Gruppo Lombardo per lo Studio della Motilità Intestinale. Anorectal manometry with water-perfused catheter in healthy adults with no functional bowel disorders

ANORECTAL MANOMETRY STANDARD OF A BRAZILIAN POPULATION AT PRODUCTIVE AGE WITHOUT PELVIC FLOOR DISORDERS: A PROSPECTIVE VOLUNTEERED STUDY

Background:

Due to the lack of normal standards of anorectal manometry in Brazil, data used are subject to normality patterns described at different nationalities.

Aim:

To determine the values and range of the parameters evaluated at anorectal manometry in people, at productive age, without pelvic floor disorders comparing the parameters obtained between male and female.

Methods:

Prospective analysis of clinical data, such as gender, age, race, body mass index (BMI) and anorectal manometry, of volunteers from a Brazilian university reference in pelvic floor disorders.

Results:

Forty patients were included, with a mean age of 45.5 years in males and 37.2 females (p=0.43). According to male and female, respectively in mmHg, resting pressures were similar (78.28 vs. 63.51, p=0.40); squeeze pressures (153.89 vs. 79.78, p=0.007) and total squeeze pressures (231.27 vs. 145.63, p=0.002). Men presented significantly higher values of anorectal squeeze pressures, as well as the average length of the functional anal canal (2.85 cm in male vs. 2.45 cm in female, p=0.003).

Conclusions:

Normal sphincter pressure levels in Brazilians differ from those used until now as normal literature standards. Male gender has higher external anal sphincter tonus as compared to female, in addition a greater extension of the functional anal canal

High-Resolution Anorectal Manometry - New Insights in the Diagnostic Assessment of Functional Anorectal Disorders

Functional anorectal disorders such as faecal incontinence (FI), functional anorectal pain, and functional defecation disorders (FDD) are highly prevalent and represent a high socioeconomic burden. Several tests of anorectal function exist in this setting; however, high-resolution anorectal manometry (HR-ARM) is a new tool that depicts pressure all along the anal canal and can assess rectoanal coordination. HR-ARM is used in the diagnosis of FI and especially FDD although data in health is still sparse, and pressure phenomena seen during simulated defecation, such as dyssynergia, are highly prevalent in health.

Are Obese Patients at an Increased Risk of Pelvic Floor Dysfunction Compared to Non-obese Patients?

PURPOSE

Factors associated with increased intra-abdominal pressure such as chronic cough, morbid obesity, and constipation may be related to pelvic floor dysfunction. In this study, we compared anorectal manometry values and clinical data of class II and III morbidly obese patients referred to bariatric surgery with that of non-obese patients.

METHODS

We performed a case-matched study between obese patients referred to bariatric surgery and non-obese patients without anorectal complaints. The groups were matched by age and gender. Men and nulliparous women with no history of abdominal or anorectal surgery were included in the study. Anorectal manometry was performed by the stationary technique, and clinical evaluation was based on validated questionnaires.

RESULTS

Mean age was 44.8 ± 12.5 years (mean ± SD) in the obese group and 44.1 ± 11.8 years in the non-obese group (p = 0.829). In the obese group, 65.4% of patients had some degree of fecal incontinence. Mean squeeze pressure was significantly lower in obese than in non-obese patients (155.6 ± 64.1 vs. 210.1 ± 75.9 mmHg, p = 0.004), and there was no significant difference regarding mean rest pressure in obese patients compared to non-obese ones (63.7 ± 23.1 vs. 74.1 ± 21.8 mmHg, p = 0.051). There were no significant differences in anorectal manometry values between continent and incontinent obese patients.

CONCLUSIONS

The prevalence of fecal incontinence among obese patients was high regardless of age, gender, and body mass index. Anal squeeze pressure was significantly lower in obese patients compared to non-obese controls.

Manometric evaluation of anorectal function in patients treated with neoadjuvant chemoradiotherapy and total mesorectal excision for rectal cancer

BACKGROUND

An altered anorectal function is reported after chemoradiotherapy (CRT) and surgery for rectal cancer.

AIM

The aim of this study was to clarify the relative contribution of neoadjuvant chemoradiation and surgical resection on the impairment of anorectal function as evaluated by anorectal manometry.

METHODS

Thirty-nine patients with rectal cancer, who underwent neoadjuvant CRT and laparoscopic rectal resection, were evaluated with the Pescatori Faecal Incontinence score, and with anorectal manometry: before neoadjuvant therapy (T0), after neoadjuvant therapy and before surgery (T1), 12 months after stoma closure (T2).

RESULTS

Resting and/or maximum squeeze pressure and/or volume thresholds for urgency were below the normal values in 12 (30%) patients at baseline. After CRT the mean resting pressure significantly decreased (p=0.007). Surgery determined a significantly decrease of the resting pressure (p=0.001), of the maximum squeeze pressure (p=0.001) and of the volume threshold for urgency (p=0.001). Impairment of continence was reported by 5, 11 and 18 patients at T0, T1 and T2, with a mean incontinence score of 3, 3.8 and 3.9 respectively.

CONCLUSIONS

CRT is detrimental to the function of the internal anal sphincter. Rectal resection significantly affects both internal and external anal sphincter function and the maximum tolerated volume of the neo-rectum, particularly in patients with low rectal cancer, significantly impairing anal continence.

Three-Dimensional Anorectal Manometry Findings in Primigravida

BACKGROUND

Vaginal delivery is an identified risk factor for anal sphincter injury. Therefore, to identify postpartum injury, an antepartum value or a normal range is required. However, at present, the normal values of 3D manometry are not available for primigravida or pregnant mothers.

AIMS

Our study aims at describing normal values of 3D manometry in primigravida.

METHODS

We analyzed 3DARM data of 101 consecutive primigravid mothers in the third trimester. 3DARM was performed using the Given Imaging(®) ManoScan system.

RESULTS

The mean age was 24.7 (SD 5.1) years. All patients had a normal Cleveland Clinic Incontinence Score. The mean resting pressure (RP) was 87.02 (SD 18.43) mmHg and the maximum squeeze pressure (SP) was 179.21 (SD 52.96) mmHg. The mean length of the high-pressure zone (HPZ) was 3.67 (SD 0.52) cm. Mean volumes for initial rectal sensation, urge, and discomfort were 50.36 (± 25.57), 76.70 (± 35.17), and 143.40 (± 66.26) ml, respectively. The pressure asymmetry was highest in the lower anal sphincter and lowest in the mid-sphincter. There was a statistically significant relationship between the HPZ and RP (Pearson ρ -0.23, p = 0.01), height (Pearson ρ 0.22, p = 0.028), and weight (Pearson ρ 0.25, p = 0.012). There were no statistically significant correlations between age, height, or weight with RP, SP, or balloon fill volumes. The characteristic appearance of the normal RP and SP was clearly visualized in all patients.

CONCLUSIONS

Normal 3DARM values for Sri Lankan primigravid mothers have been established. These may be used as reference values by other investigators.

Management of chronic intractable constipation in children

BACKGROUND

Chronic intractable constipation (CIC) is a debilitating disease that is challenging to manage. Treatment options in children include medications, enemas, and surgical management in selected cases.

METHOD

We reviewed medical records of pediatric patients diagnosed as having CIC at Tufts Medical Center from 2005 to 2012. Demographic variables, diagnostic procedures, and medical and surgical outcomes were collected. Clinical outcome was defined using the Rome III criteria.

RESULTS

A total of 14 patients were included in the study (10 boys). The age range was 10 to 21 years. All of the patients had the diagnosis of CIC. Eleven patients had cecostomy placement. During the follow-up period, 10 patients underwent total abdominal colectomy with ileorectal anastomosis, 1 had total colectomy with ileostomy, and 1 had partial colectomy with colorectal anastomosis. Successful clinical outcome was reported in 7 patients with 3 patients reporting persistent fecal incontinence. Colonic motility studies were performed on 12 patients (colonic neuropathy in 11 patients and normal study in 1 patient). Defecography was consistent with isolated pelvic floor dysfunction in 1 patient, abnormal motility and anatomy in 1 patient, pelvic floor dysfunction and abnormal motility in 2 patients, and found abnormal motility only in 5. Defecography study was normal in 5 patients. All of the patients with abnormal colonic manometry underwent a surgical procedure.

CONCLUSIONS

Anorectal manometry, colonic manometry, and defecography help in understanding the pathophysiology of defecation disorders in children. The majority of patients with abnormal colonic manometry underwent TAC-IRA. There was no statistical correlation between individual investigations (anorectal manometry, colonic manometry, and defecography) with surgical intervention (P > 0.35). TAC-IRA may be safe and useful intervention in a subset of patients when other treatment options have failed.

Anorectal manometric parameters are influenced by gender and age in subjects with normal bowel function

PURPOSE

Anorectal manometry provides objective information about anorectal function, but its results depend on the examiner's skill, the type of equipment, and subject characteristics like age or gender. This single institution, prospective study was performed to investigate the effect of gender and age on the results of anorectal manometry.

METHODS

All included subjects completed a questionnaire to assess their bowel function. The survey included 13 validated questions (eight on constipation and five on incontinence) and was used to exclude subjects with pathological constipation or incontinence. Subjects with normal bowel function underwent anorectal manometry to measure anal sphincter length (ASL), maximum resting pressure (MRP), and maximum squeeze pressure (MSP), and the results were compared by gender and age.

RESULTS

The mean age of the 154 participants (94 male and 60 female) was 59.1 years. ASL was greater in men (4.23 vs. 3.85 cm, p < 0.001). MRP was not significantly different according to gender (p = 0.93), but MSP was higher in men (190.18 vs. 116.49 mmHg, p < 0.001). ASL did not correlate with age (p = 0.707). MRP was inversely related to age in both men (R (2) = 0.152, p < 0.001) and women (R (2) = 0.282, p < 0.001), and MSP only in women (R (2) = 0.210, p < 0.001).

CONCLUSIONS

Anorectal manometric parameters are influenced by gender and age. This should be taken into consideration when interpreting manometric readings in a clinical setting.

Three-dimensional high-resolution anorectal manometry in the diagnosis of paradoxical puborectalis syndrome compared with healthy adults: a retrospective study in 79 cases

OBJECTIVES

The aim of this study is to evaluate the three-dimensional anorectal pressure topography of normal healthy adults and patients with paradoxical puborectalis syndrome (PPS) using a novel three-dimensional high-resolution manometry (3D-HRM) of the anorectum.

METHODS

The 3D-HRM probe has a 6.4 cm long sensing segment that is composed of 256 independent pressure transducers around its circumference. It generates a 3D pressure topographic profile of the anorectum. We evaluated 41 women and 38 men with PPS (median age 52 years), and compared them with 37 women and 34 men who were healthy (median age 51 years). The three-dimensional anorectal pressure topography was evaluated at rest, and during squeeze, stimulated defecation, and balloon inflation.

RESULTS

Maximum resting pressure, mean resting pressure, high pressure zone length, and residual anal pressure were significantly higher in patients with PPS compared with healthy adults (P<0.01 each). The rectoanal pressure differential was significantly lower in the PPS patients compared with healthy adults (P<0.05). There was a characteristic purple high-pressure area in the posterior wall of the pressure cylinder of patients with PPS during stimulated defecation that was absent in healthy adults. The longest diameter and widest diameter of this purple high-pressure area were 1.71 ± 0.25 and 1.07 ± 0.14 cm. The maximum, mean, and minimum pressures of the posterior distal pressure zone were significantly higher in patients with PPS (270.1 ± 8.2, 152.7 ± 4.8, and 51.9 ± 2.7 mmHg, respectively) compared with healthy adults (168.5 ± 11.1, 88.0 ± 5.9, and 30.7 ± 2.8 mmHg, respectively) (P<0.01).

CONCLUSION

Using the 3D-HRM technique, the increase in the resting pressure and residual anal pressure and decrease in the rectoanal pressure differential in patients with PPS compared with healthy adults further indicated the mechanism of this disease. Unlike traditional manometry, the 3D-HRM technique could find, locate, and evaluate the scope and the pressure of the paradoxical contraction of puborectalis muscle, which further indicates the value of manometry in terms of diagnosis.

Normal values and pressure morphology for three-dimensional high-resolution anorectal manometry of asymptomatic adults: a study in 110 subjects

OBJECTIVES

The purpose of this study is to evaluate normal values and pressure morphology of three-dimensional high-resolution anorectal manometry (3D-HRM) in asymptomatic volunteers and to determine the relationship between objective measurable values, gender, and age.

PATIENTS AND METHODS

Anorectal pressures and rectal sensation were evaluated in 110 asymptomatic volunteers (46 females and 64 males) ranging in age from 18 to 80 years (median age, 52 years) in left lateral position by three-dimensional high-resolution manometry.

RESULTS

Maximum squeeze pressure, residual anal pressure, and intrarectal pressure were significantly higher in males compared to females (p < 0.05 each). Duration of sustained squeeze was significantly lower in males compared to females (p < 0.05). Maximum resting pressure, mean resting pressure, and maximum squeeze pressure were inversely correlated (r = -0.310, p < 0.01, r = -0.276, p < 0.01, and r = -0.198, p < 0.05) with age. The value of rectoanal pressure differential was -13.1 ± 5.8 mmHg which was negative during defecation. Overall variation coefficient in anorectal pressures ranged between 0.21 and 0.34.

CONCLUSION

This study establishes normal values for anorectal pressure by 3D-HRM in asymptomatic volunteers. There are significant gender differences concerning squeeze patterns. Increasing age is associated with lower maximum resting pressure, mean resting pressure, and maximum squeeze pressure. Normal characteristic pressure morphology of anorectum can be obtained at rest, during squeeze, and bear down as in defecation by 3D-HRM.

The effect of standard compared to enhanced instruction and verbal feedback on anorectal manometry measurements

BACKGROUND

Guidelines recommend instruction and motivation during anorectal manometry; however, its impact on findings has not been reported. This study assessed the effects of standard versus enhanced instruction and verbal feedback on the results of anorectal manometry.

METHODS

High-resolution manometry was performed by a solid-state catheter with 10 circumferential sensors at 6 mm separation across the anal canal and two rectal sensors. Measurements were acquired first with standard instruction and then with enhanced instruction and verbal feedback. On both occasions, squeeze pressure and duration during three voluntary contractions and intra-rectal pressure and recto-anal pressure gradient (RAPG) during three attempts at simulated defecation were assessed.

KEY RESULTS

A total of 70 consecutive patients (54 female; age 25-82 years) referred for investigation of fecal incontinence (n = 31), constipation, and related disorders of defecation (n = 39) were studied. Enhanced instruction and verbal feedback increased maximum squeeze pressure (Δ10 ± 28.5 mmHg; P < 0.0038) and duration of contraction (Δ3 ± 4 s; P < 0.0001). During simulated defecation, it increased intra-rectal pressure (Δ12 ± 14 mmHg; P < 0.003) and RAPG (Δ11 ± 20 mmHg; P < 0.0001). Using standard diagnostic criteria, the intervention changed manometric findings from locally validated 'pathologic' to 'normal' values in 14/31 patients with incontinence and 12/39 with disorders of defecation.

CONCLUSIONS & INFERENCES

Enhanced instruction and verbal feedback significantly improved voluntary anorectal functions and resulted in a clinically relevant change of manometric diagnosis in some patients. Effective explanation of procedures and motivation during manometry is required to ensure consistent results and to provide an accurate representation of patient ability to retain continence and evacuate stool.

Normative values in anorectal manometry using microtip technology: a cohort study in 172 subjects

PURPOSE

The aims of this study were to obtain normative values in resting/squeeze pressure and surface electromyography (s-EMG) in anorectal manometry using microtip technology and to determine the relationship between objective measurable values, gender and age in a cohort with no anorectal disorders.

METHODS

One hundred seventy-two white central European subjects (106 males/66 females) were recruited prior to left colonic or upper rectal surgery and studied by anorectal rapid pull-through manometry with a microtip transducer system and endoanal s-EMG using a bipolar plug electrode. s-EMG patterns were determined as plateau, peak and decrease by a blinded co-investigator. Objective measurable sphincter pressures and s-EMG values were correlated with gender, age and s-EMG patterns.

RESULTS

Squeeze pressure, voluntary pressure as well as s-EMG amplitude and its area under the curve were significantly lower in women compared to men (p < 0.001 each), whereas resting pressure showed no gender differences. s-EMG patterns were strongly influenced by gender. Male patients showed significantly more plateau pattern whereas peak pattern was significantly more often in women. In both genders, the peak pattern was associated with significant higher squeeze pressures. In all measurements, we found considerable inter-individual variations being higher in elder patients. There was no manometric parameter correlating with age.

CONCLUSIONS

Gender is the strongest factor influencing objective measurable manometric data for healthy men and women. There are significant gender differences concerning squeeze patterns. All manometric values should be interpreted in the context of gender and of methodology used. Large prospective cohort studies matched for gender are necessary to clarify the effect of ageing on anal sphincter strength.

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.

Faecal incontinence in men

AIM

A few studies have specifically addressed faecal incontinence (FI) in men. We sought to describe patterns of male FI, assess treatment outcome and compare some aspects of FI between men and women, including quality of life.

METHOD

Prospectively recorded data on 85 consecutive male patients evaluated for FI at our pelvic floor centre in 2004 and 2005 were reviewed and compared with a cohort of 408 female patients. Treatment outcome in men was assessed by questionnaire.

RESULTS

The aetiology of FI could be determined in 61 (72%) men and was most commonly related to anal surgery (n = 23), prostate cancer therapy (n = 9) and spinal injury (n = 9). Eight patients had idiopathic soiling only. Mean age, Fecal Incontinence Severity Index (FISI) and quality of life scores were similar between men and women. Maximal mean resting pressure (MRP) and squeeze pressure (MSP) were on average higher in men than in women [MRP 56.9 (26.2) vs 40 (20.4) mmHg; P < 0.0001]; [MSP 98.1 (67.3) vs 39.4 (28.5) mmHg; P < 0.0001]. Sphincter defects involved the external sphincter less often in men (35 vs 70%, P = 0.004). Differences in faecal incontinence quality of life (FIQL) and SF-36 scores between men and women were minimal. After a median follow up of 2 years, complete resolution of symptoms was reported in 17% and improvement of symptoms in another 48% of men.

CONCLUSION

Although physiological and anatomical features of FI differ between men and women, its severity and impact on quality of life are similar. External sphincter defects are less common in men; hence, direct sphincter repair is less frequently an option. Evaluation and treatment improves symptoms in more than half of male patients.