Clinical utility of colonic and anorectal manometry in chronic constipation

Understanding constipation as a geriatric syndrome

Constipation is common among older adults and significantly impacts their quality of life (QoL). Prior studies have extensively detailed constipation, but conceptualization of constipation as a geriatric syndrome is lacking. In this review, we provide an overview of constipation in the geriatric population and conceptualize constipation as a geriatric syndrome given its high prevalence, under-recognized status, and association with poor QoL and adverse outcomes among older adults. The conceptualization of constipation as a geriatric syndrome, as with frailty and delirium, highlights its importance and need for a multi-faceted approach. Future research is needed to 1) better define constipation, 2) explore the multifactorial nature of constipation in older adults and relationship with other geriatric syndromes, 3) include more older adults in pharmacological and non-pharmacological interventions for constipation, and 4) curate multidisciplinary care models. Appreciating constipation as a geriatric syndrome will yield tailored management strategies, ensure timely intervention, and avoid adverse outcomes.

The Clinical Utility of Anorectal Manometry: A Review of Current Practices

Anorectal manometry (ARM) is a diagnostic test that utilizes pressure sensors to dynamically measure intraluminal anal and rectal pressures, thus providing an objective evaluation of anorectal functional parameters (tone, contractility, and relaxation), coordination and reflex activity, and sensation. ARM is a useful test for numerous indications including for the assessment and management of functional anorectal disorders such as fecal incontinence, functional defecatory disorders, and functional anorectal pain, preoperative assessment of anorectal function, and in facilitating/assessing response to biofeedback training. In addition, while many functional anorectal disorders present with overlapping symptoms (ie constipation, anorectal pain), ARM allows delineation of more specific disease processes and may guide treatment more effectively. In recent years the development of advanced manometric methodologies such as high-resolution anorectal manometry has also led to improved spatial resolution of data acquisition, further increasing the potential for the expansion of ARM. However, despite its ability to provide detailed information on anorectal and pelvic floor muscle function and synergy as well as the endorsements of several national and international organizations, ARM is still infrequently utilized in clinical practice. The purpose of this review is to address the current clinical applications and limitations of ARM for various disorders of the lower gastrointestinal tract. In so doing, we will provide clinicians with a framework for the use of ARM in clinical practice. This review will also discuss potential barriers to widespread adoption of ARM in clinical practice and propose possible solutions to these challenges.

Effects on anorectal function of endoscopic submucosal dissection for rectal tumors involving the dentate line

OBJECTIVE

Endoscopic submucosal dissection (ESD) is a specific procedure that uses an electrosurgical knife for en-bloc resectioning large tumors. However, no study has examined the effect of ESD on the defecation function of patients with rectal tumors. We aimed to investigate the potential effects caused by ESD by analyzing changes in the morphology and movement of the anorectum pre- and post-ESD.

METHODS

This prospective observational study included 11 patients with anorectal tumors who underwent ESD between April 2020 and February 2022. Pre-ESD assessments included anorectal manometry and defecography. Post-ESD assessments were conducted 2 months later, including anorectal manometry, defecography, and proctoscopy for ulcer and stenosis evaluation.

RESULTS

The median patient age was 73 years, including seven males and four females. Eight patients (73%) had a tumor in the lower rectum, and the extent of resection was less than 50% of the rectal lumen. Resection reached the dentate line in six cases (55%). In the patients with post-ESD mucosal defects involving the dentate line, the median of functional anal canal length significantly decreased from (3.4 cm pre-ESD to 2.8 cm post-ESD, p = 0.04). Defecography revealed one case with incomplete evacuation (<50%) and incontinence post-ESD. Interestingly, patients with pre-existing rectoceles noted resolution of lesions post-ESD. None of the patients reported daily constipation or fecal incontinence.

CONCLUSIONS

While rectal ESD is unlikely to cause significant real-world defecation difficulties, alterations in rectal and anal canal morphology and function may occur if the dentate line is involved in the resection range.

Evidence-Based Clinical Guidelines for Chronic Constipation 2023

The Japan Gastroenterological Association published the first version of its clinical guidelines for chronic constipation 2023. Based on the latest evidence, these guidelines describe the definition, classification, diagnostic criteria, diagnostic testing methods, epidemiology, pathophysiology, and treatment of chronic constipation. They include flowcharts for both diagnosis and treatment of chronic constipation. In the treatment of chronic constipation, the first step involves differentiating between secondary forms, such as organic disease-associated constipation, systemic disease-associated constipation, and drug-induced constipation. The next step is to determine whether the chronic constipation stems from a motility disorder, a form of primary chronic constipation. For functional constipation and constipation-predominant irritable bowel syndrome, treatment should be initiated after evaluating symptoms like reduced bowel movement frequency type or defecation difficulty type. The first line of treatment includes the improvement of lifestyle habits and diet therapy. The first drugs to consider for oral treatment are osmotic laxatives. If these are ineffective, secretagogues and ileal bile acid transporter inhibitors are candidates. However, stimulant laxatives are exclusively designated for as-needed use. Probiotics, bulk-forming laxatives, prokinetics, and Kampo medicines, for which there is insufficient evidence, are considered alternative or complementary therapy. Providing the best clinical strategies for chronic constipation therapy in Japan, these clinical guidelines for chronic constipation 2023 should prove useful for its treatment worldwide. The Japan Gastroenterological Association published the first version of its clinical guidelines for chronic constipation 2023. Based on the latest evidence, these guidelines describe the definition, classification, diagnostic criteria, diagnostic testing methods, epidemiology, pathophysiology, and treatment of chronic constipation. They include flowcharts for both diagnosis and treatment of chronic constipation. In the treatment of chronic constipation, the first step involves differentiating between secondary forms, such as organic disease-associated constipation, systemic disease-associated constipation, and drug-induced constipation. The next step is to determine whether the chronic constipation stems from a motility disorder, a form of primary chronic constipation. For functional constipation and constipation-predominant irritable bowel syndrome, treatment should be initiated after evaluating symptoms like reduced bowel movement frequency type or defecation difficulty type. The first line of treatment includes the improvement of lifestyle habits and diet therapy. The first drugs to consider for oral treatment are osmotic laxatives. If these are ineffective, secretagogues and ileal bile acid transporter inhibitors are candidates. However, stimulant laxatives are exclusively designated for as-needed use. Probiotics, bulk-forming laxatives, prokinetics, and Kampo medicines, for which there is insufficient evidence, are considered alternative or complementary therapy. Providing the best clinical strategies for chronic constipation therapy in Japan, these clinical guidelines for chronic constipation 2023 should prove useful for its treatment worldwide.

Biofeedback combined with percutaneous electrical pudendal nerve stimulation for the treatment of low anterior rectal resection syndrome: a study protocol for a randomized controlled trial

BACKGROUND

Low anterior resection syndrome (LARS) is a distressing condition that affects approximately 25-80% of patients following surgery for rectal cancer. LARS is characterized by debilitating bowel dysfunction symptoms, including fecal incontinence, urgent bowel movements, and increased frequency of bowel movements. Although biofeedback therapy has demonstrated effectiveness in improving postoperative rectal control, the research results have not fulfilled expectations. Recent research has highlighted that stimulating the pudendal perineal nerves has a superior impact on enhancing pelvic floor muscle function than biofeedback alone. Hence, this study aims to evaluate the efficacy of a combined approach integrating biofeedback with percutaneous electrical pudendal nerve stimulation (B-PEPNS) in patients with LARS through a randomized controlled trial (RCT).

METHODS AND ANALYSIS

In this two-armed multicenter RCT, 242 participants with LARS after rectal surgery will be randomly assigned to undergo B-PEPNS (intervention group) or biofeedback (control group). Over 4 weeks, each participant will undergo 20 treatment sessions. The primary outcome will be the LARS score. The secondary outcomes will be anorectal manometry and pelvic floor muscle electromyography findings and the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire-Colorectal 29 (EORTC QLQ-CR29) scores. Data will be collected at baseline, post-intervention (1 month), and follow-up (6 months).

DISCUSSION

We anticipate that this study will contribute further evidence regarding the efficacy of B-PEPNS in alleviating LARS symptoms and enhancing the quality of life for patients following rectal cancer surgery.

TRIAL REGISTRATION

Chinese Clincal Trials Register ChiCTR2300078101. Registered 28 November 2023.

Investigating the lumbar proprioception and core muscles recruitment pattern while getting up from a chair with weight lifting in patients with chronic functional constipation: cross-sectional study

INTRODUCTION AND HYPOTHESIS

Patients with chronic functional constipation have some problems such as weakness of pelvic floor muscles, and a lack of coordination of pelvic floor and abdominal muscles has been seen. The goal of this study was to investigate the lumbar proprioception and the core muscle recruitment pattern.

METHODS

The study type is a cross-sectional case-control study. There were 30 participants (case, n = 15, and control, n = 15). Electromyography of the core muscles was recorded while the subjects were getting up from the chair accompanied by lifting a weight, to check the pattern of muscle recruitment. Moreover, the lumbar proprioception was evaluated by an isokinetic device in both groups. The study was analyzed using independent t test and Mann-Whitney U test, and a nonparametric Friedman test was performed followed by Bonferroni pairwise comparison.

RESULTS

The comparison of muscle activity delay between the two groups showed that there was a significant difference between the two groups regarding the abdominal muscles, anal sphincter, and erector spinae (p < 0.05). However, there was no significant difference in the rectus femoris and gluteal muscles between the two groups (p > 0.05). Moreover, the proprioception of the lumbar region showed a significant difference (p < 0.05) between the two groups.

CONCLUSIONS

The results of this study demonstrated that the lumbar proprioception sense was reduced in the case group. This result can be justified, based on the problems in constipation (lack of coordination of muscles, weakness of pelvic floor muscles). The coordination of core muscles changed in patients with chronic functional constipation during a functional task.

Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations

BACKGROUND & AIMS

Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings.

METHODS

Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations.

RESULTS

ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices.

CONCLUSIONS

Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.

Gastrocolonic Response

PURPOSE OF REVIEW

The gastrocolonic response (GCR), is a physiologic increase in motor activity of the colon, which usually occurs within minutes following meal ingestion. Over the years several triggers that provoke GCR were recognized including gastric dilation, caloric intake, and fat component of the meal. The response is mediated by the vagal nerve and neurohumoral mechanisms, and it can be modified by several pharmacological factors. Assessment of GCR is part of high-resolution colonic manometry studies, performed in patients with suspected colonic dysmotility. This review highlights the physiologic basis of GCR as well as its clinical and diagnostic features and implementation in variable pathological conditions and clinical practice.

RECENT FINDINGS

GCR has a role in patients with constipation, diabetes, dumping syndrome, bowel hyper and hypomotility and irritable bowel syndrome. Novel sensory triggers for GCR were recently recognized. GCR is a physiological response which is evaluated during colonic manometry studies. Abnormal GCR is a marker of an underlying pathology, which can provide a potential target for treatment.

Transcutaneous Electrical Acustimulation Improves Constipation by Enhancing Rectal Sensation in Patients With Functional Constipation and Lack of Rectal Sensation

INTRODUCTION

Reduced rectal sensation is involved in the pathophysiology of constipation. The aim of this study was to investigate the effects of transcutaneous electrical acustimulation (TEA) at acupuncture point ST36 on constipation and rectal sensation as well as autonomic functions in patients with constipation and reduced rectal sensation.

METHODS

In an acute study, anorectal motility and sensation tests were performed in constipation patients (N = 53) who were treated with TEA at ST36 or sham points. In a chronic study, patients (N = 18) underwent 2 weeks of TEA or sham-TEA in a crossover design.

RESULTS

Chronic TEA increased spontaneous bowel movements (3.72 vs 2.00 per week with sham-TEA, P < 0.0001) and significantly reduced constipation symptoms and increased quality of life in comparison with sham-TEA (P < 0.05). Acute TEA reduced the sensation threshold in response to rectal distention for the urge of defecation and maximum tolerable volume (P < 0.05, vs baseline); chronic TEA reduced the sensation thresholds for first sensation and desire of defecation, and decreased the threshold volume to an elicit rectal anal inhibitory reflex (P < 0.05). Both acute and chronic TEA increased parasympathetic activity (P < 0.05).

DISCUSSION

TEA at ST36 improves chronic constipation by enhancing rectal sensation possibly mediated by the reinforcement of parasympathetic activity in patients with functional constipation and reported lack/absence of rectal sensation.

Evaluation and Treatment of Constipation in the Geriatric Population

Chronic constipation affects one-third of the US population and occurs disproportionately in the elderly and female individuals, increasing in older individuals who are institutionalized. This condition has a significant impact on health care costs and quality of life. Clinicians need to consider primary as well as secondary causes of constipation in elderly individuals because the cause is often multifactorial. Diagnostic algorithms should eliminate red-flag symptoms that may indicate a malignancy but also consider pelvic floor dysfunction, which is more common in this age group. An appropriate treatment plan is tailored to the severity of the patient's symptoms.

Dyssynergic Defecation and Anal Sphincter Disorders in Children in High-Resolution Anorectal Manometry Investigation

OBJECTIVES

Dyssynergic defecation is a common disorder in children with functional constipation (FC) because of relaxation disorders of the sphincter apparatus and intra-rectal pressure during defecation. The aim of the study was to determine frequency and type of dyssynergic defecation and to assess pressure in the anal canal poles during simulated evacuation and function of puborectalis muscle in defecation in children with FC.

METHODS

Three-dimensional (3D) high-resolution anorectal manometries (3D HRAM) were performed in 131 children with FC. In the manometric test, resting pressure measurements were assessed in 4 measuring poles of the anal canal.

RESULTS

One hundred thirty-one children ages 5 to 17 years (mean age 10.2; SD ± 3.8; median 10) were involved in the study (69 girls and 62 boys). Dyssynergic defecation was shown in 106/131 (80.9%) examined children. A statistically significant difference between the age of examined children (P < 0.02) and intrarectal pressures at the anal canal measuring points (left P < 0.009, right P < 0.005, anterior P < 0.01) was found. Correlation between the residual pressure values in lateral anal canal measurement poles and intrarectal pressure was demonstrated in all types of dyssynergy (left: r = 0.69, P < 0.0005; right: r = 0.74, P < 0.0005). In a group of 53/131 (40.5%) children, 3D HRAM showed a rectal pressure increase during simulated defecation, because of the dysfunction of the puborectalis muscle.

CONCLUSION

The increase in sphincter pressure in lateral and posterior poles in I and II types of dyssynergia and in lateral poles in other types of dyssynergia may depend on relaxation disorders of the puborectalis muscle during defecation.

Clinical Evaluation of a Patient With Symptoms of Colonic or Anorectal Motility Disorders

Constipation, irritable bowel syndrome, fecal incontinence, abdominal pain, and anorectal pain are problems that affect 40% of the population. They commonly present with overlapping symptoms indicating that their pathophysiology affects multiple segments of the gut as well as brain and gut interactions. Clinically, although some conditions are readily recognized, dyssynergic defecation, fecal incontinence, and anorectal pain are often missed or misdiagnosed. Consequently, the assessment of lower gastrointestinal symptoms in patients with suspected colonic or anorectal motility disorder(s) remains challenging for most clinicians. A detailed history, use of the Bristol stool form scale, prospective stool diaries, ideally through a phone App, digital rectal examination, and judicious use of complementary diagnostic tests are essential. Additionally, it is important to evaluate the impact of these problems on quality of life and psychosocial issues, because they are intricately linked with these disorders. The Rome IV diagnostic questionnaire for functional gastrointestinal disorders can provide additional information often missed during history taking. Here, we discuss a systematic approach for the clinical evaluation of patients with suspected lower gastrointestinal problems, grouped under 4 common diagnostic categories. We describe how to take a detailed history, perform meticulous digital rectal examination, and use validated tools to supplement clinical evaluation, including assessments of quality of life and scoring systems for disease severity and digital Apps. These tools could facilitate a comprehensive plan for clinical management including diagnostic tests, and translate the patients' complaints into definable, diagnostic categories.

High-resolution colonic manometry and its clinical application in patients with colonic dysmotility: A review

The detailed process and mechanism of colonic motility are still unclear, and colonic motility disorders are associated with numerous clinical diseases. Colonic manometry is considered to the most direct means of evaluating colonic peristalsis. Colonic manometry has been studied for more than 30 years; however, the long duration of the examination, high risk of catheterization, huge amount of real-time data, strict catheter sterilization, and high cost of disposable equipment restrict its wide application in clinical practice. Recently, high-resolution colonic manometry (HRCM) has rapidly developed into a major technique for obtaining more effective information involved in the physiology and/or pathophysiology of colonic contractile activity in colonic dysmotility patients. This review focuses on colonic motility, manometry, operation, and motor patterns, and the clinical application of HRCM. Furthermore, the limitations, future directions, and potential usefulness of HRCM in the evaluation of clinical treatment effects are also discussed.

Evaluation and management of defecatory dysfunction in women

PURPOSE OF REVIEW

To summarize the current recommendations for the evaluation and management of defecatory dysfunction in women and highlight key relationships between defecatory dysfunction and other pelvic floor disorders, including pelvic organ prolapse, fecal incontinence, and voiding dysfunction.

RECENT FINDINGS

Conservative measures including lifestyle modifications, pharmacotherapy, and biofeedback continue to be the mainstay of treatment with newer therapies emerging. Physiologic testing and/or radiologic imaging should be considered for those who fail conservative therapy or are clinically complex. Surgical management is appropriate for carefully selected patients with anatomic causes of defecatory dysfunction. Further research is needed on surgical outcomes and patient expectations.

SUMMARY

Pelvic floor disorders, including defecatory dysfunction, have a significant societal impact and are highly prevalent among women. Given its potential complexity, a broader focus is needed when evaluating women with defecatory symptoms and effective treatment may require multidisciplinary care.

Anorectal Manometry in Defecatory Disorders: A Comparative Analysis of High-resolution Pressure Topography and Waveform Manometry

Background/Aims

Whether high-resolution anorectal pressure topography (HRPT), having better fidelity and spatio-temporal resolution is comparable to waveform manometry (WM) in the diagnosis and characterization of defecatory disorders (DD) is not known.

Methods

Patients with chronic constipation (Rome III) were evaluated for DD with HRPT and WM during bearing-down “on-bed” without inflated rectal balloon and “on-commode (toilet)” with 60-mL inflated rectal balloon. Eleven healthy volunteers were also evaluated.

Results

Ninety-three of 117 screened participants (F/M = 77/16) were included. Balloon expulsion time was abnormal (> 60 seconds) in 56% (mean 214.4 seconds). A modest correlation between HRPT and WM was observed for sphincter length (R = 0.4) and likewise agreement between dyssynergic subtypes (κ = 0.4). During bearing down, 2 or more anal pressure-segments (distal and proximal) could be appreciated and their expansion measured with HRPT but not WM. In constipated vs healthy participants, the proximal segment was more expanded (2.0 cm vs 1.0 cm, P = 0.003) and of greater pressure (94.8 mmHg vs 54.0 mmHg, P = 0.010) during bearing down on-commode but not on-bed.

Conclusions

Because of its better resolution, HRPT may identify more structural and functional abnormalities including puborectal dysfunction (proximal expansion) than WM. Bearing down on-commode with an inflated rectal balloon may provide additional dimension in characterizing DD.

Anal and rectal function after intensity-modulated prostate radiotherapy with endorectal balloon

BACKGROUND AND PURPOSE

Late anorectal toxicity influences quality of life after external beam radiotherapy (EBRT) for prostate cancer. A daily inserted endorectal balloon (ERB) during EBRT aims to reduce anorectal toxicity. Our goal is to objectify anorectal function over time after prostate intensity-modulated radiotherapy (IMRT) with ERB.

MATERIAL AND METHODS

Sixty men, irradiated with IMRT and an ERB, underwent barostat measurements and anorectal manometry prior to EBRT and 6 months, one year and 2 years after radiotherapy. Primary outcome measures were rectal distensibility and rectal sensibility in response to stepwise isobaric distensions and anal pressures.

RESULTS

Forty-eight men completed all measurements. EBRT reduced maximal rectal capacity 2 years after EBRT (250 ± 10 mL vs. 211 ± 10 mL; p < 0.001), area under the pressure-volume curve (2878 ± 270 mL mmHg vs. 2521 ± 305 mL mmHg; p = 0.043) and rectal compliance (NS). Sensory pressure thresholds for first sense and first urge (both p < 0.01) increased. Anal maximum pressure diminished after IMRT (p = 0.006).

CONCLUSIONS

Rectal capacity and sensory function are increasingly affected over time after radiotherapy. There is an indication that these reductions are affected less with IMRT + ERB compared to conventional radiation techniques.

Colorectal Perforation After Anorectal Manometry for Low Anterior Resection Syndrome

We experienced 3 cases of manometry-induced colon perforation. A 75-year-old man (case 1) underwent anorectal manometry (ARM) 3 years after radiotherapy for prostate cancer and a laparoscopic intersphincteric resection for rectal cancer. A 70-year-old man (case 2) underwent ARM 3 months after conventional neoadjuvant chemoradiotherapy and a laparoscopic low anterior resection for rectal cancer. A 78-year-old man (case 3) underwent ARM 2 months after a laparoscopic intersphincteric resection for rectal cancer. In all cases, a colon perforation with fecal peritonitis occurred. All were treated successfully using prompt and active operations and were discharged without any complications. ARM with a balloon, as a measure of rectal compliance, should be performed 2 months or longer after surgery. If a perforation occurs, prompt and active surgical intervention is necessary due to the high possibility of extensive fecal peritonitis.

Habit training versus habit training with direct visual biofeedback in adults with chronic constipation: study protocol for a randomised controlled trial

Background

Constipation affects up to 20% of adults. Chronic constipation (CC) affects 1–2% of adults. Patient dissatisfaction is high; nearly 80% feel that laxative therapy is unsatisfactory and symptoms have significant impact on quality of life. There is uncertainty about the value of specialist investigations and whether equipment-intensive therapies using biofeedback confer additional benefit when compared with specialist conservative advice.

Methods/design

A three-arm, parallel-group, multicentre randomised controlled trial.

Objectives: to determine whether standardised specialist-led habit training plus pelvic floor retraining using computerised biofeedback is more clinically effective than standardised specialist-led habit training alone; to determine whether outcomes are improved by stratification based on prior investigation of anorectal and colonic pathophysiology. Primary outcome measure is response to treatment, defined as a 0.4-point (10% of scale) or greater reduction in Patient Assessment of Constipation–Quality of Life (PAC-QOL) score 6 months after the end of treatment. Other outcomes up to 12 months include symptoms, quality of life, health economics, psychological health and qualitative experience.

Hypotheses: (1) habit training (HT) with computer-assisted direct visual biofeedback (HTBF) results in an average reduction in PAC-QOL score of 0.4 points at 6 months compared to HT alone in unselected adults with CC, (2) stratification to either HT or HTBF informed by pathophysiological investigation (INVEST) results in an average 0.4-point reduction in PAC-QOL score at 6 months compared with treatment not directed by investigations (No-INVEST).

Inclusion: chronic constipation in adults (aged 18–70 years) defined by self-reported symptom duration of more than 6 months; failure of previous laxatives or prokinetics and diet and lifestyle modifications. Consenting participants (n = 394) will be randomised to one of three arms in an allocation ratio of 3:3:2: [1] habit training, [2] habit training and biofeedback or [3] investigation-led allocation to one of these arms. Analysis will be on an intention-to-treat basis.

Discussion

This trial has the potential to answer some of the major outstanding questions in the management of chronic constipation, including whether costly invasive tests are warranted and whether computer-assisted direct visual biofeedback confers additional benefit to well-managed specialist advice alone.

Trial registration

International Standard Randomised Controlled Trial Number: ISRCTN11791740. Registered on 16 July 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1880-0) contains supplementary material, which is available to authorized users.

The usefulness of anorectal manometry in patients with a stoma before and after surgery to restore the continuity of the gastrointestinal tract

The operation to restore the continuity of the gastrointestinal tract is another surgical intervention in a given patient, which directly translates into an increased risk of complications during and after surgery. That is why proper qualification is important for the operation to restore the continuity of the gastrointestinal tract in terms of performance and efficiency of the anal sphincter apparatus, among other things. The aim of the study was to evaluate the effect of restoring physiological defecation routes on the sphincter function and to observe the parameters of anorectal manometry in patients before and after surgery to restore the continuity of the gastrointestinal tract.

MATERIAL AND METHODS

The study included 29 patients scheduled for restoration of the continuity of the gastrointestinal tract, 12 women and 17 men. The average age in the group was 62 years. Anorectal manometry was performed both before surgery as well as one month and three months afterwards in all patients. The average time to have a stoma was 12 months.

RESULTS

The resting pressure in the anal canal (MRP) three months after the restoration of the continuity of the gastrointestinal tract increased by 30.4%. The maximum systolic blood pressure in the anal canal (MSP) increased by 22.2%. The value of recto-anal inhibitory reflex (RAIR) decreased by 19.2%. The length of the high pressure zone in the anal canal (HPZL) increased by 27%. The study results of visceral rectal sensation thresholds decreased by 23.3% for the sensation threshold, and 14.4% for the pressure threshold.

CONCLUSIONS

Restoring the continuity of the gastrointestinal tract improves the anal sphincter function which is evident in the parameters of anorectal manometry. The restoration of passage improves the sphincter function, and these changes are statistically significant.

Colonic Inertia: approach and treatment

Objective Revision of the state of the art of the knowledge regarding pathophysiology, diagnosis and treatment of Colonic Inertia, which predominantly affects young women and has a significant socio-economic impact.

Methods A search was made in “colonic inertia”, “colon inertia” and “slow transit constipation” in PubMed database for articles of the last 5 years, in Portuguese or English with available abstract and full text. 59 articles and 2013 guidelines of the American Gastroenterological Association on constipation were included.

Results The pathophysiology is not completely elucidated and the reduction of the interstitial cells of Cajal is the most consistent histological finding. Diagnosis requires the exclusion of secondary causes of constipation and obstructed defecation syndrome, to which contribute several complementary diagnostic tests. Given the frequency of failure of the medical treatment, surgery is often the only possible option. Sacral nerve stimulation seems to be a promising therapeutical alternative.

Conclusion A deeper investigation of the pathophysiological mechanisms is fundamental to acquire a more global and integrated vision. Rigorous patient selection for each treatment and the discovery of new therapeutical targets may avoid the use of surgical therapies.

Functional Disorders: Slow-Transit Constipation

Constipation is a very common complaint, with slow-transit constipation (STC) accounting for a significant proportion of cases. Old age, female gender, psychiatric illness, and history of sexual abuse are all associated with STC. The exact cause of STC remains elusive; however, multiple immune and cellular changes have been demonstrated. Diagnosis requires evidence of slowed colonic transit which may be achieved via numerous modalities. While a variety of medical therapies exist, these are often met with limited success and a minority of patients ultimately require operative intervention. When evaluating a patient with STC, it is important to determine the presence of concomitant obstructed defecation or other forms of enteric dysmotility, as this may affect treatment decisions. Although a variety of surgical procedures have been reported, subtotal colectomy with ileorectal anastomosis is the most commonly performed and well-studied procedure, with the best track record of success.

Chronic Constipation: a Review of Current Literature

Chronic constipation is a common health condition representing a substantial proportion of primary care visits and referrals to specialist providers. Chronic constipation can have a significant negative effect on health-related quality of life and has been associated with psychological distress in severely affected patients. It has the potential to cause patients to curtail work, school, and social activities. While different pathophysiological mechanisms have been implicated in the development of chronic constipation, in some instances, the causes of chronic constipation are not easily determined. Expenditures for the evaluation and management of chronic constipation represent a significant burden on patients and payers, and it is important for clinicians to have a clear understanding of the different pathophysiological mechanisms associated with constipation, understand the different testing modalities and treatments that are available including their appropriateness and limitations, and tailor that knowledge to the management of individual patients.

Chronic Constipation

Chronic constipation is a common disorder that affects approximately 20% of the population and significantly impacts an individual's quality of life. The diagnosis can be made using standard criteria, and in the absence of alarm signs or symptoms, a determination of the underlying etiology/etiologies should be undertaken. In many instances, these will be gleaned from the history and physical examination. Specialized diagnostic testing may be warranted after the failure of initial laxative trials. Many therapeutic classes of laxatives exist with recent analyses indicating that practicing physicians prefer to use over-the-counter therapies in lieu of more strongly evidence-based prescription pharmaceuticals.

Slow transit constipation and lower urinary tract dysfunction

INTRODUCTION

Many theories have been proposed for the coexistence of constipation and lower urinary tract dysfunction (LUTD), such as bladder compression from a distended rectum and stimulation of sacral reflexes from a full rectum. In these cases, successful treatment of constipation should result in resolution of bladder symptoms. Some children have refractory constipation and others respond well to treatment, but once treatment is discontinued most children relapse back into their constipation. This may indicate the existence of a defect in colon motility, with a persistent peristalsis problem. The existence of a common neuromuscular disorder should be the base for both bladder and bowel dysfunction (BBD).

OBJECTIVE

To study colonic transit time (CTT) in children and adolescents with refractory constipation and lower urinary tract symptoms (LUTS).

MATERIALS AND METHODS

A total of 15 children (mean age 9.7 years) with refractory constipation and LUTS were evaluated with: standardized medical history; physical examination; bladder and bowel diaries; Bristol stool scale; Rome III criteria; Dysfunctional Voiding Scoring System (DVSS); ultrasound examination of the kidneys and urinary tract, and measurement of rectal diameter; urodynamic evaluation; and a CTT study using radiopaque markers.

RESULTS

Urodynamic features were abnormal in 13 out of 15 children: 10 (66.7%) presented with detrusor overactivity (DO) and voiding dysfunction (VD), two (16.7%) had isolated DO, and one (8.3%) had a VD. The CTT study was abnormal in 12 out of 15 children: nine (60%) presented with slow transit constipation, three (20%) had outlet obstruction, and three (20%) had a normal CTT study. When comparing CTT and LUTD, nine (100%) children with slow transit constipation (STC) and three (50%) with no STC had DO (P = 0.04). Seven (77.8%) children with STC and three (50%) with no STC had VD (P = 0.29). The DVSS scores ranged from 6 to 21. The subgroup with STC had a DVSS score that was significantly higher than that of the subgroup with noF STC (Figure).

DISCUSSION

The present study showed a high prevalence of STC in children and adolescents with refractory constipation and LUTS. This was in accordance with previous studies that have demonstrated a rate of 50-60% of STC in children with refractory constipation. In addition, DO was found to be associated with STC, which raises the chance for the existence of a common neuromuscular disorder to be the base for both bladder and bowel dysmotility. The limitation of this study was the number of participants.

CONCLUSIONS

The present study demonstrated an association between DO and STC.

Manometric comparison of anorectal function after posterior vaginal compartment repair with and without mesh

Background:

Although repair augmented with mesh has been proved its priority in anatomical and functional recovery after anterior compartment reconstruction, the data about posterior compartment are scarce. The aim of this study was to compare bowel functional outcome of posterior vaginal compartment repair with and without mesh in patients with pelvic organ prolapse (POP).

Methods:

This was a prospective, double-blind, clinical pilot study of 22 postmenopausal women with symptomatic POP (overall POP-quantification [POP-Q] Stage III-IV) who underwent total pelvic floor reconstruction. Patients were grouped according to the use of mesh for posterior vaginal compartment repair: A mesh group and a nonmesh group. POP-Q stage, the pelvic floor impact questionnaire short form-7 (PFIQ-7) and anorectal manometry were evaluated before and 3 months after surgery. Anatomical success was defined as POP-Q Stage II or less. A t-test was used to compare preoperative with postoperative data in the two groups.

Results:

Totally, 17 (71%) were available for the follow-up. POP-Q measurements improved significantly compared to baseline (P < 0.05) in both groups. No recurrence was observed. Subjects in both groups reported improvement in pelvic floor symptoms, and there was no significant difference in the PFIQ-7 score between groups at follow-up (P > 0.05). Compared with baseline, the nonmesh group exhibited a statistically significant decrease in anal residual pressure, a significant increase in the anorectal pressure difference during bowel movement, and a reduced rate of dyssynergia defecation pattern (P < 0.05).

Conclusions:

Provided there is sufficient support for the anterior wall and apex of vagina with mesh, posterior compartment repair without mesh may be as effective as repair with mesh for anatomical recovery while providing better anorectal motor function.

Efficacy of procedure for prolapse and hemorrhoids vs traditional surgery for treatment of constipation caused by internal rectal prolapse with mixed hemorrhoids

AIM: To compare the clinical curative effect of procedure for prolapse and hemorrhoids (PPH) vs traditional surgery in the treatment of outlet obstructive constipation caused by internal rectal prolapse with mixed hemorrhoids.

METHODS: One hundred and twenty patients with internal rectal prolapse with mixed hemorrhoids treated from January 2010 to December 2012 were randomly divided into either a study group to receive PPH or a control group to receive traditional surgery (Milligan-Morgan hemorrhoidectomy + rectal mucosa ligation). Anorectal pressure was measured preoperatively and postoperatively and compared between the two groups. The quality of life was evaluated using the Patient Assessment of Constipation Quality of Life (PAC-QOL).

RESULTS: Anorectal pressure showed varying degrees of decrease in the two groups after operation; the decrease was not significant in the study group (P > 0.05), but was significant in the control group (P < 0.05). Except resting rectal pressure, other parameters showed significant differences between the two groups after operation (P < 0.05). The overall score and the score of each dimension of the PAC-QOL were statistically significant between the PPH and traditional operation groups, favoring the PPH group.

CONCLUSION: PPH is superior to traditional surgery with regards to curative effect and improvement of quality of life in the treatment of constipation caused by internal rectal prolapse with mixed hemorrhoids with regards to curative effect and improvement of quality of life.

Epidemiology and management of chronic constipation in elderly patients

Constipation is a common functional gastrointestinal disorder, with prevalence in the general population of approximately 20%. In the elderly population the incidence of constipation is higher compared to the younger population, with elderly females suffering more often from severe constipation. Treatment options for chronic constipation (CC) include stool softeners, fiber supplements, osmotic and stimulant laxatives, and the secretagogues lubiprostone and linaclotide. Understanding the underlying etiology of CC is necessary to determine the most appropriate therapeutic option. Therefore, it is important to distinguish from pelvic floor dysfunction (PFD), slow and normal transit constipation. Evaluation of a patient with CC includes basic blood work, rectal examination, and appropriate testing to evaluate for PFD and slow transit constipation when indicated. Pelvic floor rehabilitation or biofeedback is the treatment of choice for PFD, and its efficacy has been proven in clinical trials. Surgery is rarely indicated in CC and can only be considered in cases of slow transit constipation when PFD has been properly excluded. Other treatment options such as sacral nerve stimulation seem to be helpful in patients with urinary dysfunction. Botulinum toxin injection for PFD cannot be recommended at this time with the available evidence. CC in the elderly is common, and it has a significant impact on quality of life and the use of health care resources. In the elderly, it is imperative to identify the etiology of CC, and treatment should be based on the patient’s overall clinical status and capabilities.

Accuracy and Reproducibility of High-definition Anorectal Manometry and Pressure Topography Analyses in Healthy Subjects

BACKGROUND & AIMS

High-definition anorectal manometry (HDAM-3D) provides a topographic and 3-dimensional profile of anorectal pressure. We assessed anorectal sensorimotor function and the reproducibility of measurements made with HDAM-3D in healthy adults, and the accuracy of data analysis by its software.

METHODS

Anal sphincter pressures and rectal sensory thresholds were measured in 78 healthy subjects via placement of a 10-mm rigid probe, with 256 circumferentially arrayed pressure sensors, and a balloon in the rectum. The bearing down maneuver was assessed in a subset of 18 subjects. We compared data analyzed by an expert with findings from automated software analysis. Measurements made in a subset of 16 subjects, 2 weeks apart, were compared to determine reproducibility.

RESULTS

Resting, squeezing, and sustained squeezing pressures were significantly higher in men than in women (P < .05); other parameters were similar. Desire and urgency to defecate were similar between men and women, but the maximal tolerable volume was significantly lower in women (P < .05). Older women (>50 years) had significantly lower resting (P < .01) and sustained squeeze pressures (P < .04). Dyssynergic patterns of defecation were observed in 12 of 18 subjects (67%) who attempted to defecate without the 60-mL rectal balloon distention and in 6 of 18 subjects (33%) with the 60-mL rectal balloon distention. Test-retest values correlated (r = 0.81), as did analyses made by an expert vs software analyses of data (r = 0.99).

CONCLUSIONS

On the basis of HDAM-3D measurements in healthy adults, anal sphincter pressures are higher in men than in women, but sensory and other parameters are similar; older subjects have weaker sphincters. Many people were found to have dyssynergic patterns of defecation, which could be related to the probe or other technical issues, so this technique may not be suitable for assessing defecation patterns. Measurements made by HDAM-3D are reproducible, and data can be accurately analyzed by its software.

Clinical utility of balloon expulsion test for functional defecation disorders

Purpose

I investigated the diagnostic accuracy of balloon expulsion test (BET) with various techniques to find out the most appropriate method, and tried to confirm its clinical utility in diagnosing functional defecation disorders (FDD) in constipated patients.

Methods

Eighty-seven patients constituted the study population. FDD was defined when patients had at least two positive findings in defecography, manometry, and electromyography. BET was done 4 times in each patient with 2 different positions and 2 different volumes. The positions were seated position (SP) and left lateral decubitus position (LDP). The volumes were fixed volume (FV) of 60 mL and individualized volume with which patient felt a constant desire to defecate (CDV). The results of BETs with 4 different settings (LDP-FV, LDP-CDV, SP-FV, and SP-CDV) were statistically compared and analyzed.

Results

Of 87 patients, 23 patients (26.4%) had at least two positive findings in 3 tests and thus were diagnosed to have FDD. On receiver operating characteristic curve analysis, area under curve was highest in BET with SP-FV. With a cutoff value of 30 seconds, the specificity of BET with SP-FV was 86.0%, sensitivity was 73.9%, negative predictive value was 89.8%, positive predictive value was 65.4%, and accuracy rate was 82.8% for diagnosing FDD.

Conclusion

SP-FV is the most appropriate method for BET. In this setting, BET has a diagnostic accuracy sufficient to identify constipated patients who do not have FDD. Patients with negative results in BET with SP-FV may not need other onerous tests to exclude FDD.

Constipation in adults: diagnosis and management

OPINION STATEMENT

Symptoms of constipation occur at all ages, with the greatest prevalence in individuals older than 60 years of age. It is estimated that 35 million individuals suffer from constipation in the USA, but only a small number will ever be diagnosed. Patients identify constipation symptoms differently than physicians. Whereas a patient may define their constipation by symptoms of bloating, distension, feeling of incomplete evacuation, abdominal discomfort, hard stools, and excessive straining, physicians often interpret prolonged timing between movements as the most essential criteria. An evaluation of constipation begins with a focused history of a person's bowel habit, medications, diet, physical activity, and an anorectal examination. In the absence of alarm signs, diagnostic testing for constipation is not routinely recommended in the initial evaluation. First-line management includes lifestyle changes of increased physical activity, high-fiber diets, adequate fluid intake, and bowel management techniques such as a straight back sitting position, using known triggers to stimulate bowel contractions, and a foot stool to elevate knees above bottom during toileting. When refractory to initial management, patients should have anorectal manometry to assess outlet function; additional testing may be required. Biofeedback is an effective treatment option for dyssynergic defecation. A range of traditional and new pharmacologic therapies are available to remedy constipation, from stool softeners to agents that increase intestinal transit. Managing the primary and secondary causes of constipation, incorporating effective bowel management techniques, along with the judicious use of laxatives can reduce constipation symptoms and improve quality of life.

How to perform and assess colonic manometry and barostat study in chronic constipation

Management of chronic constipation with refractory symptoms can be challenging. Although new drugs and behavioral treatments have improved outcome, when they fail, there is little guidance on what to do next. At this juncture, typically most doctors may refer for surgical intervention although total colectomy is associated with morbidity including complications such as recurrent bacterial overgrowth. Recently, colonic manometry with sensory/tone/compliance assessment with a barostat study has been shown to be useful. Technical challenges aside, adequate preparation, and appropriate equipment and knowledge of colonic physiology are keys for a successful procedure. The test itself appears to be safe with little complications. Currently, colonic manometry is usually performed with a 6–8 solid state or water-perfused sensor probe, although high-resolution fiber-optic colonic manometry with better spatiotemporal resolutions may become available in the near future. For a test that has evolved over 3 decades, normal physiology and abnormal findings for common phenotypes of chronic constipation, especially slow transit constipation, have been well characterized only recently largely through the advent of prolonged 24-hour ambulatory colonic manometry studies. Even though the test has been largely restricted to specialized laboratories at the moment, emerging new technologies and indications may facilitate its wider use in the near future.

Constipation: understanding mechanisms and management

Constipation is a frequently diagnosed gastrointestinal disorder. Symptoms of constipation are common, with the greatest prevalence in the elderly. Evaluation of constipation begins with a detailed medical history and a focused anorectal examination. Diagnostic testing for constipation is not routinely recommended in the initial evaluation in the absence of alarm signs. Key self-management strategies include increased exercise, a high-fiber diet, and toilet training. High-fiber diets can worsen symptoms in some patients who have chronic constipation. Biofeedback is an effective treatment option for patients who have constipation caused by outlet obstruction defecation. A variety of medications are available to remedy constipation.

Toward more accurate measurements of anorectal motor and sensory function in routine clinical practice: validation of high-resolution anorectal manometry and Rapid Barostat Bag measurements of rectal function

BACKGROUND

Measurements of anorectal function using high-resolution anorectal manometry (HR-ARM) and rectal barostat technology provide more reliable results than standard ARM with an elastic balloon; however, HR-ARM results have not been compared to ARM and standard barostat protocols are impractical in routine clinical practice. The aim of this study was to validate HR-ARM against standard ARM and standard barostat against a novel Rapid Barostat Bag (RBB) measurement and elastic balloon measurements of rectal function.

METHODS

Twenty-six healthy volunteers (15 female, 11 male, 19-52 years) were studied. Measurements of anal function and simulated defecation were compared for 12-sensor HR-ARM and 6-sensor standard ARM using line plots from the same recording. Rectal capacity, compliance, and sensation (volume threshold) were measured by elastic balloon, standard barostat, and RBB methods using stepwise inflation of a 700-mL polyethylene bag to 40 mmHg distension by electronic barostat and handheld syringe monitored by sphygmo-manometer, respectively. Results are reported as mean ± SD. Bland-Altman plots and correlation coefficients (r) for measurements were calculated.

KEY RESULTS

There was excellent agreement between HR- and standard ARM measurements (r > 0.86, <25 mmHg difference) and between standard barostat and RBB measurements of rectal capacity (r = 0.97, <25 mL difference). Correlation coefficients of threshold volumes for initial perception, urgency and discomfort were 0.37, 0.71, and 0.95, respectively. No significant correlation was present with elastic balloon measurements. Time to complete studies was shorter for HR-ARM than standard ARM and for RBB than standard barostat in historical controls.

CONCLUSIONS & INFERENCES

HR-ARM with RBB measurements of anorectal function provides quick and reasonably accurate measurements of continence function suitable for use in routine clinical practice (ClinicalTrial.gov NCT01456442).

Bear-down maneuver is a useful adjunct in the evaluation of children with chronic constipation

BACKGROUND AND OBJECTIVES

Chronic constipation is a common problem in pediatrics and often the result of obstructed defecation. The aim of this study was to determine the use of the bear-down maneuver (BDM) in the evaluation of children with chronic constipation and to establish optimal conditions for its performance.

METHODS

This retrospective study compares BDM with balloon expulsion testing (BET) during anorectal manometry in 38 children with chronic constipation. BDM was performed with 0-, 20-, 40-, and 60-mL balloon inflation. BET, performed with a 60-mL balloon, was considered normal if the balloon was expelled within 1 minute.

RESULTS

Rectal pressure during BDM was 48% higher in patients able to expel the balloon during BET compared with those who could not (P < 0.05). Anal canal pressure was 46% lower in patients able to expel the balloon (P < 0.05). A rectoanal pressure differential greater than zero during BDM was 90% predictive that the subject would be able to expel the balloon. The optimal balloon inflation volume was 60 mL.

CONCLUSIONS

BDM using an inflated balloon provides valuable mechanistic information in the evaluation of children with dyssynergic defecation. We found that patients often had either an insufficient rectal pressure during bear-down or an abnormally high anal canal pressure. This information may be useful in planning further treatment for these children.

Novel techniques to study colonic motor function in children

Colonic motility is an essential component of normal colonic physiology and it controls essential bodily functions such as stool propulsion, storage, and expulsion. Disordered colonic motility may present with constipation or diarrhea as well as associated symptoms such as bloating, gas, pain, incontinence, and others. In order to assess colonic motor function, practitioners may use studies that either investigate transit time or that evaluate peristaltic activity. Transit time is the result of both the effectiveness of propulsive pressures and the physical characteristics of the stools. Its measurement allows one to quantify the extent and severity of the colonic dysfunction and permits the assessment of response to therapy. Various methods exist to investigate colon transit time and motility. In this review, we will focus on newer techniques for these investigations, including: scintigraphic transit studies, anorectal manometry, colonic manometry, and studies using a wireless motility capsule.

Clinical utility of colonic manometry in slow transit constipation

BACKGROUND

The clinical significance of colorectal sensorimotor evaluation in patients with slow transit constipation (STC) is unclear. We investigated whether colonic manometric evaluation is useful for characterizing colonic sensorimotor dysfunction and for guiding therapy in STC.

METHODS

24-h ambulatory colonic manometry was performed in 80 patients (70 females) with STC by placing a six sensor solid-state probe, along with assessment of colonic sensation with barostat. Anorectal manometry was also performed. Manometrically, patients were categorized as having colonic neuropathy or myopathy based on gastrocolonic response, waking response and high amplitude propagated contractions (HAPC); and based on colonic sensation, as colonic hyposensitivity or hypersensitivity. Clinical response to pharmacological, biofeedback, and surgical treatment was assessed at 1 year and correlated with manometric findings.

KEY RESULTS

Forty seven (59%) patients who had abnormal colonic manometry, with features suggestive of neuropathy (26%), and myopathy (33%); 41% had normal colonic manometry. Patients who had abnormal colonic sensation were 74% and 61% had overlapping dyssynergic defecation. Patients with neuropathy were more likely to have colonic hyposensitivity. Sixty-four percent of patients with colonic myopathy or normal manometry improved with medical/biofeedback therapy when compared to 15% with colonic neuropathy (P < 0.01). Selected patients with colonic neuropathy had excellent response to surgery, but many developed bacterial overgrowth.

CONCLUSIONS & INFERENCES

Colonic manometry demonstrates significant colonic sensorimotor dysfunction in STC patients and reveals considerable pathophysiological heterogeneity. It can be useful for characterizing the underlying pathophysiology and for guiding clinical management in STC, especially surgery.

A pilot study to assess the feasibility of measuring the prevalence of slow colon transit or evacuation disorder in palliative care

CONTEXT

Constipation is prevalent in palliative care. Whilst numerous factors contribute to this problem, opioid analgesia remains the most quoted aetiology. However, in gastroenterology, constipation is classified as a problem of prolonged transit times of colonic contents, impaired function of the structures of defecation or both. Little work in palliative care has used these assessments.

AIMS

The report aims to describe the feasibility of assessing the colon transit times and pelvic floor structures of constipated palliative care patients and to report the results of a pilot study of 10 people who underwent these investigations.

METHODS

Colon transit times were measured with a combination of orally administered radio-opaque markers and a single plain radiograph of the abdomen at day 5. Anal manometry plus rectal balloon expulsion was used to assess the pelvic floor. The results of the investigations were used to allocate people to one of four constipation subcategories: 1). slow colonic transit; 2) evacuation disorders; 3) mixed disorder or 4) normal transit.

RESULTS

Two people had slow transit only, 2 people had evacuation disorders only and 5 had both. Only person had neither problem. The investigations were well tolerated and took a small amount of people's time.

CONCLUSION

These pilot data strongly support the feasibility of undertaking comprehensive assessments of the colon and pelvic floor in palliative care patients with the results, although preliminary, highlighting the complexity of the problem of constipation. The results of this work underpin the need to progress to a much larger study.

Biofeedback therapy for defecatory dysfunction: "real life" experience

BACKGROUND

Biofeedback therapy (BF) is a well-established treatment modality for patients with dyssynergic defecation and fecal incontinence (FI). Randomized controlled trials from highly specialized tertiary care centers report response rates of 70% to 80% for dyssynergic defecation and 55% to 75% for FI. Whether this therapy is as successful outside of clinical trials or specialized biofeedback referral centers remains unclear.

AIM

Our primary aim was to determine what percentage of patients referred for BF actually complete therapy and identify barriers to treatment. Our secondary aim was to determine the clinical response rate in a heterogeneous population of patients undergoing BF at our institution and a variety of regional locations.

METHODS

We retrospectively reviewed patients who underwent high resolution anorectal manometry between 2007 and 2010 for symptoms of defecatory dysfunction. BF was recommended at the time of manometry analysis based on findings of dyssynergy, impaired or heightened rectal sensation, or poor augmentation of sphincter on squeeze maneuvers. Clinical response was recorded after a course of BF (≥ 5 sessions).

RESULTS

Two hundred three patients (78% female, 72% white; median age 52) underwent anorectal manometry for symptoms of constipation (130), FI (54), combination (12), and rectal pain (7). BF was recommended in 119 cases (58.6%): constipation (80), FI (27), combination (9), and rectal pain (3). Only 39 out of 80 (48%) patients with constipation ultimately underwent BF. Of the 27 FI cases, only 12 (44%) patients underwent BF. Barriers to BF included lack of insurance coverage, distance to local treatment facilities, and acute medical issues taking precedence. Of those who underwent at least 5 BF sessions, subjective short-term response rates based on patient opinion were 17/28 (60%) in the constipation group and 8/10 (80%) in the FI group. Age, sex, and race had no effect on whether the patients attended biofeedback or whether they responded to treatment. The location of BF also did not predict response to therapy.

CONCLUSIONS

In a heterogeneous patient population, less than half of patients recommended for BF ultimately underwent therapy. Despite this, the response rates in this small population undergoing BF in the "real world" are only slightly less than published randomized control trials. Prospective studies are warranted to further elucidate and eliminate barriers to BF, especially given that "real world" BF response rates may be comparable with those seen in clinical trials.

Surgical correction is ineffective for improvement of dyssynergic defecation in patients with rectal prolapse

BACKGROUND/AIMS

The patients with rectal prolapse suffer from not only a prolapse rectum but also associated dysfunction. However, most surgical techniques are successful regarding the prolapse, but either do not solve or even worsen defecation dysfunction. The purpose of this study was to investigate the functional and physiological results after surgical correction in patients with rectal prolapse.

METHODS

This study is a retrospective review of a single-institution experience. Patients with rectal prolapse who underwent anorectal manometry before and after Delorme's procedure were included. The primary outcomes measured were improvement of clinical symptoms and physiologic study.

RESULTS

Consecutive 19 patients with rectal prolapse (17 females, mean age of 68.1 ± 10.8 years) underwent anorectal manometry before and after Delorme's procedure. The two most prevalent symptoms before operation were rectal tenesmus (15/19, 78.9%) and excessive straining (13/19, 68.4%). The two most prevalent symptoms after operation were rectal tenesmus (14/19, 73.6%) and excessive straining (13/19, 68.4%). No significant differences in resting anal pressure, squeezing anal pressure, defecation index, and rectal sense were found postoperatively. However, vector asymmetry index before surgery was higher than that after surgery (35.0 vs. 32.0, P = 0.018). Ten patients (52.5%) had type I dyssynergic defecation before surgery. No improvement of dyssynergic pattern occurred after surgery.

CONCLUSIONS

In conclusion, dyssynergic defecation was not improved after reduction of rectal prolapse in patients with rectal prolapse. Further study about combination treatment with biofeedback therapy in these subgroups may be necessary.

Balloon expulsion test as a screen for outlet obstruction in children with chronic constipation

OBJECTIVE

Chronic constipation (CC) is a common problem in pediatrics and is often the result of obstructed defecation. The aim of the present study was to study the feasibility and efficacy of the balloon expulsion test (BET) in the diagnosis and management of children with CC.

METHODS

Retrospective study comparing BET and high-resolution anorectal manometry (ARM). The BET was done together with ARM in 29 children, ages 8 to 19 years, with CC. For BET, a 60-mL balloon was used. Passage of balloon in 1 minute or less was considered normal.

RESULTS

Fifteen of the 29 children had a normal BET. Of these, 14 also had an ARM, all of which were normal (except for 2 cases with a hypertonic baseline anal sphincter). Thus 12 of 14 with BET and ARM were normal on both (correlation between the tests 86%). Of the 14 children that failed BET, 10 had distal abnormalities by ARM, contrast studies, EMG, or assessment by a pelvic physical therapist. All of the patients with a nonrelaxing sphincter or outlet obstruction were treated with laxatives, anal sphincter Botox, and/or pelvic physical therapy and biofeedback. In follow-up of at least 3 months, all of the patients with a failed BET were improved.

CONCLUSIONS

We found a high correlation between a normal ARM and BET. If the BET is abnormal and the ARM does not identify a cause for the distal obstruction, additional studies may be needed, including contrast enema, defecography, or electromyography. BET appears to be a safe, reliable, and useful test in the evaluation and management of CC in children.

Clinical examination remains more important than anorectal function tests to identify treatable conditions in women with constipation

Introduction and hypothesis

Many women with chronic constipation are referred for anorectal function tests (AFT) when they fail initial conservative treatment with lifestyle advice and laxatives. Our goal was to prospectively investigate the diagnostic potential of AFT in women with constipation in order to identify treatable conditions.

Methods

Between May 2003 and June 2011, all women with constipation referred to our tertiary referral center completed a questionnaire regarding their perianal complaints and underwent physical examination and were evaluated according to our AFT protocol, including anorectal manometry (ARM) and anal endosonography.

Results

One hundred and thirteen women were referred and classified as having idiopathic constipation (n = 100), neurological disorder (n = 8), or others (n = 5). Of the 100 women with idiopathic constipation, clinical examination identified 25 (25 %) with hypertonia of the pelvic floor (dyssynergic pelvic floor) and 15 (15 %) with a rectocele. In 37/100 women also complaining of impaired evacuation, the yield of rectocele was 15 (41 %) and of hypertonia 5 (14 %). Women with hypertonia were younger (40 vs. 51 years; P = 0.002) and had no rectoceles identified (P = 0.02), and fewer women could relax during straining on ARM (56 % vs. 92 %; P < 0.001) compared with women without pelvic hypertonia. Other ARM measurements showed no differences between women with evacuation disorders, rectoceles, or hypertonia. Anal endosonography showed no internal sphincter hypertrophia.

Conclusion

Potentially treatable conditions, such as rectocele and pelvic floor hypertonia, are found on clinical examination in 40 % of women with idiopathic constipation. Impaired evacuation is associated with the presence of a rectocele. AFT contributes little and should be reserved for selected cases.

Consensus statement AIGO/SICCR: Diagnosis and treatment of chronic constipation and obstructed defecation (part I: Diagnosis)

Chronic constipation is a common and extremely trou-blesome disorder that significantly reduces the quality of life, and this fact is consistent with the high rate at which health care is sought for this condition. The aim of this project was to develop a consensus for the diagnosis and treatment of chronic constipation and obstructed defecation. The commission presents its results in a “Question-Answer” format, including a set of graded recommendations based on a systematic review of the literature and evidence-based medicine. This section represents the consensus for the diagnosis. The history includes information relating to the onset and duration of symptoms and may reveal secondary causes of constipation. The presence of alarm symptoms and risk factors requires investigation. The physical examination should assess the presence of lesions in the anal and perianal region. The evidence does not support the routine use of blood testing and colonoscopy or barium enema for constipation. Various scoring systems are available to quantify the severity of constipation; the Constipation Severity Instrument for constipation and the obstructed defecation syndrome score for obstructed defecation are the most reliable. The Constipation-Related Quality of Life is an excellent tool for evaluating the patient‘s quality of life. No single test provides a pathophysiological basis for constipation. Colonic transit and anorectal manometry define the pathophysiologic subtypes. Balloon expulsion is a simple screening test for defecatory disorders, but it does not define the mechanisms. Defecography detects structural abnormalities and assesses functional parameters. Magnetic resonance imaging and/or pelvic floor sonography can further complement defecography by providing information on the movement of the pelvic floor and the organs that it supports. All these investigations are indicated to differentiate between slow transit constipation and obstructed defecation because the treatments differ between these conditions.

Increased rectal wall stiffness after prostate radiotherapy: relation with fecal urgency

BACKGROUND

  Late anorectal toxicity is a frequent adverse event of external beam radiotherapy (EBRT) for prostate cancer. The pathophysiology of anorectal toxicity remains unknown, but we speculate that rectal distensibility is impaired due to fibrosis. Our goal was to determine whether EBRT induces changes of rectal distensibility as measured by an electronic barostat and to explore whether anorectal complaints are related to specific changes of anorectal function.

METHODS

  Thirty-two men, irradiated for localized prostate carcinoma, underwent barostat measurements, anorectal manometry, and completed a questionnaire prior to and 1 year after radiotherapy. The primary outcome measure was rectal distensibility in response to stepwise isobaric distensions. In addition, we assessed sensory thresholds, anal pressures, and anorectal complaints.

KEY RESULTS

  External beam radiotherapy reduced maximal rectal capacity (227 ± 14 mL vs 277 ± 15 mL; P < 0.001), area under the pressure-volume curve (3212 ± 352 mL mmHg vs 3969 ± 413 mL mmHg; P < 0.005), and rectal compliance (15.7 ± 1.2 mL mmHg(-1) vs 17.6 ± 0.9 mL mmHg(-1) ; P = 0.12). Sensory pressure thresholds did not significantly change. Sixteen of the 32 patients (50%) had one or more anorectal complaints. Patients with urgency (n = 10) had a more reduced anal squeeze and maximum pressure (decrease 29 ± 11 mmHg vs 1 ± 7 mmHg; P < 0.05 and 31 ± 12 mmHg vs 2 ± 8 mmHg; P < 0.05 respectively) compared with patients without complaints, indicating a deteriorated external anal sphincter function.

CONCLUSIONS & INFERENCES

  Irradiation for prostate cancer leads to reduced rectal distensibility. In patients with urgency symptoms, anal sphincter function was also impaired.

Obstructed defecation: the role of anorectal manometry

BACKGROUND

The aim of the study was to evaluate the clinical usefulness of anorectal manometry (AM) in patients affected by obstructed defecation (OD).

METHODS

Between January 2007 and December 2010, 379 patients (287 women and 92 men) affected by OD were evaluated. After a preliminary clinical evaluation, defecography and AM were performed. The results were compared with those from 20 healthy control subjects.

RESULTS

Overall anal resting pressure was not significantly different between patients and controls. Maximal voluntary contraction (MVC) data were significantly lower when compared with those of controls (P < 0.01). The straining test was considered positive in 143 patients. No significant difference was noted between patients and controls in maximal tolerated volume data. Patients had a significantly higher conscious rectal sensitivity threshold than controls (P < 0.02).

CONCLUSIONS

A positive straining test, low MVC and impaired rectal sensation are the main abnormalities detected by AM in patients with OD.