaecatory dyssynergia (mostly types II and IV), abnormal balloon expulsion, diminished rectal sensation and, in some, lacking rectoanal inhibitory reflex. 62% exhibited colonic transit delay by wireless motility capsule study, while 57% had combined manometric and transit abnormalities, suggesting of overlap constipation. Symptoms of infrequent defaecation, straining and incomplete evacuation were not discriminatory. There was a relationship between constipation scores and colonic transit times (p=0.01); Parkinson's disease scores and duration were not correlated with either the manometric or transit findings. Faecal incontinence was seen in 26% of the patients.

CONCLUSIONS

Chronic constipation in patients with Parkinson's disease may reflect pelvic floor dyssynergia, slow transit constipation or both, and may be associated with faecal incontinence, suggesting both motor and autonomic dysfunction. Anorectal manometry and wireless motility capsule testing are useful in the assessment of these patients.