Defaecography in patients with irritable bowel syndrome and healthy volunteers

Pelvic floor complaints in gastroenterology practice: results of a survey in the netherlands

OBJECTIVE

The pelvic floor is an integrated structure; dysfunctions may lead to a wide range of symptoms, involving voiding, defecation and sexual functioning (SF). Functional symptoms such as constipation and lower abdominal pain are often caused by pelvic floor dysfunction (PFD), and they highly impact the quality of life. Multiple specialists are responsible for a specific part of the pelvic floor, but its treatment asks for a holistic approach. The authors are still unaware of gastroenterologists' knowledge on PFD or whether they are addressing pelvic floor complaints in their daily practice.

DESIGN

A 42-itemed anonymous questionnaire was mailed to all 402 members of the Dutch Society of Gastroenterology (gastroenterologists and residents-in-training).

RESULTS

169 (42%) questionnaires were analysed. Most gastroenterologists address lower urinary tract symptoms in their history-taking, 92% in female patients and 84% in male patients. When patients indicate irritable bowel syndrome-like complaints, more than 60% of the physicians inquire about SF to their female patients, compared with 38% inquiries to male patients (p<0.001). A reason not to inquire about SF is a lack of knowledge about female and male sexuality (19% and 23%, respectively). Forty-six per cent of the respondents regard it rather important to receive more training on PFD in male patients versus 61% in female patients.

CONCLUSION

Awareness of PFD is not yet routinely integrated into the history taken by gastroenterologists.

Anorectal function and dyssynergic defecation in different subgroups of patients with irritable bowel syndrome

PURPOSE

The purpose of this study was to evaluate anorectal function in different subgroups of patients with irritable bowel syndrome (IBS), including those with mixed bowel habits.

MATERIALS AND METHODS

Sixty-six IBS patients selected according to Rome III criteria (39 female and 27 male patients; mean age, 41.5 +/- 15.4) and 20 subjects in the control group (13 female and 7 male patients; mean age, 41.4 +/- 13.7) were examined. The IBS patients were divided into three subgroups according to bowel movement pattern: patients with constipation (27%), patients with diarrhea (27%), and patients with mixed bowel habits (46%). Anorectal manometry and rectal distension test were performed using a four-lumen water-perfused catheter with a polyethylene balloon.

RESULTS

No significant differences in manometric parameters between the subgroups of IBS patients and the control group were found, except for pelvic floor dyssynergia (PFD), which was more frequent in all subgroups of IBS (41% of patients) than in controls (5% of subjects) (p < 0.01). Lower rectal pain threshold was observed particularly in IBS patients with diarrhea and mixed bowel habits (p < 0.01).

CONCLUSION

Manometric parameters characterizing anal sphincter function are not correlated with the predominant bowel movement pattern in IBS. The features of PFD are significantly more frequent in all subgroups of IBS patients than in controls, suggesting that, in general, IBS patients show changes in the mobility of the pelvic floor. Hypersensitivity to rectal distension is commonly observed in IBS, but it does not seem to be a highly specific marker of the disorder.

Relationships between pelvic floor symptoms and function in irritable bowel syndrome

BACKGROUND

Pelvic floor dyssynergia (PFD) within irritable bowel syndrome (IBS) is often overlooked and the relationship between symptoms and physiology is relatively unexplored. Our aims were to determine relationships between clinical features and anorectal function in non-diarrhea predominant IBS (non-D IBS) patients and whether certain clinical or physiological features predict PFD in IBS.

METHODS

Two groups of patients were evaluated. Group I: 32 female non-D IBS patients with >or=2 symptoms suggesting PFD underwent comprehensive symptom and anorectal function assessment. Group II: 32 female non-D IBS patients recruited from the community underwent symptom assessment.

KEY RESULTS

Prevalence of PFD symptoms was similar in both groups. In group I patients, increased frequency of digitation was associated with a longer balloon expulsion time (P = 0.03). Higher scores for anal pain were associated with both a low resting anal pressure (P = 0.04) and a shorter duration of maximum squeeze (P = 0.03). Reduced perineal descent was associated with anxiety (P = 0.03) and depression (P = 0.01). A shorter duration of maximum squeeze was associated with higher parity (P = 0.02) and previous hysterectomy (P = 0.047). Duration of PFD symptoms was higher (P = 0.02) and maximum tolerated volume was lower (P = 0.05) in 22 patients with a physiological diagnosis of PFD compared to 10 without PFD. No symptoms independently predicted a physiological diagnosis of PFD.

CONCLUSIONS & INFERENCES

Important relationships between certain PFD symptoms and disordered anorectal physiology have been demonstrated in these non-D IBS patients. However, symptoms alone could not predict PFD, and certain clinical features should therefore highlight the need for comprehensive anorectal function tests.

Dynamic imaging of posterior compartment pelvic floor dysfunction by evacuation proctography: techniques, indications, results and limitations

The clinical management of patients with anorectal and pelvic floor dysfunction is often difficult. Evacuation proctography has evolved from a method to evaluate the anorectum for functional disorders to its current status as a practical method for evaluating anorectal dysfunction and pelvic floor prolapse. It has a high observer accuracy and yield of positive diagnosis. Clinicians find it of major benefit and has altered management from surgical to medical and vice versa in a significant number of cases.

Rectal sensation, pelvic floor function and symptom severity in Hispanic population with irritable bowel syndrome with constipation

OBJECTIVE

In patients with irritable bowel syndrome with constipation (IBS-C, Rome II) we determined if pelvic floor function correlates with rectal sensitivity and tone, and if the pelvic and rectal measurements correlate with symptoms.

PATIENTS AND METHODS

Sensory thresholds and tone in fasting and postprandial states were evaluated with an electronic barostat in 34 patients and 10 normal controls. The pelvic floor was assessed by defaecography.

RESULTS

Pain threshold to rectal distension was lower in IBS-C patients (P = 0.007). Postprandially, IBS-C patients showed lower values for sensation of gas, perception of urge, and pain threshold compared with controls. In IBS-C the anorectal angle widened less and showed less perineal mobility during defecation; the rectal tone in fasting IBS-C patients correlated with the angle at rest (P = 0.04) and with the perineal descent at rest (P = 0.01). The severity of abdominal discomfort or pain, and abdominal fullness correlated with the anorectal angle. The duration of symptoms and frequency of bowel movements correlated with perineal descent. Straining, mucus expulsion, and the feeling of incomplete evacuation correlated with rectal sensitivity variables.

CONCLUSION

Patients with IBS-C have lowered sensory thresholds for noxious and non-noxious stimuli, increased visceral sensitivity after food, less perineal mobility during defecation, and symptoms that correlate with rectal sensitivity and pelvic floor parameters.

Dynamic evaluation of the anorectum

The evaluation of EP is complicated by the lack of any gold standard and a shifting clinical emphasis as management regimens go in and out of favor. As with all functional bowel disease, there is a residue of patients who are difficult to manage, and in whom a clinician will want maximum information before deciding on treatment. The examination has been criticized as lacking clinical relevance, and of having poor interobserver reliability except for rectal emptying and rectocele formation. Others have found a higher (83.3%) observer accuracy and a high yield of positive diagnoses. A questionnaire showed that clinicians found EP of major benefit in 40%, altering management from surgical to medical in 14% and vice versa in 4%. Radiographic examinations only impact on clinical management when findings alter management. Management protocols are evolving in functional disorders, but important features that EP reveals are anismus, trapping in rectoceles, IAI, and rectal prolapse. EP is the only method to diagnose some of these conditions and within defined parameters is extremely valuable in clinical management.

Irritable bowel syndrome: a little understood organic bowel disease?

Irritable bowel syndrome affects 10% of adults with an unexplained female predominance. Although only a few people see their family doctor, the disease causes reduced quality of life and represents a multi-billion pound health-care problem. The disorder clusters in families, which is possibly because of intra-familial learning and a genetic predisposition. Visceral hypersensitivity is a key feature in most patients. Results of imaging studies of regional cerebral blood flow during rectal distension suggest underlying disturbances of central processing of afferent signals, though this is not unique to the disorder, since it is seen in other chronic pain syndromes. Environmental factors that are strongly implicated in at least some patients include gastrointestinal infection and inflammation and chronic stress. Diagnosis is based on positive symptoms and absence of any alarm indicators. Treatment remains unsatisfactory and hinges on an excellent doctor-patient relationship, with drugs for symptom exacerbations. Cognitive behavioural treatment, psychotherapy, and hypnosis could provide long-lasting benefit in some patients. Tricyclic antidepressants in low doses seem to be the most effective class of drugs for the disorder on the basis of limited data.

Diagnosis of irritable bowel syndrome

Irritable bowel syndrome (IBS) is the most common disorder seen in gastroenterology practice. It is also a large component of primary care practices. Although the classic IBS symptoms of lower abdominal pain, bloating, and alteration of bowel habits is easily recognizable to most physicians, diagnosing IBS remains a challenge. This is in part caused by the absence of anatomic or physiologic markers. For this reason, the diagnosis of IBS currently needs to be made on clinical grounds. A number of symptom-based diagnostic criteria have been proposed over the last 15 years. The most recent of these, the Rome II criteria, seem to show reasonable sensitivity and specificity in diagnosing IBS. However, the role of the Rome II criteria in clinical practice remains ill defined. A review of the literature shows that, in patients with no alarm symptoms, the Rome criteria have a positive predictive value of approximately 98%, and that additional diagnostic tests have a yield of 2% or less. Diagnostic evaluation should also include a psychosocial assessment specifically addressing any history of sexual or physical abuse because these issues significantly influence management strategies and treatment success.

Descending perineum syndrome: audit of clinical and laboratory features and outcome of pelvic floor retraining

OBJECTIVE

Our aim was to retrospectively analyze the Mayo Clinic experience of descending perineum syndrome from 1987-1997.

METHODS

Clinical records were abstracted for demographic features, risk factors, results of anorectal and defecation tests, and a mailed questionnaire evaluated outcome and current symptoms.

RESULTS

All results are mean +/- SD. Clinically, 39 patients (38 women, one man), mean age 53+/-14 yr, presented with constipation (97%), incomplete rectal evacuation (92%), excessive straining (97%), digital rectal evacuation (38%), and fecal incontinence (15%). Laboratory tests showed anal sphincter resting pressure was 54+/-26 mm Hg, and squeeze pressure was 96+/-35 mm Hg; expulsion from the rectum of a 50-ml balloon required > 200 g added weight in 27%; perineal descent was 4.4+/-1 cm (normal < 4 cm) by scintigraphy. Scintigraphic evacuation, rectoanal angle change during defecation, and perineal descent were abnormal in 23%, 57%, and 78% of the patients, respectively. Associated features included female gender (96%), multiparity with vaginal delivery (55%), hysterectomy or cystocele/rectocele repair (74%). On follow-up, 64% responded; 17 of these 25 responders underwent pelvic floor retraining. At 2-yr median follow-up (range, 1-6 yr), 12 still experienced constipation or excessive straining; their perineal descent was greater than in patients who responded to retraining (p = 0.005).

CONCLUSIONS

Descending perineum syndrome is identifiable by clinical history and examination, and the most prevalent abnormality on testing is perineal descent > 4 cm; rectal balloon expulsion is an insensitive screening test for descending perineum syndrome. Pelvic floor retraining is a suboptimal treatment for this chronic disorder of rectal evacuation; the extent of perineal descent appears to be a useful predictor of response to retraining.