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

Defecation Symptoms in Relation to Stool Consistency Significantly Reflect the Dyssynergic Pattern in High-resolution Anorectal Manometry in Constipated Patients

GOALS

To evaluate the usefulness of a 2-week patient-completed bowel habit and symptom diary as a screening tool for disordered rectoanal coordination (DRC).

BACKGROUND

DRC is an important subgroup of chronic constipation that benefits from biofeedback treatment. Diagnosis of DRC requires a dyssynergic pattern (DP) of attempted defecation in high-resolution anorectal manometry (HRAM) and at least 1 other positive standardized examination, such as the balloon expulsion test or defecography. However, HRAM is generally limited to tertiary gastroenterology centres and finding tools for selecting patients for referral for further investigations would be of clinical value.

STUDY

Retrospective data from HRAM and a 2-week patient-completed bowel habit and symptom diary from 99 chronically constipated patients were analyzed.

RESULTS

Fifty-seven percent of the patients had a DP pattern during HRAM. In the DP group, 76% of bowel movements with loose or normal stool resulted in a sense of incomplete evacuation compared with 55% of the non-DP group ( P =0.004). Straining and sensation of incomplete evacuation with the loose stool were significantly more common in the DP group ( P =0.032). Hard stool was a discriminator for non-DP ( P =0.044). Multiple logistic regression including incomplete evacuation and normal stool predicted DP with a sensitivity of 82% and a specificity of 50%.

CONCLUSIONS

The sensation of incomplete evacuation with loose or normal stool could be a potential discriminator in favor of DP in chronically constipated patients. The bowel habit and symptom diary may be a useful tool for stratifying constipated patients for further investigation of suspected DRC.

The patient with obstructed defecatory symptoms: Management differs considerably between physicians and surgeons

BACKGROUND

Patients with obstructed defecatory symptoms (ODS) are commonly referred to either gastroenterologists (GE) or colorectal surgeons (CS). Further management of these patients may be impacted by this choice of referral.

METHODS

An online survey of specialist practice was disseminated to GE and CS in Australia and New Zealand. A case vignette of a patient presenting with ODS was described, with multiple subsequent scenarios designed to delineate the responder's preferred approach to management of this patient.

KEY RESULTS

A total of 107 responders participated in the study, 62 CS and 45 GE. For a female patient with ODS not responding to pharmacological treatment, GE were more likely than CS to refer patients for anorectal manometry, while CS were more likely to refer for dynamic imaging. A quarter of CS and GE referred patients directly to pelvic floor physiotherapy, without any pre-treatment testing. Knowing the result of dynamic imaging, especially if a rectocele was demonstrated, substantially influenced management for both of the specialties: GE became more likely to refer the patients for CS consultation and less likely to refer directly for biofeedback or physiotherapy and CS were more likely to opt for an operative pathway over conservative management than they were prior to knowledge of the imaging findings. The majority (>75%) of GE and CS did not find it necessary to obtain a gynecological consultation, even in the presence of a rectocele.

CONCLUSIONS & INFERENCES

Practice variation across medical specialties affects diagnostic and management recommendations for patients with ODS, impacting treatment pathways. Our findings provide an incentive toward establishing interdisciplinary, uniform, management guidelines.

Analyzing the Role of Anal Sphincter Pressure in Rectocele Formation

Purpose

Constipation is a common entity in society with various factors in the etiology. In this study, we evaluated the role of anal sphincter pressure of patients who refer to surgery clinic with complaint of constipation.

Methods

Sixty patients who refer to surgery clinic with complaint of constipation and were diagnosed with constipation due to Rome III criteria between July 2010 and September 2014. These patients were evaluated with defecography and were divided into 2 groups based on presence of rectocele. Both groups’ anal sphincter pressures were evaluated using anal manometry and findings were compared.

Results

The patients with rectocele and without rectocele using defecography were inspected with anal manometry regarding resting tone pressure, squeeze pressure, maximum squeeze pressure and simulated defecation response pressure, first sensation volume, urge sensation volume, and maximum tolerable volume. Results were compared and no significant difference was found regarding groups with rectocele and without rectocele (P > 0.05).

Conclusion

We have proved the hypothesis arguing that increased sphincter pressures do not play a role in the formation of rectocele by inducing an obstruction and the formation of dilation in proximal bowel, and demonstrated that the presence of rectocele is not dependent on an increase in sphincter pressures.

Clinical outcomes of stapled transanal rectal resection for obstructed defaecation syndrome at 10-year follow-up

AIM

The long-term efficacy of stapled transanal rectal resection (STARR) for surgical management of obstructed defaecation syndrome (ODS) has not been evaluated. Therefore, we investigated the long-term efficacy (> 10 years) of STARR for treatment of ODS related to rectocele or rectal intussusception and the factors that predict treatment outcome.

METHOD

This study was a retrospective cohort analysis conducted on prospectively collected data. Seventy-four consecutive patients who underwent STARR for ODS between January 2005 and December 2006 in two Italian hospitals were included.

RESULTS

Seventy-four patients [66 women; median age 61 (29-77) years] underwent STARR for ODS. No serious postoperative complications were recorded. Ten years postoperatively, 60 (81%) patients completed the expected follow-up. Twenty-three patients (38%) reported persistent perineal pain and 13 (22%) experienced the urge to defaecate. ODS symptoms recurred in 24 (40%) patients after 10 years. At the 10-year follow-up, 35% of patients were very satisfied and 28% would recommend STARR and undergo the same procedure again if necessary. In contrast, 21% of patients would not select STARR again. Previous uro-gynaecological or rectal surgery and high constipation scores were identified as risk factors for recurrence.

CONCLUSIONS

Stapled transanal rectal resection significantly improves the symptoms of ODS in the short term. In the long term STARR is less effective, however.

Functional Disorders: Rectocele

Rectoceles are a very common finding in patients, and symptoms most commonly include pelvic pain, pressure, or difficulty with passing stool. However, there are often other associated pelvic floor disorders that accompany rectoceles, making the clinical significance of it in an individual patient often hard to determine. When evaluating a patient with a rectocele, a thorough history and physical exam must be conducted to help delineate other causes of these symptoms. Treatment consists of addressing other defecatory disorders through various methods, with surgery reserved for select cases in which obstructed defecation is well documented.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Defecating Disorders: A Common Cause of Constipation in Women

Defecating disorders are a common and complex problem. There are a range of anatomical and functional bowel abnormalities that can lead to this condition. Treatment is difficult and needs a multidisciplinary approach. First line treatment for defecating disorders is conservative. For those that fail conservative treatment, some may respond to surgical therapy but with variable results. The aim of this review is to offer an overview of defecating disorders as well as provide an algorithm on how to diagnose and treat them with the help of a multidisciplinary and multimodal approach.

Chronic severe constipation: current pathophysiological aspects, new diagnostic approaches, and therapeutic options

Chronic constipation is a considerable problem because it significantly affects the quality of a patient's life. Constipation can be diagnosed at every age and is more frequent in women and among the elderly. In epidemiological studies, its incidence is estimated at 2-27% in the general population. Chronic constipation may be primary or secondary. However, primary constipation (functional or idiopathic) can be classified into normal transit constipation, slow transit constipation, and pelvic outlet obstruction. In this review we make an attempt to present the current pathophysiological aspects and new therapeutic options for chronic idiopathic constipation, particularly highlighting the value of patient assessment for accurate diagnosis of the cause of the problem, thus helping in the choice of appropriate treatment.

Laparoscopic ventral rectopexy for the treatment of outlet obstruction associated with recto-anal intussusception and rectocele: a valid alternative to STARR procedure in patients with anal sphincter weakness

OBJECTIVE

This study was designed to assess the safety and outcomes achieved with Stapled Trans-Anal Rectal Resection (STARR) vs laparoscopic ventral rectopexy (LVR) in obstructed defecation patients.

METHOD

From 2002 to 2011, 52 patients (females) had a rectocele with outlet obstruction. After clinical assessment by an Obstructed Defecation Syndrome score (ODS), an anorectal manometry, a defecography and an endoanal ultrasound, the patients underwent either a STARR (n=25) or a LVR (n=27) according to the existence of an asymptomatic anal sphincter injury. Functional results were evaluated clinically and by the preoperative and 18 months postoperative ODS score and by an 18 months postoperative score of satisfaction.

RESULTS

Average ages were 56 ± 10 years in the STARR and 60 ± 9 years in LVR. The 1-month postoperative complication rates were comparable for the 2 groups (25%). Mean length of stay was shorter for STARR than for LVR (5.6 ± 2.1 vs. 7.1 ± 2.9, P=0.009). After treatment, the ODS was lowered by 56% in LVR and 59% in the STARR (P=0.0001) but with no difference between the 2 groups. Eighty percent of patients were very or moderately satisfied after LVR, versus 84% after STARR.

CONCLUSIONS

The 2 surgical procedures obtain good results with 80% of satisfied patients with a length of stay a little shorter in the STARR.

BRIEF SUMMARY

In our retrospective study, Stapled Trans-Anal Rectal Resection (STARR) and laparoscopic ventral rectopexy improved the outlet obstruction associated with recto-anal intussusception and rectocele.

Psycho-echo-biofeedback: a novel treatment for anismus--results of a prospective controlled study

BACKGROUND

Anismus or non-relaxing puborectalis muscle (PRM), detectable with anal/vaginal ultrasound (US), is a cause of obstructed defecation (OD) and may be treated with biofeedback (BFB). Many patients with anismus are anxious and/or depressed. The aim of this prospective study was to evaluate the outcome of the novel procedure psycho-echo-BFB in patients with anismus and psychological disorders.

METHODS

Patients presenting at our unit with anismus and psychological disorders between January 2009 and December 2013, and not responding to conventional conservative treatment, were enrolled in the study. All underwent four sessions of psycho-echo-BFB, carried out by two psychologists and a coloproctologist, consisting of guided imagery, relaxation techniques and anal/vaginal US-assisted BFB. A validated score for OD was used, and PRM relaxation on straining measured before and after the treatment. PRM relaxation was also measured in a control group of 7 patients with normal bowel habits.

RESULTS

Ten patients (8 females, median age 47 years, range 26-72 years) underwent psycho-echo-BFB. The OD score, evaluated prior to and at a median of 25 months (range 1-52 months) after the treatment, improved in 7 out of 10 patients, from 13.5 ± 1.2 to 9.6 ± 2.2 (mean ± standard error of the mean (SEM)), p = 0.06. At the end of the last session, PRM relaxed on straining in all cases, from 0 to 7.1 ± 1.1 mm, i.e., physiological values, not statistically different from those of controls (6.6 ± 1.5 mm). Two patients reported were cured, 3 improved and 5, all of whom had undergone prior anorectal surgery, unchanged. No side effects were reported.

CONCLUSIONS

Psycho-echo-BFB is safe and inexpensive and allows all patients with anismus to relax PRM on straining. Previous anorectal surgery may be a negative predictor.

Psycho-echo-biofeedback: a novel treatment for anismus--results of a prospective controlled study

BACKGROUND

Anismus or non-relaxing puborectalis muscle (PRM), detectable with anal/vaginal ultrasound (US), is a cause of obstructed defecation (OD) and may be treated with biofeedback (BFB). Many patients with anismus are anxious and/or depressed. The aim of this prospective study was to evaluate the outcome of the novel procedure psycho-echo-BFB in patients with anismus and psychological disorders.

METHODS

Patients presenting at our unit with anismus and psychological disorders between January 2009 and December 2013, and not responding to conventional conservative treatment, were enrolled in the study. All underwent four sessions of psycho-echo-BFB, carried out by two psychologists and a coloproctologist, consisting of guided imagery, relaxation techniques and anal/vaginal US-assisted BFB. A validated score for OD was used, and PRM relaxation on straining measured before and after the treatment. PRM relaxation was also measured in a control group of 7 patients with normal bowel habits.

RESULTS

Ten patients (8 females, median age 47 years, range 26-72 years) underwent psycho-echo-BFB. The OD score, evaluated prior to and at a median of 25 months (range 1-52 months) after the treatment, improved in 7 out of 10 patients, from 13.5 ± 1.2 to 9.6 ± 2.2 (mean ± standard error of the mean (SEM)), p = 0.06. At the end of the last session, PRM relaxed on straining in all cases, from 0 to 7.1 ± 1.1 mm, i.e., physiological values, not statistically different from those of controls (6.6 ± 1.5 mm). Two patients reported were cured, 3 improved and 5, all of whom had undergone prior anorectal surgery, unchanged. No side effects were reported.

CONCLUSIONS

Psycho-echo-BFB is safe and inexpensive and allows all patients with anismus to relax PRM on straining. Previous anorectal surgery may be a negative predictor.

In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort

BACKGROUND

The indications for operation in patients with obstructed defecation syndrome (ODS) with rectocele are not well defined.

METHODS

A total of 90 female patients with ODS and rectocele were prospectively evaluated and treated with fiber supplements and biofeedback training. Univariate and multivariate regression was used to determine factors predictive of failing medical management.

RESULTS

Obstructive symptoms were the most prevalent presenting complaint (82.2%). Ultimately, 71.1% of patients responded to medical management and biofeedback. Multivariate regression analysis suggested that the presence of internal intussusception was associated with a lower chance of undergoing surgery to address ODS symptoms [odds ratio 0.18; P = .05], whereas inability to expel balloon, contrast retention on defecography, and splinting were not (P ≥ .15).

CONCLUSION

Rectoceles with concomitant intussusception in patients with ODS appear to portend a favorable response to biofeedback and medical management. We argue that all patients considered for surgery for rectoceles because of ODS should first undergo appropriate bowel retraining.

Diagnostic testing for dyssynergic defecation in chronic constipation: meta-analysis

BACKGROUND

Dyssynergic defecation (DD) results from inadequate relaxation of the pelvic floor on attempted defecation. The prevalence of DD in patients with chronic constipation (CC) is not certain. Aims of this study are to estimate the prevalence of abnormal findings associated with DD across testing modalities in patients referred for physiological testing for CC.

METHODS

Systematic search of MEDLINE, EMBASE and PUBMED databases were conducted. We included full manuscripts reporting DD prevalence in CC, and specific findings at pelvic floor diagnostic tests. Random effects models were used to calculate pooled DD prevalences (with 95% CI) according to individual tests and specific findings.

KEY RESULTS

A total of 79 studies on 7581 CC patients were included. The median prevalence of any single abnormal finding associated with DD was 37.2%, ranging from 14.9% (95% CI 7.9-26.3) for absent opening of the anorectal angle (ARA) on defecography to 52.9% (95% CI 44.3-61.3) for a dyssynergic pattern on ultrasound. The prevalence of a dyssynergic pattern on manometry was 47.7% (95% CI 39.5-56.1). The prevalence of DD was similar across specialty and geographic area as well as when restricting to studies using Rome criteria to define constipation.

CONCLUSIONS & INFERENCES

Dyssynergic defecation is highly prevalent in CC and is commonly detected across testing modalities, type of patient referred, and geographical regions. We believe that the lower prevalence of findings associated with DD by defecography supports use of manometry and balloon expulsion testing as an initial evaluation for CC.

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

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (Part II: Treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

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

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

Obstructed defaecation: what is the role of rehabilitation?

AIM

The study was designed to evaluate the results of rehabilitative treatment in patients suffering from obstructed defaecation.

METHOD

Between January 2008 and July 2010, 39 patients (37 women, age range 25-73 years; and two men, aged 57 and 67 years) affected by obstructed defaecation were included in the study. After a preliminary clinical evaluation, including the Obstructed Defaecation Syndrome (ODS) score, defaecography and anorectal manometry were performed. All 39 patients underwent rehabilitative treatment according to the 'multimodal rehabilitative programme' for obstructive defaecation. At the end of the programme, all 39 patients were reassessed by clinical evaluation and anorectal manometry. Postrehabilition ODS scores were used to categorize patients arbitrarily into three classes, as follows: class I, good (score ≤ 4); class II, fair (score > 4 to ≤ 8); and class III, poor (score > 8).

RESULTS

After rehabilitation, there was significant improvement in the overall mean ODS score (P < 0.001). Thirty (76.9%) patients were included as class I (good results), of whom eight (20.5%) were symptom free. Five (12.8%) patients were considered class III. A significant postrehabilitative direct correlation was found between ODS score and pelvic surgery (ρ(s) = 0.54; P < 0.05). Significant differences were found between pre- and postrehabilitative manometric data from the straining test (P < 0.001), duration of maximal voluntary contraction (P < 0.001) and conscious rectal sensitivity threshold (P < 0.02).

CONCLUSION

After rehabilitation, some patients become symptom free and many had an improved ODS score.

Treatment of obstructed defecation

Obstructed defecation is a common problem that adversely affects the quality of life for many patients. Known causes of obstructed defecation include pelvic dyssynergy, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse. Management of this condition requires an understanding of urinary, defecatory, and sexual function to achieve an optimal outcome. The goal of surgical treatment is to restore the various pelvic organs to their appropriate anatomic positions. However, there is a poor correlation between anatomic and functional results. As the pelvis contains many structures, a pelvic support or function defect frequently affects other pelvic organs. Optimal outcomes can only be achieved by selecting appropriate treatment modalities that address all of the components of a patient's problem.

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.

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.

The evaluation of constipation

Constipation is a major medical problem in the United States, affecting 2% to 28% of the population. Individual patients may have different conceptions of what constipation is, and the findings overlap with those in other functional gastrointestinal disorders. In 1999, an international panel of experts laid out specific criteria for the diagnosis of constipation known as the Rome II criteria. When patients present with complaints of constipation, a complete history and physical examination can elicit the cause of constipation. It is imperative to rule out a malignancy or other organic causes of the patient's symptoms prior to making the diagnosis of functional constipation. Many patients' symptoms can be relieved with lifestyle and dietary modification, both of which should be implemented before other potentially unnecessary tests are performed. Functional constipation is divided into two subtypes: slow transit constipation and obstructive defecation. Because many different terms are used interchangeably to describe these subtypes of constipation, physicians need to be comfortable with the language. Slow transit constipation is due to abnormal colonic motility. The diagnosis is made with the use of a colonic transit study. We continue to use a single-capsule technique as first described in the literature, but modifications of the capsule technique as well as scintigraphic techniques are validated and can be substituted in place of the capsule. Obstructive defecation is a much more complex problem, with etiologies ranging from rare diseases such as Hirschsprung's to physiologic abnormalities such as paradoxical puborectalis contraction. To fully evaluate the patient with obstructive defecation, anorectal manometry, defecography, and electromyography should be utilized. The different techniques available for each test are fully covered in this article. When evaluating each patient with constipation, it is important to keep in mind that the disease may be specific to one subtype or a combination of both subtypes. Because it is difficult to differentiate the subtypes from the patient's history, we feel it is imperative to evaluate patients fully for both slow transit and obstructive defecation prior to any surgical intervention. Furthermore, we have described many tests that need to be applied to one's population of patients on the basis of the capabilities and expertise the institution offers.

Stapled transanal rectal resection for obstructed defecation: a cautionary tale

PURPOSE

This prospective study was designed to assess the efficacy and safety of a novel technique in treating outlet obstruction syndrome using a transanal double-stapling procedure.

METHODS

Two hundred thirty patients (187 female) with obstructed defecation underwent stapled transanal rectal resection over a six-year period with follow-up at 2, 6, and 12 months, then yearly; median follow-up was 24 (range, 12-68) months. All failed conservative measures. Patients with slow transit constipation and puborectalis dyssynergia were excluded.

RESULTS

Operating time was short (median, 35 (range, 20-95) minutes), with 159 (69%) performed as day cases (outpatient). Major complications were seen in 16 (7%); there were no deaths. Twelve (5%) patients reported severe postoperative pain. Immediate postoperative fecal urgency was reported by 107 (46%) patients, but persisted at six months in only 26 (11%). Three (1%) developed recurrent rectal prolapse. Nearly all incontinent patients (98%) reported an improvement, with a median Wexner score reduction of 5 points (P < 0.0001). Constipation improved in 77% of patients. Seventy-seven percent of patients were "very glad" they had the operation, and 86% "recommended" stapled transanal rectal resection to a friend.

CONCLUSION

Stapled transanal rectal resection can be performed on a day-case basis with high levels of patient satisfaction. Incontinence and constipation are improved. However, significant morbidity occurs in 7% of patients, and urgency of defecation persists beyond six months in 11%.

The impact of stapled transanal rectal resection on anorectal function in patients with obstructed defecation syndrome

PURPOSE

A careful preoperative selection of patients was performed in order to identify those eligible for stapled transanal rectal resection to correct obstructed defecation syndrome. The aim was to assess the consequences of surgery on anorectal function and patient outcomes.

METHODS

From January 2004 to June 2007, 33 female patients (median age, 56.3 years; range, 27-77 years) eligible for stapled transanal rectal resection completed standardized questionnaires for the assessment of constipation (constipation scoring system), quality of life (Patient Assessment of Constipation-Quality of Life Questionnaire), and patient satisfaction (visual analogue scale). A complete clinical reassessment including anorectal manometry and defecography was performed after one year.

RESULTS

At a median follow-up of 18 months, significant improvement in constipation scoring system, quality of life, and visual analog scale (P < 0.0001) was observed. Postoperative defecography confirmed the correction of internal rectal prolapse (P < 0.01) and rectocele (P < 0.0001) with an increase in rectal sensitivity (P < 0.0001). Significant correlations were observed between rectocele correction and rectal sensitivity, as evidenced by a decrease in rectal sensory threshold volumes (P = 0.017; Phi = 0.7), increased rectal sensitivity, and patient's satisfaction index (P = 0.011; Phi = 0.64).

CONCLUSIONS

Stapled transanal rectal resection allowed for the correction of rectocele and intussusceptions. These corrections increased rectal sensitivity, diminished symptoms of obstructed defecation syndrome, and improved the quality of life of patients.

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.

The role of biofeedback in the treatment of gastrointestinal disorders

Biofeedback is a form of treatment that has no adverse effects and can be provided by physician extenders. The therapy relies on patients' ability to learn how to influence their bodily functions through dedicated machinery and teaching. This Review provides a comprehensive overview of all potential therapeutic applications of biofeedback for functional constipation, fecal incontinence, functional anorectal pain, IBS, functional dyspepsia, and aerophagia. Practical clinical applications of biofeedback therapy supported by randomized, controlled trials (RCTs) are limited to fecal incontinence and dyssynergic defecation. For fecal incontinence, RCTs suggest that biofeedback combining strength training and sensory discrimination training is effective in approximately 75% of patients and is more effective than placebo. However, verbal feedback provided by a therapist during extended digital examination may be equally effective, and children whose fecal incontinence is associated with constipation plus fecal impaction do no better with biofeedback than medical management. For dyssynergic defecation, RCTs show that biofeedback combining pelvic floor muscle relaxation training, practice in defecating a water-filled balloon, and instruction in effective straining is effective in approximately 70% of patients who have failed to respond to laxative treatment. For both incontinence and dyssynergic defecation, the benefits of biofeedback last at least 12 months.

Biofeedback therapy for dyssynergic defecation

Dyssynergic defecation is one of the most common forms of functional constipation both in children and adults; it is defined by incomplete evacuation of fecal material from the rectum due to paradoxical contraction or failure to relax pelvic floor muscles when straining to defecate. This is believed to be a behavioral disorder because there are no associated morphological or neurological abnormalities, and consequently biofeedback training has been recommended for treatment. Biofeedback involves the use of pressure measurements or averaged electromyographic activity within the anal canal to teach patients how to relax pelvic floor muscles when straining to defecate. This is often combined with teaching the patient more appropriate techniques for straining (increasing intra-abdominal pressure) and having the patient practice defecating a water filled balloon. In adults, randomized controlled trials show that this form of biofeedback is more effective than laxatives, general muscle relaxation exercises (described as sham biofeedback), and drugs to relax skeletal muscles. Moreover, its effectiveness is specific to patients who have dyssynergic defecation and not slow transit constipation. However, in children, no clear superiority for biofeedback compared to laxatives has been demonstrated. Based on three randomized controlled studies in the last two years, biofeedback appears to be the preferred treatment for dyssynergic defecation in adults.

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.

Pelvic outlet obstruction

Despite the wide variety of definitions and descriptions of constipation, ideally, the diagnostic approach should be uniform. The evaluation process should begin with a careful and thorough patient history and physical exam; appropriate efforts should be made to exclude organic causes of constipation. Patients suffering from pelvic outlet obstruction often respond poorly to conservative treatment. Diagnostic tests include intestinal transit studies, anorectal manometry, defecography, balloon expulsion, and anal sphincter electromyography. For many patients constipation is multifactorial and accordingly, so is the treatment. In our opinion the first line of treatment should be based on conservative measures including adequate intake of fluids, dietary fiber supplementation, and laxatives. Biofeedback training should be offered, particularly to patients with paradoxical puborectalis contraction. Surgical management can, in very limited circumstances, be offered only to those patients with disabling symptoms who have failed other standard therapeutic measures.

Treatment of obstructed defecation

Obstructed defecation is a common problem that adversely affects the quality of life for many patients. Known causes of obstructed defecation include pelvic dyssynergy, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse. Management of this condition requires an understanding of urinary, defecatory, and sexual function to achieve optimal outcomes. The goal of surgical treatment is to restore the various pelvic organs to their appropriate anatomic positions. However, there is a poor correlation between anatomic and functional results. It must be remembered that the pelvis contains many structures and that defects of pelvic support or function frequently affect other pelvic organs. Optimal outcomes can be achieved only by selecting appropriate treatment modalities that address all of the components of an individual patient's problem.

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[Differential diagnosis in descending perineum syndrome]

Clinical symptoms in descending perineum syndrome show considerable variations, ranging from obstructed defecation to combined fecal and urinary incontinence and including different types of prolapse. Differential diagnosis has to compete with this complexity. Common pelvic floor disorders associated with descending perineum are rectocele, rectal prolapse, enterocele, and sigmoidocele. Standardized diagnostic tools include detailed history and clinical examination with proctorectoscopy as well as anorectal manometry, endoanal ultrasound, defecography, and dynamic MR of the pelvic floor. The diagnosis and proposed therapy have to be developed within an interdisciplinary concept.

[Obstructed defecation]

Adequate therapy of obstructed defecation (pelvic outlet obstruction) is often challenging, as the etiology and clinical symptoms include a wide range of disorders. Standardized diagnostic assessment has to differentiate between obstructed defecation caused by either pelvic outlet obstruction or slow transit constipation. Additionally, morphologic changes of colon, rectum, or the pelvic floor have to be separated from functional disorders. Providing defecography or dynamic MR of the pelvic floor, common causes of outlet obstruction such as sigmoidoceles, in which surgery is indicated, and rectal prolapse can be diagnosed with high accuracy. However, the diagnosis and therapeutic options in symptomatic rectocele and intussusception are controversial. Patients with functional disorders such as rectoanal dyssynergia are candidates for conservative treatment (biofeedback). To identify patients who will benefit from surgery for obstructed defecation, careful patient selection remains the crucial issue in diagnostic assessment.

Constipation caused by functional outlet obstruction

Functional constipation is a very common problem in Western societies. Functional outlet obstruction, part of the spectrum of functional constipation, is suspected when patients present with select symptoms. Diagnosis is commonly made with anorectal manometry, electromyography, and rectal evacuation tests. Abnormal test patterns include poor relaxation and contraction of the anal sphincter in response to attempted defecation and difficult rectal evacuation. Several treatment approaches have been tested in these patients. Biofeedback training is considered the most specific therapeutic modality, and it is particularly attractive because of its safety. This review provides an assessment of the diagnostic tests for functional outlet obstruction and summarizes current options for therapy.

Rectocele: pathogenesis and surgical management

BACKGROUND

Rectocele is a common finding in patients with intractable evacuatory disorders. Although much rectocele surgery is conducted by gynecologists en passant with other forms of vaginal surgery, many reports lack appreciation of the importance of coincident anorectal symptoms, and do not report functional and clinical outcome data. The pathogenesis of rectocele is still controversial, as is the embryological and anatomical importance of the rectovaginal septum as well as recognizable defects in its integrity and its relevance in formal repair when rectocele is operated upon as the principal condition in patients with intractable evacuatory difficulty.

DISCUSSION

The investigation and surgical management of rectocele is controversial given the relatively small numbers of operated patients in any single specialist unit and the relative lack of prospective data concerning functional outcome in operated cases. The imaging of rectocele patients is currently in a state of change, and the newer diagnostic modalities including dynamic magnetic resonance imaging frequently display a multiplicity of pelvic floor disorders. When surgery is indicated, coloproctologists most commonly utilize an endorectal defect-specific repair, but there are few controlled randomized data regarding outcome and response criteria of specific symptoms with particular surgical approaches. A Medline-based literature search was conducted for this review to assess the clinical results of defect-specific rectocele repairs using the endorectal, transvaginal, transperineal, or combined approaches. Only the studies are included that report both pre- and postoperative symptoms including constipation, evacuatory difficulty, pelvic pain, the impression of a pelvic mass, fecal incontinence, dyspareunia or the need for assisted digitation to aid defecation.

CONCLUSION

The history of rectocele repair, its clinical and diagnostic features and the advantages, disadvantages and indications for the different surgical techniques are presented in this review. Suggested diagnostic and surgical therapeutic algorithms for management have been included. It is recommended that a multicenter controlled randomized trial comparing surgical approaches for symptomatic evacuatory dysfunction where rectocele is the principal abnormality should be conducted.

Rectocele repair improves evacuation and prolapse complaints independent of anorectal function and colonic transit time

BACKGROUND AND AIMS

Evacuation disorders associated with a rectocele can be improved by rectocele repair. This study investigated whether anorectal function tests results change after rectocele repair.

PATIENTS AND METHODS

Fourteen patients with 2nd or 3rd degree rectocele and evacuation disorder were treated by posterior colporrhaphy and evaluated pre- and postoperatively (after 8 months, range 3-14) using questionnaires, anal manometry and endosonography, rectal barostat testing, and colonic transit time measurement with radio-opaque markers. Results from female controls were used for comparison.

RESULTS

Preoperatively, rectocele patients had high maximal basal sphincter pressures, large sphincter lengths, and low maximal squeeze pressures, with an anal sphincter defect in seven and lower visceral sensitivity scores than in controls. Postprandial rectal responses (more than 10% decrease in postprandial volume after 1 h) were found in 3 of 14 patients compared to 2 of 11 parous and 9 of 11 nulliparous controls. After repair, a rectocele of 2nd degree was found in four patients. Questionnaire scores were significantly decreased for straining, evacuation disorder, manual support, and protrusion. Overall patient satisfaction with the operation scored 8.25 (range 3-10). Defecation frequencies and stool consistencies were unaltered. Anal pressures, rectal compliance-curves, visceral sensitivity, and colonic transit times were unaltered after the rectocele repair.

CONCLUSION

Rectocele repair improved complaints of evacuation disorder and protrusion, but defecation frequency and stool consistency were not affected. Anorectal function was unaltered after rectocele repair. Selection of patients for rectocele repair should be performed based on evacuation and protrusion complaints, anorectal function, or colonic transit time measurements have a limited role.

Does the need to self-digitate or the presence of a large or nonemptying rectocoele on proctography influence the outcome of transanal rectocoele repair?

INTRODUCTION

Transanal repair of anterior rectocoele is a well described technique with variable success rate. In our department we offer repair to patients who fit the following criteria; the need to self digitate (transvaginal or perineal); a large rectocoele; a nonemptying rectocoele. Using these selection criteria previous authors have shown excellent results. The aim of our study was to review our results using this selective approach and also to determine whether the need to self digitate, the presence of a large rectocoele and the degree of emptying could predict which patients would achieve a successful result.

METHODS

Fifty-five patients underwent repair over a three-year period. The main presenting symptom was noted for each patient and also whether self-digitation was required in order to achieve successful evacuation. Dynamic evacuation proctography was performed on all patients. Size of rectocoele, percentage of paste expelled and other proctographic abnormalities were noted for each patient. Follow up was at 6 weeks and 6 months at which point patients were asked whether their symptoms had resolved, improved, remained the same or had worsened.

RESULTS

Complete data were available for 48 of the patients (median age 52 years, IQR 43-63). The presenting complaint was constipation in 22 patients, obstructive defaecation in 15, incomplete evacuation in 5, postdefaecation soiling in 4 and dyspareunia in 2. Thirty-eight patients noted the need to self-digitate, 10 did not. Proctography revealed a large rectocoele (> 4 cm) in 22 patients and a medium or small rectocoele (< 4 cm) in 26 patients. There was a rectocoele alone in 34 patients, in combination with perineal descent in 11 and with intussusception in 3. Median percentage of paste expelled was 70% (range 20-95). At 6 weeks postoperatively, 43 patients had complete resolution of their symptoms whilst 5 reported only some or no improvement. At 6 months, 37 patients sustained complete resolution of their symptoms and 11 did not. Pre-operative factors were compared for these two groups of patients. There was no difference in age (P > 0.05, Mann-Whitney U-test) between the two groups There was also no difference in size of rectocoele, degree of emptying, the presence of another proctographic abnormality and the need to self-digitate between the two groups (P > 0.05, Fisher's exact test).

DISCUSSION

No factors were seen to distinguish between the successful and unsuccessful groups of patients following rectocoele repair, however, an overall success rate of 75% was achieved using our selection criteria. This figure is in keeping with reported success rates in the literature.

Treatment of constipation in adults associated with idiopathic megarectum by behavioural retraining including biofeedback

BACKGROUND

Constipation in adults associated with a grossly dilated rectum and recurrent faecal impaction, idiopathic megarectum, is rare. The aetiology of idiopathic megarectum is unknown, but may involve neuromuscular or behavioural factors. It is unknown whether the condition is reversible. This study aimed to determine the efficacy of behavioural therapy, including biofeedback, in such patients.

METHODS

Six patients (4 female; median age 27) with a history of rectal faecal impaction and a grossly dilated rectum on radiological examination were evaluated by structured questionnaire before, immediately after biofeedback therapy, and on follow-up. Physiological testing was performed before treatment, and 2 patients were evaluated by repeat physiological testing and contrast radiology on follow-up.

RESULTS

On median follow-up of 18 months (range 11-27), five patients felt major and one patient minor improvement in symptoms, including two with complete symptom relief. Four patients came off laxatives without recurrent faecal impaction. In the 2 studied patients rectal size did not appear to decrease.

CONCLUSION

Behavioural retraining, including biofeedback, improved symptoms in most patients with idiopathic megarectum. In some patients symptoms completely resolved, without the need for laxatives. Although further studies are necessary in terms of both larger number of patients and longer follow-up period, behavioural treatment may be useful for such patients.

[New physiological, diagnostic and therapeutic concepts in the management of rectoceles in women]

Anterior rectocele is not only a herniation of the anterior rectal wall into the vagina, but rather a complex anatomical and functional abnormality which may be isolated or associated with other pelvic floor disorders. It could result in rectal obstruction with dyschezia, manual extraction of feces, and fecal or gas incontinence. The purpose of this review is to describe and to assess the most useful methods for the diagnosis and for the treatment of the rectocele. Data from physical examination may be improved by defecography. Surgery remains the main treatment: several surgical ways (perineal, anal, abdominal, laparoscopic) are described. Analysis of the anatomical and functional results allows to assess these techniques and to determine the best therapeutic option.

Constipation and fecal incontinence in the elderly

Although constipation and fecal incontinence are common symptoms in the elderly, relatively little research has been done to differentiate physiologic changes in rectoanal function resulting from aging and pathologic changes resulting from diseases occurring as patients age. Certain physiologic changes occur in many older patients and may predispose them to the development of constipation or fecal incontinence. These symptoms need the same thoughtful evaluation and management in the elderly as in younger patients. Results of therapy often can be good, leading to alleviation of suffering and the ability to lead a fuller life.

Approach to patients with refractory constipation

Constipation is a very frequent problem, particularly in elderly patients. Constipation is a common reason for patients to seek medical advice, and it accounts for a large number of different prescription and over-the-counter medications. In many cases, no definite cause can be found. Most patients respond to conservative therapy with increased fiber and fluid intake alone. Patients with constipation that is more difficult to control or with alarm symptoms (eg, blood in stool, sudden onset, weight loss, or decreasing stool caliber) warrant further investigation. A variety of medical, behavioral, and surgical therapies can be employed to help these more refractory patients.