Prospective assessment of biofeedback for the treatment of paradoxical puborectalis contraction

Expert consensus document: Advances in the evaluation of anorectal function

Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.

Functional Disorders of Constipation: Paradoxical Puborectalis Contraction and Increased Perineal Descent

Paradoxical puborectalis contraction (PPC) and increased perineal descent (IPD) are subclasses of obstructive defecation. Often these conditions coexist, which can make the evaluation, workup, and treatment difficult. After a thorough history and examination, workup begins with utilization of proven diagnostic modalities such as cinedefecography and anal manometry. Advancements in technology have increased the surgeon's diagnostic armamentarium. Biofeedback and pelvic floor therapy have proven efficacy for both conditions as first-line treatment. In circumstances where PPC is refractory to biofeedback therapy, botulinum toxin injection is recommended. Historically, pelvic floor repair has been met with suboptimal results. In IPD, surgical therapy now is directed toward the potentially attendant abnormalities such as rectoanal intussusception and rectal prolapse. When these associated abnormalities are not present, an ostomy should be considered in patients with IPD as well as medically refractory PPC.

The Role of Biofeedback Therapy in Functional Proctologic Disorders

Background and Aims:

The question which patients with functional proctologic disorders truly benefit from the biofeedback has not been equivocally resolved. The aim of this study was to assess our results of biofeedback therapy in patients with anal incontinence or constipation.

Material and Methods:

Fifty-two consecutive patients who were treated with biofeedback therapy between January 1998 and March 2002 were studied. Data was collected from our proctologic database.

Results:

Of the twenty-two patients with anal incontinence who underwent biofeedback therapy during the study period, twenty patients had incontinence affecting quality of life. Twelve patients (60 percent) benefited from biofeedback as judged by improvement of incontinence symptoms affecting quality of life; all four patients with partial sphincter defects, three out of four patients after secondary repair, three out of five patients with persistent incontinence after rectal prolapse surgery and two out of seven patients having idiopathic incontinence. Of the thirty patients who underwent biofeedback therapy for constipation, twenty-five had intractable symptoms of constipation. Constipation resolved in sixteen patients (64 percent); in thirteen out of nineteen (68 percent) of those with pelvic floor dysfunction (PFD) and in three out of six (50 percent) having combined PFD and slow transit constipation. In patients with PFD constipation was resolved in ten out of thirteen patients (77 percent) with anismus but in only three out of six (50 percent) having other causes.

Conclusions:

Biofeedback therapy improves incontinence after sphincter repairs and in patients with partial external sphincter defects, but does not improve idiopathic incontinence. Biofeedback is also effective in patients with constipation, especially when anismus is the only cause for symptoms of constipation and difficult evacuation.

Clinical and investigative assessment of constipation: a study from a referral center in western India

INTRODUCTION

Constipation may be primary or secondary. Pathophysiologic subtypes of primary constipation are dyssynergic defecation (DD), slow (STC), and normal transit constipation (NTC). Clinical subtypes are functional constipation (FC) and constipation predominant IBS (C-IBS).

AIMS

The objectives of this paper are to study the clinical profile, categorize and compare various subtypes of primary constipation, and to assess the success of biofeedback therapy (BFT) in a non-randomized, uncontrolled open-label study among patients with DD.

MATERIAL AND METHODS

Consecutive constipation patients (April 2011 to December 2012) were evaluated. Patients <18 years and secondary constipation were excluded. FC and C-IBS were classified by Rome III module. All patients, after excluding secondary constipation, underwent anorectal manometry (ARM) with balloon expulsion test and colon transit study (CTS). Patients with DD were given BFT.

RESULTS

Out of 128 patients, 23 %, 58 %, and 19 % had secondary constipation, FC, and C-IBS, respectively. Ninety-nine patients had primary constipation. Among those with primary constipation mean age was 53.5 (21-86) years, (77 % males). Forty-six, 15, and 40 had NTC, STC, and DD, respectively. Out of those with DD, 34 had paradoxical anal contraction and 6 had impaired rectal propulsion. FC and C-IBS were clinically and pathophysiologically similar except for abdominal pain. Patients with DD were more likely to have history of finger evacuation, straining, incomplete evacuation, sensation of anorectal obstruction than no DD. Sixty-nine percent of the patients with STC had ≤3 stools/week compared to 37 % with NTC (p-value 0.018). Thirty out of 40 (75 %) patients with DD underwent BFT but 20 completed ≥4 sessions. Seventy percent with ≥4 sessions had improved complete spontaneous bowel movements (CSBM).

CONCLUSION

NTC was the most common subtype of primary constipation. Symptoms of finger evacuation, sensation of anorectal obstruction, incomplete evacuation, and straining were more prevalent in DD. ARM and CTS could easily identify patients with DD and STC.

Biofeedback for treatment of chronic idiopathic constipation in adults

BACKGROUND

Biofeedback therapy has been used to treat the symptoms of people with chronic constipation referred to specialist services within secondary and tertiary care settings. However, different methods of biofeedback are used within different centres and the magnitude of suggested benefits and comparable effectiveness of different methods of biofeedback has yet to be established.

OBJECTIVES

To determine the efficacy and safety of biofeedback for the treatment of chronic idiopathic (functional) constipation in adults.

SEARCH METHODS

We searched the following databases from inception to 16 December 2013: CENTRAL, the Cochrane Complementary Medicine Field, the Cochrane IBD/FBD Review Group Specialized Register, MEDLINE, EMBASE, CINAHL, British Nursing Index, and PsychINFO. Hand searching of conference proceedings and the reference lists of relevant articles was also undertaken.

SELECTION CRITERIA

All randomised trials evaluating biofeedback in adults with chronic idiopathic constipation were considered for inclusion.

DATA COLLECTION AND ANALYSIS

The primary outcome was global or clinical improvement as defined by the included studies. Secondary outcomes included quality of life, and adverse events as defined by the included studies. Where possible, we calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes and the mean difference (MD) and 95% CI for continuous outcomes. We assessed the methodological quality of included studies using the Cochrane risk of bias tool. The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria.

MAIN RESULTS

Seventeen eligible studies were identified with a total of 931 participants. Most participants had chronic constipation and dyssynergic defecation. Sixteen of the trials were at high risk of bias for blinding. Attrition bias (4 trials) and other potential bias (5 trials) was also noted. Due to differences between study populations, the heterogeneity of the different samples and large range of different outcome measures, meta-analysis was not possible. Different effect sizes were reported ranging from 40 to 100% of patients who received biofeedback improving following the intervention. While electromyograph (EMG) biofeedback was the most commonly used, there is a lack of evidence as to whether any one method of biofeedback is more effective than any other method of biofeedback. We found low or very low quality evidence that biofeedback is superior to oral diazepam, sham biofeedback and laxatives. One study (n = 60) found EMG biofeedback to be superior to oral diazepam. Seventy per cent (21/30) of biofeedback patients had improved constipation at three month follow-up compared to 23% (7/30) of diazepam patients (RR 3.00, 95% CI 1.51 to 5.98). One study compared manometry biofeedback to sham biofeedback or standard therapy consisting of diet, exercise and laxatives. The mean number of complete spontaneous bowel movements (CSBM) per week at three months was 4.6 in the biofeedback group compared to 2.8 in the sham biofeedback group (MD 1.80, 95% CI 1.25 to 2.35; 52 patients). The mean number of CSBM per week at three months was 4.6 in the biofeedback group compared to 1.9 in the standard care group (MD 2.70, 95% CI 1.99 to 3.41; 49 patients). Another study (n = 109) compared EMG biofeedback to conventional treatment with laxatives and dietary and lifestyle advice. This study found that at both 6 and 12 months 80% (43/54) of biofeedback patients reported clinical improvement compared to 22% (12/55) laxative-treated patients (RR 3.65, 95% CI 2.17 to 6.13). Some surgical procedures (partial division of puborectalis and stapled transanal rectal resection (STARR)) were reported to be superior to biofeedback, although with a high risk of adverse events in the surgical groups (wound infection, faecal incontinence, pain, and bleeding that required further surgical intervention). Successful treatment, defined as a decrease in the obstructed defecation score of > 50% at one year was reported in 33% (3/39) of EMG biofeedback patients compared to 82% (44/54) of STARR patients (RR 0.41, 95% CI 0.26 to 0.65). For the other study the mean constipation score at one year was 16.1 in the balloon sensory biofeedback group compared to 10.5 in the partial division of puborectalis surgery group (MD 5.60, 95% CI 4.67 to 6.53; 40 patients). Another study (n = 60) found no significant difference in efficacy did not demonstrate the superiority of a surgical intervention (posterior myomectomy of internal anal sphincter and puborectalis) over biofeedback. Conflicting results were found regarding the comparative effectiveness of biofeedback and botulinum toxin-A. One small study (48 participants) suggested that botulinum toxin-A injection may have short term benefits over biofeedback, but the relative effects of treatments were uncertain at one year follow-up. No adverse events were reported for biofeedback, although this was not specifically reported in the majority of studies. The results of all of these studies need to be interpreted with caution as GRADE analyses rated the overall quality of the evidence for the primary outcomes (i.e. clinical or global improvement as defined by the studies) as low or very low due to high risk of bias (i.e. open label studies, self-selection bias, incomplete outcome data, and baseline imbalance) and imprecision (i.e. sparse data).

AUTHORS' CONCLUSIONS

Currently there is insufficient evidence to allow any firm conclusions regarding the efficacy and safety of biofeedback for the management of people with chronic constipation. We found low or very low quality evidence from single studies to support the effectiveness of biofeedback for the management of people with chronic constipation and dyssynergic defecation. However, the majority of trials are of poor methodological quality and subject to bias. Further well-designed randomised controlled trials with adequate sample sizes, validated outcome measures (especially patient reported outcome measures) and long-term follow-up are required to allow definitive conclusions to be drawn.

Excellent response rate of anismus to botulinum toxin if rectal prolapse misdiagnosed as anismus ('pseudoanismus') is excluded

AIM

Anismus causes obstructed defecation as a result of inappropriate contraction of the puborectalis/external sphincter. Proctographic failure to empty after 30 s is used as a simple surrogate for simultaneous electromyography/proctography. Botulinum toxin is theoretically attractive but efficacy is variable. We aimed to evaluate the efficacy of botulinum toxin to treat obstructed defecation caused by anismus.

METHOD

Botulinum toxin was administered, under local anaesthetic, into the puborectalis/external sphincter of patients with proctographic anismus. Responders (resolution followed by recurrence of obstructed defecation over a 1- to 2-month period) underwent repeat injection. Nonresponders underwent rectal examination under anaesthetic (EUA). EUA-diagnosed rectal prolapse was graded using the Oxford Prolapse Grade 1-5.

RESULTS

Fifty-six patients were treated with botulinum toxin. Twenty-two (39%) responded initially and 21/22 (95%) underwent repeat treatment. At a median follow up of 19.2 (range, 7.0-30.4) months, 20/21 (95%) had a sustained response and required no further treatment. Isolated obstructed defecation symptoms (OR = 7.8, P = 0.008), but not proctographic or physiological factors, predicted response on logistic regression analysis. In 33 (97%) of 34 nonresponders, significant abnormalities were demonstrated at EUA: 31 (94%) had a grade 3-5 rectal prolapse, one had internal anal sphincter myopathy and one had a fissure. Exclusion of these alternative diagnoses revised the initial response rate to 96%.

CONCLUSION

Simple proctographic criteria overdiagnose anismus and underdiagnose rectal prolapse. This explains the published variable response to botulinum toxin. Failure to respond should prompt EUA seeking undiagnosed rectal prolapse. A response to an initial dose of botulinum toxin might be considered a more reliable diagnosis of anismus than proctography.

Outcome of biofeedback therapy in dyssynergic defecation patients with and without irritable bowel syndrome

AIM

The Rome II and III diagnostic criteria for dyssynergic defecation require the exclusion of irritable bowel syndrome (IBS). To prospectively study whether the presence of IBS affects the outcome of biofeedback therapy in dyssynergic defecation patients.

METHODS

Consecutive patients with dyssynergic defecation underwent biofeedback therapy. Dyssynergic defecation was diagnosed based on symptoms, anorectal manometries, balloon expulsion tests, and colonic transit studies. The defecation dynamics and balloon expulsion time were evaluated at the end of the biofeedback therapy in all patients. IBS symptoms were graded before and 4 weeks after the biofeedback therapy using a 4-point Likert scale. Failure of the biofeedback therapy was defined as <50% improvement of constipation symptoms, which were evaluated using a 10 cm long visual analog scale before and 4 weeks after biofeedback therapy.

RESULTS

Fifty patients completed the study. The biofeedback therapy was successful in 30 patients. Twenty-nine patients fulfilled the Rome II criteria for IBS. Patients with or without IBS demonstrated similar responses to the biofeedback therapy (16 of 29 vs. 14 of 21, P>0.05). The disappearance of IBS symptoms was observed more frequently in patients with an improved defecation index compared with those with no improvement (8 of 12 vs 4 of 17, P<0.05). A high pretreatment constipation symptom score, a high rectal sensory threshold, and a delayed colonic transit time were associated with a poor treatment outcome.

CONCLUSIONS

The presence of IBS in dyssynergic defecation did not affect the outcome of biofeedback therapy. In addition, treating dyssynergic defecation patients with IBS by biofeedback therapy improved both constipation and IBS symptoms.

Pelvic floor dyssynergia: efficacy of biofeedback training

BACKGROUND AND STUDY AIMS

Paradoxical contraction of the pelvic floor during attempts to defaecate is described as pelvic floor dyssynergia (anismus). It is a behavioural disorder (no associated morphological or neurological abnormalities); consequently, biofeedback training has been recommended as a behavioural therapy for such a disorder. The aim of the present study was to evaluate long-term satisfaction of patients diagnosed with pelvic floor dyssynergia after biofeedback.

PATIENTS AND METHODS

Sixty patients (35 females and 25 males) with a mean age of 30±12years and a 4year duration of constipation were included. Forty-five patients had normal colonic transit and 15 patients had slow colonic transit. History, physical examination and barium enema were done to exclude constipation secondary to organic causes. Colonic and pelvic floor functions (colon-transit time, anorectal manometry, EMG and defaecography) were performed before and after biofeedback treatments. Patients were treated on a weekly basis with an average of (6±2) sessions.

RESULTS

At the end of sessions, 55 out of 60 patients (91.6%) reported a subjectively overall improvement. Symptoms of dyschezia were reported less frequently after biofeedback. Age and gender were not predictive factors of outcome. No symptoms at initial assessment were predictive for patient's satisfaction but the only factor of predictive value was the diagnosis of anismus and the motivated patient who wanted to continue the sessions.

CONCLUSION

Biofeedback remains a morbidity free, low-cost and effective outpatient therapy for well-motivated patients complaining of functional constipation and diagnosed as pelvic floor dyssynergia.

Comparative study between surgical and non-surgical treatment of anismus in patients with symptoms of obstructed defecation: a prospective randomized study

PURPOSE

This study came to compare the results of biofeedback retraining biofeedback (BFB), botulinum toxin botulinum type A (BTX-A) injection and partial division of puborectalis (PDPR) in the treatment of anismus patients.

PATIENTS AND METHODS

Consecutive patients treated for anismus fulfilled Rome II criteria for functional constipation at our institution were evaluated for inclusion. Participants were randomly allocated to receive BFB, BTX-A injection, and PDPR. All patients underwent anorectal manometry, balloon expulsion test, defecography, and electromyography activity of the anal sphincter. Follow up was conducted weekly in the first month then monthly for about 1 year. Study variables included clinical improvement, patient satisfaction, and objective improvement.

RESULTS

Sixty patients with anismus were randomized and completed the study. The groups differed significantly regarding clinical improvement at 1 month (50% for BFB, 75%BTX-A injection, and 95% for PDPR, P = 0.006) and differences persisted at 1 year (30% for BFB, 35%BTX-A injection, and 70% for PDPR, P = 0.02). Constipation score of the patients significantly improved postPDPR and BTX-A injection. Manometric relaxation was achieved significantly in the three groups.

CONCLUSION

Biofeedback retraining has a limited therapeutic effect, BTX-A injection seems to be successful for temporary treatment but PDPR is found to be an effective with lower morbidity in contrast to its higher success rate in treating anismus.

Predictive capability of anorectal physiologic tests for unfavorable outcomes following biofeedback therapy in dyssynergic defecation

The purpose of this study is to evaluate the predictive capability of anorectal physiologic tests for unfavorable outcomes prior to the initiation of biofeedback therapy in patients with dyssynergic defecation. We analyzed a total of 80 consecutive patients who received biofeedback therapy for chronic idiopathic functional constipation with dyssynergic defecation. After classifying the patients into two groups (responders and non-responders), univariate and multivariate analyses were performed to determine the predictors associated with the responsiveness to biofeedback therapy. Of the 80 patients, 63 (78.7%) responded to biofeedback therapy and 17 (21.3%) did not. On univariate analysis, the inability to evacuate an intrarectal balloon (P=0.028), higher rectal volume for first, urgent, and maximal sensation (P=0.023, P=0.008, P=0.007, respectively), and increased anorectal angle during squeeze (P=0.020) were associated with poor outcomes. On multivariate analysis, the inability to evacuate an intrarectal balloon (P=0.018) and increased anorectal angle during squeeze (P=0.029) were both found to be independently associated with a lack of response to biofeedback therapy. Our data show that the two anorectal physiologic test factors are associated with poor response to biofeedback therapy for patients with dyssynergic defecation. These findings may assist physicians in predicting the responsiveness to therapy for this patient population.

Paradoxical puborectalis contraction and increased perineal descent

Paradoxical puborectalis contraction and increased perineal descent are two forms of functional constipation presenting as challenging diagnostic and treatment dilemmas to the clinician. In the evaluation of these disorders, the clinician should take special care to exclude anatomic disorders leading to constipation. Physical examination is supplemented by additional diagnostic modalities such as cinedefecography, electromyography, manometry, and pudendal nerve tefninal motor latency. Generally, these investigations should be used in combination with the two playing the more relied upon techniques. Treatment is typically conservative with biofeedback playing a principal role with favorable results when patient compliance is emphasized. When considering paradoxical puborectalis contraction, failure of biofeedback is usually augmented with botulinum toxin injection. Increased perineal descent is generally treated with biofeedback and perineal support maneuvers. Surgery has little or no role in these conditions. The patient who insists on surgical intervention for either of these two conditions should be offered a stoma.

Chronic constipation: overview and challenges

Despite its high prevalence and cost implications, our understanding of the pathophysiology of constipation remains primitive, and available therapies have limited efficacy. The purpose of this supplement is to address critically the reasons for the current lack of understanding and to propose avenues of future research to address these deficiencies.

Comparative study between botulinum toxin injection and partial division of puborectalis for treating anismus

OBJECTIVES

The objective of this study was to compare the results of partial division of puborectalis (PDPR) versus local botulinum toxin type A (BTX-A) injection in treating patients with anismus.

PATIENTS AND METHODS

This prospective randomized study included 30 male patients suffering from anismus. Diagnosis was made by clinical examination, barium enema, colonoscopy, colonic transit time, anorectal manometry, balloon expulsion test, defecography, and electromyography. Patients were randomized into: group I which included 15 patients who were injected with BTX-A and group II which included 15 patients who underwent bilateral PDPR. Follow-up was conducted for about 1 year. Improvement was considered when patients returned to their normal habits.

RESULTS

BTX-A injection achieved initial success in 13 patients (86.7%). However, long-term success persisted only in six patients (40%). This was in contrast to PDPR which achieved initial success in all patients (100%) with a long-term success in ten patients (66.6%). Recurrence was observed in seven patients (53.8%) and five patients (33.4%) following BTX-A injection and PDPR, respectively. Minor degrees of incontinence were confronted in two patients (13.3%) following PDPR.

CONCLUSION

BTX-A injection seems to be successful for temporary treatment of anismus.

Successful physical therapy for constipation related to puborectalis dyssynergia improves symptom severity and quality of life

PURPOSE

This study evaluated symptom severity and quality of life in patients with puborectalis dyssynergia before and after physical therapy.

METHODS

Twenty-two patients with puborectalis dyssynergia were prospectively enrolled into a multidisciplinary program for the treatment of pelvic floor and bowel disorders in this case series. All patients had functional constipation and evidence of puborectalis dyssynergia. Physical therapy and behavioral counseling were offered to all. Patients completed the Patient Health Questionnaire, the Patient-Assessment of Constipation Symptom Questionnaire, and the Patient-Assessment of Constipation Quality of Life Questionnaire.

RESULTS

Sixteen patients successfully completed the program. Symptom severity decreased after physical therapy (2.1 +/- 0.7 vs. 1.3 +/- 0.9, P = 0.007). Quality of life also improved significantly (2.6 +/- 0.8 vs. 1.5 +/- 1.0, P = 0.007). Patients reported less physical discomfort, fewer worries/concerns, and indicated satisfaction with treatment. The difference in symptom severity was highly correlated with improvement in quality of life (r = 0.7, P = .005).

CONCLUSIONS

Successful physical therapy for patients with puborectalis dyssynergia is associated with improvements in constipation-related symptoms and in quality of life.

Systematic review of randomized controlled trials of the effectiveness of biofeedback for pelvic floor dysfunction

BACKGROUND

Pelvic floor dysfunction (PFD) is a type of functional constipation. The effectiveness of biofeedback as a treatment remains unclear.

METHODS

A systematic review of all randomized controlled trials evaluating the effectiveness of biofeedback in adults with PFD was carried out. All online databases from 1950 to 2007 were searched. This was supplemented by hand searching references of retrieved articles.

RESULTS

Seven trials fulfilled the inclusion criteria. Three compared biofeedback with non-biofeedback treatments and four compared different biofeedback modalities. Electromyography feedback was most widely utilized. The trials were heterogeneous with varied inclusion criteria, treatment protocols and definitions of success. Most had methodological limitations. Quality of life and psychological morbidity were assessed rarely. Meta-analysis of the studies involving any form of biofeedback compared with any other treatment suggested that biofeedback conferred a sixfold increase in the odds of treatment success (odds ratio 5.861 (95 per cent confidence interval 2.175 to 15.794); random-effects model).

CONCLUSION

Although biofeedback is the recommended treatment for PFD, high-quality evidence of effectiveness is lacking. Meta-analysis of the available evidence suggests that biofeedback is the best option, but well designed trials that take into account quality of life and psychological morbidity are needed.

Slow-transit constipation: evaluation and treatment

Slow-transit constipation is characterized by delay in transit of stool through the colon, caused by either myopathy or neuropathy. The severity of constipation is highly variable, but may be severe enough to result in complete cessation of spontaneous bowel motions. Diagnostic tests to assess colonic transit include radiopaque marker or radioisotope studies, and intraluminal tests (colonic and small bowel manometry). Most patients with functional constipation respond to laxatives, but a small proportion are resistant to this treatment. In some patients biofeedback is helpful although the mechanism by which this works is still uncertain. Other patients are resistant to all conservative modes of therapy and require surgical intervention. Extensive clinical and physiological preoperative assessment of patients with slow colonic transit is essential before considering surgery, including an assessment of small bowel motility and identification of coexistent obstructed defecation. The psychological state of the patient should always be taken into account. When surgery is indicated, subtotal colectomy and ileorectal anastomosis is the operation of choice. Segmental colonic resection has been reported in a few patients, but methods of identifying the affected segment need to be developed further. Less invasive and reversible surgical options include laparoscopic ileostomy, antegrade colonic enema and sacral nerve stimulation.

Treatment strategies in obstructed defecation and fecal incontinence

Obstructed defecation (OD) and fecal incontinence (FI) are challenging clinical problems, which are commonly encountered in the practice of colorectal surgeons and gastroenterologists. These disorders socially and psychologically distress patients and greatly impair their quality of life. The underlying anatomical and pathophysiological changes are complex, often incompletely understood and cannot always be determined. As a consequence, many medical, surgical, and behavioral approaches have been described, with no panacea. Over the past decade, advances in an understanding of these disorders together with rational and similar methods of evaluation in anorectal physiology laboratories (ARP), radiology studies, and new surgical techniques have led to promising results. In this brief review, we discuss treatment strategies and recent updates on clinical and therapeutic aspects of obstructed defecation and fecal incontinence.

Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus)

Although 30-50% of constipated patients exhibit dyssynergia, an optimal method of diagnosis is unclear. Recently, consensus criteria have been proposed but their utility is unknown. To examine the diagnostic yield of colorectal tests, reproducibility of manometry and utility of Rome II criteria. A total of 100 patients with difficult defecation were prospectively evaluated with anorectal manometry, balloon expulsion, colonic transit and defecography. Fifty-three patients had repeat manometry. During attempted defecation, 30 showed normal and 70 one of three abnormal manometric patterns. Forty-six patients fulfilled Rome criteria and showed paradoxical anal contraction (type I) or impaired anal relaxation (type III) with adequate propulsion. However, 24 (34%) showed impaired propulsion (type II). Forty-five (64%) had slow transit, 42 (60%) impaired balloon expulsion and 26 (37%) abnormal defecography. Defecography provided no additional discriminant utility. Evidence of dyssynergia was reproducible in 51 of 53 patients. Symptoms alone could not differentiate dyssynergic subtypes or patients. Dyssynergic patients exhibited three patterns that were reproducible: paradoxical contraction, impaired propulsion and impaired relaxation. Although useful, Rome II criteria may be insufficient to identify or subclassify dyssynergic defecation. Symptoms together with abnormal manometry, abnormal balloon expulsion or colonic marker retention are necessary to optimally identify patients with difficult defecation.

Categorization of dysmotility in patients with chronic constipation and its significance for management

BACKGROUND

Chronic constipation is a common gastrointestinal symptom with different patterns of dysmotility for which there is not one simple and effective diagnostic method for categorization. The present study assessed the diagnostic method used in patients with chronic constipation and its significance for clinical management.

METHODS

The study group comprised 210 consecutive patients with chronic constipation who underwent history, digital anorectal examination (DARE), gastrointestinal transit test (GITT) and anorectal manometry (ARM) to determine the pattern of dysmotility. Symptoms and the examinations were summarized for establishing the diagnostic method and evaluation of the role of the examinations.

RESULTS

Outlet obstructive constipation (OOC), slow transit constipation (STC) and mixed constipation (MC) accounted for 50.8%, 10.2% and 39.0% of cases, respectively. The stool was harder in STC or MC than in OOC (P = 0.036). The presence of a paradoxical inverse contraction of anal sphincter when straining to defecate during DARE or ARM was significant for the diagnosis of OOC (P < 0.001). The distribution of the residual markers on abdominal plain film after 48 h GITT was significant for the diagnosis of STC (P < 0.001). The sensitivity of DARE, GITT and ARM was 82.5%, 89.1% and 94.4%, and specificity was 95.2%, 87.9% and 82.6%, respectively. Clinical management was modified in 69.5% of patients after categorizing the constipation pattern.

CONCLUSIONS

The symptoms, DARE, GITT and ARM are effective methods of evaluating the dysmotility patterns in patients with chronic constipation. DARE and ARM could improve the diagnostic rate of OOC, and GITT assists in diagnosis of STC. Proper categorization of the dysmotility pattern is important for the clinical management of chronic constipation.

Effects of biofeedback training by EMG on patients with chronic functional constipation

AIM: To study characteristics of anorectal pressure, EMG activity and effect of biofeedback training system on patient with chronic functional constipation (CFC).

METHODS: Anorectal manometry was carried out in 144 cases of CFC by a monitor system (liquid-phase type) and Biolab dynamics parameter before and after the biofeedback training. 20 healthy individuals were taken as control.

RESULTS: Compared with controls, CFC patients showed slightly lower anal quiesent pressure (P>0.05), lower anorectal sphincteric squeezing pressure (15.7±1.4 vs 12.7± 1.4) (P < 0.01), higher rectal defection volume thresholds and higher rectal maximum talerable volume thresholds (12±6.2 vs 14.9±6.6; 29.3±6.8 vs 36.0±7.3) (P < 0.01; P < 0.01); EMG assessments showed that 100% patients with CFC had the contradictory movement between the pelvic floor muscle (PFM) and abdominal anterior oblique muscle (AAOM). The movement extent of the PFM rose from 5.3±2.8 to 10.2±2.8 under quiet state (P < 0.01), and AAOM reduced from 34.4±5.2 to 30.8±4.9 (P < 0.01); All the abnormalities significantly improved with Orion PC/ 12 m EMG biofeedback training therapy. After biofeedback training therapy, symptoms of CFC patients were improved with efficient rate of 84.03%; With increase of the treatment time and shortenning of the interval and assistant training, the curative efficacy rose and the recurrence rate reduced (78.8% vs 91.7%; 69.2% vs 92.8%) (P < 0.05; P < 0.05).

CONCLUSION: CFC patients have abnormal anorectal pressure, sensation threshold and unusual anus electric activities. Biofeedback training therapy can improve the above-mentioned indexes and is effective in 84.03% of the patients. The relatively intensive long-time training can improve the curative rate in a short period, and family assistant training can reduce the recurrance rate of the disease.

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Chronic idiopathic slow transit constipation: pathophysiology and management

OBJECTIVE

Patients with idiopathic slow-transit constipation comprise a small proportion of the total population complaining of constipation. The purpose of this review is to present an update of pathophysiology of this disorder and its application in clinical management.

METHODS

Medline was used to search English language articles published up to the end of September 2002 on the subject of slow-transit constipation.

RESULTS AND CONCLUSIONS

Patients with idiopathic slow-transit constipation can be divided into 2 subgroups: 1. patients with normal proximal gastrointestinal motility and with onset of constipation in connection with childbirth or pelvic surgery. This subgroup may benefit from consideration of surgical treatment; 2. patients who have a dysfunctional enteric nervous/neuroendocrine system and exhibit colonic dysmotility as part of a generalised gastrointestinal dysmotility. Surgical approach in this subgroup seems to be unhelpful and medical treatment appears to be a better approach.

Obstructed defecation

BACKGROUND

In the last decade our understanding of pelvic floor function and dysfunction has improved significantly. A more rational diagnostic and therapeutic approach is now possible for the group of patients with constipation due to obstructed defecation (OD).

METHODS

The review is based on a literature search using the PubMed database focusing mainly on recent literature addressing the subject.

RESULTS

Obstructed defecation occurs in about 7% of the adult population. Different pathophysiological mechanisms, either functional or anatomical, eventually lead to OD. Different tests (defecography, balloon evacuation test, manometry, electromyography, colonic transit time measurementmanometry) play an important role to quantify the problem. These tests are not without problems as abnormal results are also found in asymptomatic controls. Also, there is poor agreement between different tests and a poor correlation with symptomatology. Thus, for most syndromes conservative treatment including biofeedback is appropriate. Surgery can yield excellent results in selected cases.

CONCLUSION

Validation of scoring systems and quantitative tests is still needed. More uniform and strict criteria for anismus should be applied to make therapeutic approaches comparable. Appropriate selection of patients for surgery is the key to success.

Pilot study of subtotal colectomy with antiperistaltic cecoproctostomy for the treatment of chronic slow-transit constipation

PURPOSE

Functional results of total colectomy with ileorectal anastomosis for the treatment of chronic constipation caused by colonic inertia are often considered unsatisfactory because of the frequency of postoperative diarrhea and the high rate of postoperative small-bowel obstruction. Patients affected by severe colonic inertia underwent a subtotal colectomy with a novel antiperistaltic cecorectal anastomosis. The aim of the study was to assess the functional results after preservation of the cecorectal junction.

METHODS

Eight females affected by isolated colonic inertia and two females with both paradoxical puborectalis contraction and colonic inertia, of a median age of 40 years, underwent subtotal colectomy with antiperistaltic cecorectal anastomosis. Before antiperistaltic cecorectal anastomosis all ten patients were laxative-dependant, with a mean bowel frequency of ten days; eight of them (80 percent) had distention, seven (70 percent) bloating, and three (30 percent) abdominal pain.

RESULTS

There was no mortality or major postoperative morbidity. One month after antiperistaltic cecorectal anastomosis, bowel frequency was a mean of 2.2 (range, 1-4) per day, with a semiliquid stool consistency. After one year, bowel frequency was a mean of 1.3 (range, 0.5-3) per day, with a solid stool consistency; the same results were recorded at last follow-up. Although no patients used antidiarrheal medicine, laxatives continued to be used by both patients with paradoxical puborectalis contraction. All ten (100 percent) of the patients reported a good or improved quality of life.

CONCLUSION

This preliminary experience seems to show that antiperistaltic cecorectal anastomosis is safe and effective for patients with colonic inertia. It results in prompt and prolonged relief from constipation for patients with isolated colonic inertia.

Electromyography of the pelvic floor musculature in the assessment of obstructed defecation symptoms

PURPOSE

The purpose of this study was to use electromyography to examine the behavior of the external sphincter, puborectalis muscle, and pubococcygeus muscle during attempted defecation in patients with symptoms of obstructed defecation and in normal subjects to highlight differences of clinical significance.

METHODS

A total of 35 patients (31 females) aged 20 to 80 (mean, 53.7 +/- 13.3) years with unprepared bowel who had normal colon transit time and obstructed defecation symptoms and 12 voluntary control subjects (7 females) aged 23 to 68 (mean, 48 +/- 11.5) years underwent an electromyography evaluation of the activity of the external sphincter, puborectalis muscle, and pubococcygeus muscle during attempted defecation. The patients were also examined in separate sessions with defecography and anal manometry.

RESULTS

During attempted defecation, puborectalis muscle and external sphincter always reacted in the same manner. When evaluated with pubococcygeus muscle, three main patterns of activity were observed either in patients or in controls: 1) coordinated activation pattern; 2) coordinated inhibition pattern; and 3) uncoordinated or equivocal pattern: activation of pubococcygeus muscle with inhibition of puborectalis muscle/external sphincter, activation followed by inhibition of the three muscles, and activation followed by inhibition of pubococcygeus muscle and no change in the others. We never observed activation of puborectalis muscle/external sphincter concomitant with inhibition of pubococcygeus muscle. The inhibitory coordinated pattern occurred significantly (P = 0.01) more frequently in controls than in patients. These subjects also presented a significantly (P = 0.01) lower frequency of pubococcygeus muscle inhibition.

CONCLUSIONS

Either activation or inhibition appears as a physiological behavior, possibly adopted in different circumstances, of the pelvic floor muscles during attempted defecation. The higher prevalence of coordinated inhibitory patterns in normal subjects and the lower frequency of pubococcygeus muscle inhibition in patients with symptoms of obstructed defecation, however, suggests that a loss of inhibition capacity progressing from pubococcygeus muscle to puborectalis muscle/external sphincter muscles could determine the insurgence of obstructed defecation symptoms in some subjects, who should therefore benefit from biofeedback retraining aimed at reacquisition of the inhibition capacity of all muscles of the pelvic floor during defecation.

Clinical applications and techniques of cinedefecography

BACKGROUND

Cinedefecography is of value in routine examination of functional disorders of the pelvic floor. Interest in this technique has rapidly expanded owing to the increased availability of colorectal physiologic testing and better understanding of the multifactorial pathophysiology involving evacuation disorders.

METHODS

A summary of the available techniques, methodology, and indications for cinedefecography was undertaken. In addition, information was provided on interpretation of these images particularly in the context of anatomic abnormalities and clinical applications.

RESULTS

Cinedefecography can be rapidly and easily performed using standard radiographic equipment. Effective radiation dose is significantly lower than for other intestinal contrast studies. The technique has been found most useful for measurements of perineal descent, puborectalis length, and ascertaining the function of the puborectalis muscle and pelvic floor. Common diagnoses that can be made by this test include nonrelaxing puborectalis syndrome, perineal descent, rectocele, enterocele, sigmoidocele, and rectoanal intussusception.

CONCLUSION

Cinedefecography provides a wide range of information to assist the surgeon with the evaluation and management of patients with evacuatory and other associated pelvic floor disorders.

Biofeedback avoids surgery in patients with slow-transit constipation: report of four cases

Biofeedback is established treatment for intractable constipation in patients with an element of pelvic floor dysfunction. In those with intractable slow-transit constipation and normal pelvic floor function, colectomy is usually recommended. We report four patients with isolated slow-transit constipation who benefited from biofeedback and avoided surgery. All four patients were extensively investigated for pelvic floor dysfunction before undergoing a standard biofeedback course of four outpatient sessions. All improved in terms of bowel frequency, laxative use, bloating, straining, and lifestyle. Improvement has been maintained for a median of nine (range, 5-12) months without the requirement for further treatment. Biofeedback represents a safe and inexpensive treatment for these patients and may avoid surgery in a significant proportion.

Outcome and management of patients with large rectoanal intussusception

OBJECTIVES

Rectoanal intussusception is the funnel-shaped infolding of the rectum, which occurs during evacuation. The aims of this study were to evaluate the risk of full thickness rectal prolapse during follow-up of patients with large rectoanal intussusception, and whether therapy improved functional outcome.

METHODS

Between September 1988 and July 1997, patients diagnosed with a large rectoanal intussusception by cinedefecography (intussusception > or = 10 mm, extending into the anal canal) were retrospectively evaluated. Patients with full thickness rectal prolapse on physical examination or cinedefecography were excluded, as were patients with colonic inertia or a history of surgery for rectal prolapse. The patients were divided into three groups according to the treatment received: group I, conservative dietary therapy; group II, biofeedback; and group III, surgery. Outcomes were obtained by postal questionnaires or telephone interviews. Parameters included age, gender, past medical and surgical history, change of bowel habits, fecal incontinence score, and development of full thickness rectal prolapse.

RESULTS

Of the 63 patients, 18 were excluded (seven patients had confirmed full thickness rectal prolapse, four had previous surgery for rectal prolapse, three had colonic inertia, and four died). Follow-up data were obtained in 36 (80%) of the remaining 45 patients. The mean follow-up of this group was 45 months (range, 12-118 months). There were 34 women and two men, with a mean age of 72.4 yr (range, 37-91 yr). The mean size of the intussusception was 2.2 cm (range, 1.0-5.0 cm). The patients were classified as follows: group I, 13 patients (36.1%); group II, 13 patients (36.1%); and group III, 10 patients (27.8%). Subjectively, symptoms improved in five (38.5%), four (30.8%), and six (60.0%) patients in the three groups (p > 0.05). Among the patients with constipation, the decrease in numbers of assisted bowel movements per week (time of diagnosis to present) was significantly greater in group II compared to group 1 (8.1+/-2.8 vs 0.8+/-0.5, respectively, p = 0.004). Among the patients with incontinence, incontinence scores improved more in group II as compared to either group I or group III (time of diagnosis to present, 3.7+/-4.2 to 1.1+/-5.4 vs 1.4+/-2.2, respectively, p > 0.05). Six patients (two in group I, three in group II, and one in group III) had the sensation of rectal prolapse on evacuation; however, only one patient in group I developed full thickness rectal prolapse.

CONCLUSIONS

This study demonstrated that the risk of full thickness rectal prolapse developing in patients medically treated for large intussusception is very small (1/26, 3.8%). Moreover, biofeedback is beneficial to improve the symptoms of both constipation and incontinence in these patients. Therefore, biofeedback should be considered as the initial therapy of choice for large rectoanal intussusception.

Dyssynergic defecation

Dyssynergic defecation is a common clinical problem that affects half of patients with chronic constipation. In many patients, there is a significant overlap with slow transit constipation. The chief underlying pathophysiologic mechanism is a failure of rectoanal coordination. By using a combination of history, prospective stool diaries, detailed clinical evaluation, and anorectal physiologic tests, it is possible to diagnose this problem. Controlled trials are under way to evaluate the efficacy of biofeedback therapy. Meanwhile, it is possible to treat most patients by using neuromuscular conditioning and biofeedback therapy. Further refinements in diagnostic criteria and in rehabilitation therapy programs should facilitate better diagnosis and treatment of patients with dyssynergic defecation.

Surgical treatment of constipation and fecal incontinence

Fecal incontinence is a disabling and distressing condition. Many patients are reluctant to discuss the condition with a physician. A thorough history, good physical examination, and detailed anorectal physiologic investigations can help in the therapeutic decision-making algorithm. Patients with isolated anterior sphincter defects are candidates for overlapping repair. In the presence of unilateral or bilateral pudendal neuropathy, the patient should be counseled preoperatively regarding a [table: see text] lower anticipation of success. If the injury occurred shortly before the planned surgery and neuropathy is present, it may be prudent to wait because neuropathy sometimes can resolve within 6 to 24 months of the injury. Pudendal nerve study may help determine surgical timing. An anterior sphincter defect combined with a rectovaginal fistula can be approached by overlapping sphincter repair and a concomitant transanal advancement flap. Patients who had undergone multiple such procedures may benefit from concomitant fecal diversion at the time of repeat sphincter repair. Patients with global or multifocal sphincter injury may be candidates for a neosphincter procedure. The stimulated graciloplasty and artificial bowel sphincter are reasonable options. In the absence of the availability of these techniques or because of financial constraints, consideration could be given to bilateral gluteoplasty or unilateral or bilateral nonstimulated graciloplasty. The postanal repair still serves a role in patients with isolated decreased resting pressures with or without neuropathy or external sphincter injury with minimal degrees of incontinence. Biofeedback and the Procon device may play a role in these patients. Lastly, fecal diversion must be considered as a means of improving the quality of life because the patient can participate in the activities of daily living without the fear of fecal incontinence.

An increased rectal maximum tolerable volume and long anal canal are associated with poor short-term response to biofeedback therapy for patients with anismus with decreased bowel frequency and normal colonic transit time

PURPOSE

Biofeedback is an effective therapy for a majority of patients with anismus. However, a significant proportion of patients still failed to respond to biofeedback, and little has been known about the factors that predict response to biofeedback. We evaluated the factors associated with poor response to biofeedback.

METHODS

Biofeedback therapy was offered to 45 patients with anismus with decreased bowel frequency (less than three times per week) and normal colonic transit time. Any differences in demographics, symptoms, and parameters of anorectal physiologic tests were sought between responders (in whom bowel frequency increased up to three times or more per week after biofeedback) and nonresponders (in whom bowel frequency remained less than three times per week).

RESULTS

Thirty-one patients (68.9 percent) responded to biofeedback and 14 patients (31.1 percent) did not. Anal canal length was longer in nonresponders than in responders (4.53 +/- 0.5 vs. 4.08 +/- 0.56 cm; P = 0.02), and rectal maximum tolerable volume was larger in nonresponders than in responders. (361 +/- 87 vs. 302 +/- 69 ml; P = 0.02). Anal canal length and rectal maximum tolerable volume showed significant differences between responders and nonresponders on multivariate analysis (P = 0.027 and P = 0.034, respectively).

CONCLUSIONS

This study showed that a long anal canal and increased rectal maximum tolerable volume are associated with poor short-term response to biofeedback for patients with anismus with decreased bowel frequency and normal colonic transit time.

Prognostic significance of rectocele, intussusception, and abnormal perineal descent in biofeedback treatment for constipated patients with paradoxical puborectalis contraction

PURPOSE

The findings of paradoxical puborectalis contraction, rectocele, sigmoidocele, intussusception, and abnormal perineal descent often coexist in constipated patients, as noted by defecographic study. Moreover, some of these conditions are often found in asymptomatic patients. Biofeedback is the treatment of choice for constipated patients with paradoxical puborectalis contraction; the main determinant of successful biofeedback is patient compliance. The significance of coexistent and highly prevalent variants, such as rectocele, intussusception, sigmoidocele, or abnormal perineal descent, on the success of biofeedback is unknown. This review was designed to assess whether these coexisting defecographic findings have any prognostic significance for the outcome of biofeedback.

METHODS

From July 1988 to December 1996, 209 constipated patients with paradoxical puborectalis contraction underwent biofeedback treatment after defecography. A total of 173 patients (120 females) who had more than one biofeedback session after defecography formed the study group. Defecographic findings included concomitant rectoceles, 40 (23 percent); evidence of circumferential intussusception, 17 (10 percent); sigmoidocele, 13 (8 percent); and abnormal perineal descent, 109 (63 percent).

RESULTS

Whereas 65 patients failed to complete the course of biofeedback therapy, 108 (62.4 percent) patients completed the course of biofeedback and were discharged by the therapist. Within the completed group 59 (55 percent) improved, and 49 (45 percent) patients failed biofeedback therapy. In the improved group 14 (23.7 percent) had a rectocele, 5 (8.5 percent) had intussusception, 5 (8.5 percent) had a sigmoidocele, and 37 (62.7 percent) had abnormal perineal descent. In the failure group 9 (18.4 percent) had a rectocele, 5 (10.2 percent) had an intussusception, 2 (4.1 percent) had a sigmoidocele, and 31 (63.3 percent) had abnormal perineal descent (P = not significant). The success of biofeedback was then analyzed relative to the number of coexisting conditions. Specifically, the outcome in patients with paradoxical puborectalis contraction alone and with one, two, and three other defecographic findings were compared. No statistically significant difference was found among these four groups.

CONCLUSION

Although other defecographic findings frequently coexist with paradoxical puborectalis contraction, none of the concomitant findings adversely affected the outcome of biofeedback treatment. Therefore, biofeedback can be recommended to patients with coexistent defecographic findings, with expectation of success in over 50 percent of individuals who complete the course of therapy.

Behavioural treatment (biofeedback) for constipation following hysterectomy

BACKGROUND

Constipation after hysterectomy has been postulated to be due to pelvic nerve damage, but there may be emotional or reversible physical factors of pathophysiological relevance. The aim of this study was to determine whether such constipation is responsive to behavioural treatment.

METHODS

Three groups of patients who had completed a course of biofeedback treatment were compared: women with no history of abdominal or pelvic surgery (n = 25), women for whom a hysterectomy had led to no change in bowel function (n = 27) and women who stated that their constipation was precipitated (n = 18) or severely worsened (n = 8) by hysterectomy. Pretreatment and post-treatment details about bowel function and symptoms were assessed using structured interview, and pretreatment whole-gut transit time and anorectal physiology testing were assessed for prognostic relevance.

RESULTS

Follow-up after completing treatment was a median of 28 (range 12-44) months. Forty-eight of 78 patients considered that their constipation had improved with treatment; the proportion in each group was similar (P = 0.73). Biofeedback reduced the need to strain, reduced abdominal pain, improved bowel frequency, and reduced laxative use to a similar degree in all three groups. Thirty-three of 53 patients with slow transit considered there was an improvement, compared with 15 of 22 with measured normal transit. Physiological testing did not predict outcome and did not differ between the three groups.

CONCLUSION

The majority of patients complaining of constipation induced or worsened by hysterectomy respond subjectively to behavioural treatment, in a similar proportion to those with idiopathic constipation. In contrast to the widely held view that nerve damage is responsible for symptoms, reversible factors are likely to be important in many patients.

Transanal repair of rectocele corrects obstructed defecation if it is not associated with anismus

PURPOSE

Rectocele is often associated with anorectal symptoms. Various surgical techniques have been described to repair the rectocele. The surgical results are variable. This study evaluated the results of transanal repair of rectocele, with particular emphasis on the impact of concomitant anismus on postoperative functional outcome.

METHODS

Fifty-nine consecutive females who underwent transanal repair of rectocele for obstructed defecation were prospectively reviewed. All 59 patients were parous with a median parity of 2 (range, 1-6) and a median age of 58 (range, 46-68) years. The median length of follow-up was 19 (range, 6-40) months. Anismus was detected by anorectal physiology and defecography. The functional outcome was assessed by a standard questionnaire, physical examination, anorectal manometry, neurophysiology, and defecography. The quality-of-life index was obtained using a visual analog scale (from 1-10, with 10 being the best).

RESULTS

The functional outcome of transanal repair of rectocele was superior in patients without anismus. Forty (93 percent) of the 43 patients without anismus showed improved evacuation after repair compared with 6 (38 percent) of the 16 patients with anismus (P<0.05). The quality-of-life index improved (9 vs. 4) if anismus was not present (P<0.05). There were minimal complications. Hemorrhage requiring blood transfusion (2 units) occurred in one patient and urinary retention in another.

CONCLUSION

Transanal repair of rectocele is safe and, in the absence of anismus, effectively corrects obstructed defecation.

Prospective, randomized trial comparing four biofeedback techniques for patients with constipation

PURPOSE

The aim of this study was to compare four methods of biofeedback for patients with constipation.

METHODS

Thirty-six patients were prospectively, randomly assigned to one of four protocols: 1) outpatient intra-anal electromyographic biofeedback training; 2) electromyographic biofeedback training plus intrarectal balloon training; 3) electromyographic biofeedback training plus home training; or 4) electromyographic biofeedback training, balloon training, and home training. All 36 patients received weekly one-hour outpatient biofeedback training. Success was measured by increased unassisted bowel movements and reduction in cathartic use. In all instances patients maintained a daily log in which documentation was maintained regarding each bowel evacuation and the need for any cathartics. RESULTS; There was a statistically significant increase in unassisted bowel movements for Groups 1, 2, and 4 (P < 0.05) and a reduction in the use of cathartics in Groups 1, 2, and 3 (P < 0.05).

CONCLUSION

There was a significant improvement in outcome after all four treatment protocols for constipation; however, no significant difference was found among the treatments. Therefore, electromyographic biofeedback training alone is as effective as with the addition of balloon training, home training, or both.

Surgical treatment of complete rectal prolapse: results of abdominal and perineal approaches

This retrospective study reports the results of our 5-year experience in the diagnosis and treatment of rectal prolapse with fecal incontinence by the abdominal (laparotomy or laparoscopy) and perineal approaches. Twenty-five patients (group A; 22 women and 3 men; mean age 57.3 years; range 22-76 years) were operated on by the abdominal approach and ten (group B; 8 women and 2 men; mean age 68.9 years; range 58-84 years) by the perineal approach. All patients were evaluated by clinical examination, proctosigmoidoscopy, pancolonic transit time, dynamic defecography, anorectal manometry, and anal electromyography preparatory to surgery. In patients of group A, we performed an abdominal rectopexy in 19 cases (7 by laparoscopy) and in the remaining 6 cases, a sigmoid resection-rectopexy (3 of which were by laparoscopy). All patients of group B were treated by a perineal operation using Delorme's mucosectomy in 4 cases and Altemeier's rectosigmoidectomy with total perineoplasty in 6 cases. The mean follow-up was 38.8 months in group A and 25.7 months in group B. The postoperative complication rate was 8% (two cases) in group A, whereas no significant complications occurred in group B. Dyschezia and fecal incontinence improved significantly in both groups (P < 0.05 in group A and P < 0.005 in group B), whereas anoperineal pain was not significantly reduced. At 1-year follow-up, the recurrences rates were 8% in group A and 30% in group B. Rectopexy or resection-rectopexy proved to be a safe and effective procedure for external prolapse, without a discernible difference between the laparotomic and laparoscopic techniques. In selected cases, the perineal approach gives good results regarding fecal incontinence without complications, even if in these patients, the likelihood of recurrence is high.

Electromyography of the external anal sphincter: comparison between needle and surface electrodes

PURPOSE

Electromyography of the external anal sphincter is frequently used when investigating patients with defecation disorders. Investigations are often performed using an invasive technique by perineal insertion of a needle or wire electrode. The aim of the present study was to investigate whether surface electromyography, with electrodes applied to the perineal skin, is a reliable method in the diagnosis of paradoxical anal sphincter reaction.

METHODS

Seventy-one patients with defecation disorders participated in the present study. They were investigated with electromyography of the external anal sphincter using surface and needle electrodes.

RESULTS

In 65 of 71 (92 percent) patients the electromyography recording showed the same result during straining using surface electrodes when compared with needle electrodes. Twenty-two of these 65 patients had paradoxical anal sphincter reaction, and 43 patients had decreased electromyography activity. In 6 of 71 (8 percent) patients the electromyography recording showed a different pattern during straining using surface electrodes when compared with needle electrodes.

CONCLUSION

The present study demonstrates a good correlation between surface electrodes applied to the perineal skin and concentric needle electrodes in the diagnosis of paradoxical anal sphincter reaction. Noninvasive electromyography recordings of the external anal sphincter are often preferred in the diagnosis of paradoxical anal sphincter reaction.

Biofeedback for anismus: has placebo effect been overlooked?

OBJECTIVE

Multiple uncontrolled studies have concluded that biofeedback is successful in treating anismus. This study's objective was to assess the physiological effects of placebo and biofeedback treatment on patients with anismus and to correlate changes with clinical improvement.

PATIENTS AND METHODS

Twelve patients with symptoms and electrophysiological findings of anismus were studied. Initial assessment included a detailed history, symptom assessment by linear analogue scales, anorectal manometric and electrophysiological studies, colon transit scintigraphy, and scintigraphic proctography. Patients underwent 5 days of placebo treatment, followed 1 week later by re-assessment of symptoms and physiological studies. Five days of biofeedback was then given followed by another complete re-assessment 1 week later. A final interview was performed 2 months later. All assessments were by an independent observer who was not responsible for the treatments.

RESULTS

Seven patients reported an overall improvement in symptoms following placebo treatment. A total of seven patients reported improvement following biofeedback, three of whom had already reported an improvement with placebo. One patient who reported improvement following placebo had worsening of symptoms following biofeedback. The only symptoms or tests which changed more with biofeedback than placebo were anal pressure and electromyographic activity on attempted defaecation in the left lateral position. There was no demonstrable correlation between change in symptoms and change in physiological tests. The scintigraphic 'ejection fraction' of the rectum was unchanged by treatment.

CONCLUSION

Clinical improvement in previous studies may in part be due to placebo effect and observer bias. Improvement with biofeedback may be due to physiological changes which are not detected with conventional anorectal physiological tests.

Constipation, diarrhea, and irritable bowel syndrome

Constipation, diarrhea, and irritable bowel syndrome are commonly encountered in the primary care practice. Most episodes of constipation and diarrhea are benign and self-limited. Patients with chronic constipation should undergo a screening evaluation to exclude organic disease, after which most can be managed successfully with dietary modification and fiber supplementation. The cause of chronic diarrhea usually can be discerned clinically, with irritable bowel syndrome, inflammatory bowel disease, and lactose intolerance being diagnosed most frequently. Irritable bowel syndrome is a functional gastrointestinal disorder characterized by abdominal pain and disordered defecation, which is successfully managed with a strong physician-patient relationship and periodic pharmacologic intervention.

AGA technical review on anorectal testing techniques

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. Following external review, the paper was approved by the committee on May 17, 1998.

Comparison of laparoscopic rectopexy with open technique in the treatment of complete rectal prolapse: clinical and functional results

The aim of this retrospective study was to compare the functional and clinical results of laparoscopic rectopexy with those of the open technique in two similar groups of patients with complete rectal prolapse and fecal incontinence. Between November 1992 and June 1997, 21 patients underwent abdominal rectopexy. Thirteen patients (group A: 12 women and 1 man, mean age 52.9 years, range 28-70) and 8 patients (group B: 8 women, mean age 58.2 years, range 20-76) were submitted to Well's rectopexy by the open technique and the laparoscopic approach, respectively, without division of the lateral rectal ligaments. Assignment to each group was done randomly. Before the operation, a detailed clinical history was taken, and patients were studied with inspection and digital examination of the anorectum, proctosigmoidoscopy, determination of pancolonic transit time, dynamic defecography, anorectal manometry, and anal electromyography. After the operation, all patients underwent perineal physiotherapy, external electric stimulation, and perineal biofeedback. The mean follow-up time was 29.5 months (range 6-54) in group A and 25.7 months (range 8-45) in group B. Values were compared by chi-square, Mann-Whitney U, and Wilcoxon tests, as appropriate; differences were considered significant at p < 0.05. In both groups, dyschezia and fecal incontinence improved significantly (p < 0.05) after the operation. Basal pressure of anal sphincter, squeezing pressure, and rectoanal reflex improved without significance, whereas anoperineal pain was not significantly reduced. In group B, the postoperative hospital stay was shorter than in group A, with a marked reduction of costs. Laparoscopic Well's rectopexy has the same clinical and functional results as the open technique, with a shorter postoperative hospital stay and lower costs.

Pudendal nerve function in normal and encopretic children

BACKGROUND

Abnormal pudendal nerve function contributes to fecal retention and incontinence in adults. To determine the role of pudendal neuropathy in childhood, we prospectively evaluated pudendal nerve function in normal and encopretic children.

METHODS

We studied pudendal nerve terminal motor latency in 23 encopretic children and in an equal number of similarly aged, normal children. Anal manometry and electromyography were also obtained in all children.

RESULTS

Pudendal nerve latency in the encopretic children equaled 1.58 +/- 0.33 msec, which was the same as that in control children. Of the 75 pudendal nerves tested, latency was prolonged in only one encopretic child. In contrast, anal electromyography demonstrated nonrelaxation of the external anal sphincter in 75% of the encopretic children but in only 13% of the normal children (p < 0.001). Anorectal manometry demonstrated, on average, lower and sphincter pressures at rest and with squeezing in the encopretic children (p < 0.01), but only 17% had sphincter pressures more than two standard deviations below normal.

CONCLUSIONS

Other than poor relaxation response of the external anal sphincter during evacuation, these data reveal a paucity of functionally important abnormalities in encopretic children. In particular, we find no evidence that abnormal pudendal nerve function is important in the etiology or pathogenesis of encopresis in children.

Prospective study of biofeedback for treatment of constipation

PURPOSE

This study was designed to evaluate prospectively the results of pelvic floor physiotherapy with the aid of biofeedback in a heterogeneous group of patients with intractable constipation.

METHODS

Biofeedback was used to treat 19 patients (age range, 16-78 (median, 63) years) with intractable constipation. Assessment, using visual linear analog scales of symptoms, was performed prospectively by an independent researcher. Biofeedback was performed by a physiotherapist, and patients were required to attend six sessions on an outpatient basis. The cause of constipation was heterogeneous, with no specific disorder being implicated on testing with anal manometry, defecating proctography, and colonic transit time.

RESULTS

At six weeks, there was a median 27 percent (range, -8-93 percent) improvement in symptom scores. At six months, there was a median 23 percent (range, -54-64 percent) improvement in symptom scores. These were statistically significant compared with the scores at outset, six weeks (P = 0.0006), and six months (P = 0.012). However, only two (12.5 percent) patients at the six-month follow-up had an improvement of greater than 50 percent in their symptoms.

CONCLUSION

Biofeedback is not recommended in the management of constipation.

Results of biofeedback in constipated patients: a prospective study

PURPOSE

The aims of this study were to assess the results of biofeedback treatment in constipated patients and to identify variables that might be used to predict the outcome.

METHOD

Twenty-eight patients (5 men; median age, 46 (range, 22-72) years) with any degree of paradoxical activation measured with thin hook needle electromyography in the external sphincter or puborectalis muscle were included. The symptom duration varied between 1 and 30 (median, 9) years. The patients had eight outpatient training sessions with electromyography-based audiovisual feedback. All patients were followed up prospectively with a validated bowel function questionnaire from which a symptom index was created.

RESULTS

At three months, nine patients had no improvement and underwent other treatments. The remaining 19 patients were followed up for a median of 14 (range, 12-34) months. Twelve patients (43 percent) stated they had improved rectal emptying. A good result was associated with increased stool frequency (P < 0.05), improved symptom index (P < 0.01), and reduction of laxative use (P < 0.05). A long symptom duration, a high pretreatment symptom index, and laxative use were related to a poor result (P < 0.01-0.05). The improved group had less perineal descent (P < 0.05), and a prominent puborectalis impression on defecography tended to be more common (P = 0.06).

CONCLUSION

With the use of wide inclusion criteria, biofeedback was successful in 43 percent of patients, with a treatment effect lasting at least one year. The results suggest that biofeedback should be used as the initial treatment of constipated patients with a paradoxical puborectalis contraction.

Outcome and predictors of success of biofeedback for constipation

BACKGROUND

A study was undertaken to determine outcome and to identify predictors of success for biofeedback for constipation.

METHODS

Patients who had at least one biofeedback session were evaluated whether or not they completed a treatment course. Parameters assessed included use of cathartics, number of spontaneous bowel movements per week, presence of rectal pain, number of biofeedback sessions and results of anorectal physiology.

RESULTS

A total of 194 patients (59 male, 135 female) of median age 71 (range 11-96) years, including 30 with concomitant rectal pain, were treated. The median number of spontaneous bowel movements per week before treatment was 0. Some 35 per cent of patients had complete success (three or more spontaneous bowel movements per week with discontinuation of cathartics), 13 per cent had partial success (fewer than three spontaneous bowel movements per week with continued use of cathartics) and 51 per cent had no improvement. Neither patient age, sex nor duration of symptoms significantly affected outcome. Only 18 per cent of patients who had between two and four sessions had complete success, compared with 44 per cent of those who had five or more (P < 0.001). A total of 63 per cent of patients who completed the treatment protocol experienced complete success, compared with 25 per cent of those who self-discharged (P < 0.0001).

CONCLUSIONS

This large study indicates that the success rate of biofeedback for patients with constipation is less than previously reported. However, the success rate improves significantly after five or more sessions and is significantly related to the patient's willingness to complete treatment.