Patient characteristics and treatment outcome in functional anorectal pain

Pathoetiology of Levator Ani Syndrome and Its Treatment With Translumbosacral Neuromodulation Therapy

INTRODUCTION

The pathoetiology and treatment of levator ani syndrome (LAS) remain unclear.

METHODS

We evaluated pathophysiology using translumbosacral motor-evoked potentials and anorectal manometry in patients with LAS and compared with healthy controls. A cohort underwent translumbosacral neuromodulation therapy (TNT).

RESULTS

Lumbar and sacral motor-evoked potential latencies were prolonged in 32 patients with LAS compared with 31 controls ( P < 0.013), with higher prevalence of anal neuropathy ( P = 0.026). TNT improved anorectal pain ( P = 0.003) and neuropathy ( P < 0.02) in 13 patients with LAS.

DISCUSSION

Patients with LAS demonstrate significant lumbosacral neuropathy that may cause anorectal pain. TNT improved anorectal pain and neuropathy, providing a novel therapeutic option.

Psychological status of patients with functional anorectal pain and treatment efficacy of paroxetine in alleviating the symptoms: a retrospective study

The aim of this study was to investigate the clinical characteristics, psychological status, sleep quality, and quality of life of patients with functional anorectal pain (FAP). The study also assessed the treatment efficacy of paroxetine in alleviating FAP symptoms. A retrospective comparative study of forty-three patients with FAP who were first treated with an anal plug compound glycolate suppository versus paroxetine combined with anal plug compound glycolate suppository between November 2021 and August 2022. Pain, quality of life, depression, anxiety and sleep quality were assessed before and after treatment by the Chinese version of the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2), Health-related quality of life scale (The 12-Item Short-Form Health Survey, SF-12), 17-item Hamilton Depression Rating Scale (HDRS), 14-item Hamilton Anxiety Scale (HAMA), and Pittsburgh Sleep Quality Index (PSQI). A total of 46.5% of patients with FAP were found to have anxiety symptoms (HAMA ≥ 7), 37.2% of patients with FAP were found to have depressive symptoms (HDRS ≥ 8). A total of 32.6% of patients with FAP had sleep disorders (PSQI > 10). Within 1 week after drug withdrawal, the short-term efficacy rate of oral paroxetine was 95.5%. After treatment, the symptom pain score (VAS) and sleep score were lower than those before treatment (P < 0.01). In the areas of vitality (VT), Social Functioning (SF), and Mental Health (MH), the difference between the pre-treatment and 8 weeks posttreatment scores of the study group and the control group was statistically significant (P < 0.05). FAP patients have obvious symptoms of anxiety and depression, and the incidence of sleep disturbance is prevalent. Paroxetine, a typical serotonin reuptake inhibitor (SSRI), was able to alleviate depression, anxiety, and pain symptoms in FAP, which might have clinical application prospects.

Erectile dysfunction, depression, and anxiety in patients with functional anorectal pain: a case-control study

BACKGROUND

Men with functional anorectal pain (FARP) report having erectile dysfunction (ED) and significant changes in psychological status.

AIM

The study sought to investigate the risk factors associated with FARP among male Chinese outpatients, alongside the impact of FARP on patients' ED, depression, and anxiety.

METHODS

This case-control study included 406 male participants, divided into FARP (n = 323) and healthy control (n = 73) groups. Demographic and disease characteristics were collected from the patients, and the 5-item International Index of Erectile Function, Patient Health Questionnaire-9, and Generalized Anxiety Disorder 7 were used to assess erectile function, depression, and anxiety symptoms. Baseline characteristics were described using descriptive statistics, logistic regression analysis identified factors influencing FARP, and its association with ED, depression, and anxiety were analyzed using linear and ordinal logistic regression analyses. Validity was ensured through subgroup and sensitivity analyses.

OUTCOMES

The primary outcome was the association between FARP and ED, depression, and anxiety; the secondary outcome was the influencing factors of FARP such as lifestyle and work habits.

RESULTS

Men with FARP were likely to have more serious ED (59.8% vs 32.9%), depression (20.7% vs 4.1%), and anxiety(31.5% vs 12.3%); have lower 5-item International Index of Erectile Function scores; or have higher Patient Health Questionnaire-9 and Generalized Anxiety Disorder 7 scores compared with unaffected participants. Alcohol intake, family relationship, high work pressure, and prolonged bowel movements were significantly associated with FARP severity. The association between FARP with ED, depression, and anxiety was statistically significant in both crude and adjusted models. FARP was associated with 2.47, 2.73, and 2.67 times higher risk for ED, depression, and anxiety, respectively. An increase pain severity increased the incidence of ED (moderate pain: 4.80 times, P < .000; severe pain: 3.49 times, P < .004), depression (moderate pain: 1.85 times, P < .017; severe pain: 2.04 times, P < .037), and anxiety (moderate pain: 1.86 times, P < .014).Clinical Implications: Changes in lifestyle and work habits can help prevent pain symptom exacerbation. Attention to erection and psychological issues in patients with FARP and interdisciplinary comprehensive treatment may improve the efficacy.

STRENGTHS AND LIMITATIONS

The study highlights a correlation between FARP and ED, depression, and anxiety, with pain severity being a contributing factor. However, the study's limitations include a small sample size and potential recall bias, and other sexual functions were not thoroughly explored.

CONCLUSION

Patients with FARP have a higher prevalence of ED, depression, and anxiety, which increase with pain severity. Factors such as alcohol intake, work pressure, prolonged sitting, and longer defecation times are significantly correlated with FARP pain severity.

Prevalence and Correlates of Depression and Anxiety in Patients with Functional Anorectal Pain

Purpose

Patients with functional anorectal pain (FAP) often experience psychological distress, impaired quality of life, increased healthcare utilisation, and even suicidal tendencies. However, limited data exists on the psychological correlates of FAP in Chinese patients. Therefore, this study aimed to examine the prevalence of depression, anxiety, and related psychosocial factors in Chinese patients with FAP.

Methods

We used a cross-sectional research design and recruited 100 patients with FAP from SuBei Hospital's multidisciplinary clinic for pelvic floor disorders between January and December 2021. Information on patients' demographic and disease characteristics was also collected. Depressive and anxiety symptoms were assessed using the Patient Health Questionnaire Depression (PHQ-9) and the Generalised Anxiety Disorder Questionnaire (GAD-7). Multiple logistic regression analysis was used to examine factors associated with depression and anxiety.

Results

The prevalence of depressive and anxiety symptoms among patients with FAP was 55% and 46%, respectively. Being a woman, specific marital status (single, divorced, separated, or widowed), longer FAP duration, and sleep disturbance were significantly associated with an increased risk of depressive symptoms. Additionally, specific marital status (single, divorced, separated, or widowed), sleep disturbance, and high Visual Analogue Scale scores were associated with anxiety symptoms.

Conclusion

Depressive and anxiety symptoms are prevalent in patients with FAP. Several socio-demographic and clinical predictors have been identified. There is a need for psychologists to be involved in the treatment of patients with FAP. Thus, multidisciplinary treatment may be the optimal treatment strategy.

Diagnosis and Management of Functional Pouch Disorders: A Systematic Review

BACKGROUND

Functional disorders impart significant morbidity in patients with inflammatory bowel disease who undergo restorative proctocolectomy.

OBJECTIVE

This systematic review aimed to summarize the management strategies for various functional disorders of the pouch.

DATA SOURCES

A database search of PubMed was conducted to identify relevant clinical studies assessing the management of various functional disorders in patients who underwent restorative proctocolectomy.

STUDY SELECTION

Published clinical studies investigating a functional disorder of the pouch in patients who previously underwent a colectomy with ileal pouch-anal anastomosis.

INTERVENTIONS

Restorative proctocolectomy was completed in patients with inflammatory bowel disease or other indications such as a diagnosis of familial adenomatous polyposis.

MAIN OUTCOME MEASURES

The primary outcomes described in this review include the prevalence of functional disorders of the pouch in patients undergoing restorative proctocolectomy and the relevant management strategies.

RESULTS

Ten clinical studies were identified using the predetermined search terms and screened for relevancy to patients with inflammatory bowel disease who previously underwent colectomy with ileal pouch-anal anastomosis. A qualitative summary was developed on the basis of data from these studies and from current guidelines developed for the management of inflammatory bowel disease.

LIMITATIONS

This systematic review is limited by the small number and low quality of the clinical studies included as well as the nonquantitative summary of the findings.

CONCLUSIONS

Functional disorders of the pouch are likely underdiagnosed. Although a source of significant morbidity, these diseases require additional clinical studies to better elucidate effective management strategies.

Optimal management of functional anorectal pain: a systematic review and network meta-analysis

Functional anorectal is idiopathic and characterised by severe and potentially intractable anorectal pain. The current review aims to appraise available evidence for the management of functional anorectal pain and synthesise reported outcomes using network meta-analysis. PubMed, CENTRAL and Web of Science databases were searched for studies investigating treatments for functional anorectal pain. The primary outcome was clinical improvement of symptoms and the secondary outcome was pain scores reported during follow-up. A Bayesian network meta-analysis of interventions was performed. A total of 1538 patients were included from 27 studies. Intramuscular injection of triamcinolone, sacral neuromodulation (SNM) and biofeedback were most likely to be associated with improvement in symptoms [SUCRA (triamcinolone) = 0.79; SUCRA (SNM) = 0.74; SUCRA (Biofeedback) = 0.61]. Electrogalvanic stimulation (EGS), injection of botulinum toxin A and topical glyceryl trinitrate (GTN) were less likely to produce clinical improvement [SUCRA (EGS) = 0.53; SUCRA (Botox) = 0.30; SUCRA (GTN) = 0.27]. SNM and biofeedback were associated with the largest reductions in pain scores [mean difference, range (SNM) = 4.6-8.2; (Biofeedback) = 4.6-6]. As biofeedback is noninvasive and may address underlying pathophysiology, it is a reasonable first-line choice in patients with high resting pressures or defecation symptoms. In patients with normal resting pressures, SNM or EGS are additional options. Although SNM is more likely to produce a meaningful response compared to EGS, EGS is noninvasive and has less morbidity. Whilst triamcinolone injection is associated with symptomatic clinical improvement, the magnitude of pain reduction is less.

Dyssynergic Defecation and Other Evacuation Disorders

Constipated patients are frequently referred to gastroenterologists for symptoms refractory to lifestyle modifications and laxatives. Dyssynergic defecation, the dyscoordination of rectoanal, abdominal, and pelvic floor muscles to facilitate defecation, is a major cause of refractory primary constipation. Understanding of the diagnosis, evaluation, and management of dyssynergic defecation and other evacuation disorders will allow providers to effectively manage these patients. This review focuses on the definition, pathophysiology, evaluation, and treatment of dyssynergic defecation and other evacuation disorders. Emerging treatments for these disorders include home biofeedback therapy for dyssynergic defecation and translumbosacral neuromodulation therapy for levator ani syndrome.

A Pain in the Butt: Hemorrhoids, Fissures, Fistulas, and Other Anorectal Syndromes

Painful and bothersome anorectal syndromes can be a diagnostic and therapeutic challenge for clinicians because structural and functional abnormalities may often coexist and require a multidisciplinary approach to management. Although it is often difficult to attribute all of a patient's anorectal symptoms to a singular disorder with definitive intervention and cure, improving quality of life, treating coexistent conditions such as functional constipation and/or defecation disorders, addressing psychological comorbidities if present, and confirming there is no evidence of inflammatory or malignant conditions are top priorities.

Clinical diagnosis and treatment of functional anorectal pain

Functional anorectal pain (FARP) is a kind of nonorganic, idiopathic pain that occurs in the anus and/or rectum. The pathogenesis of FARP is very complex, and there is no unified conclusion in the academic world. This paper reviews the clinical diagnosis and treatment of FARP to provide a reference for clinicians.

Proctalgia Syndromes: Update in Diagnosis and Management

PURPOSE OF REVIEW

Functional anorectal pain syndromes are a neglected yet often disabling clinical entity resulting in significant economic and psychological burden to the patient. The aim of this review is to update the practicing gastroenterologist/coloproctologist on the diagnosis and management of these complicated disorders.

RECENT FINDINGS

The updated Rome foundation diagnostic criteria (Rome IV) for functional anorectal pain subgroups chronic proctalgia (levator ani syndrome and unspecified functional anorectal pain) and acute proctalgia (proctalgia fugax) on the basis of symptom duration and digital rectal examination findings. Chronic proctalgia is thought to be secondary to paradoxical pelvic floor contraction in many patients and biofeedback to improve the defecation effort has proven effective for over 90% in the short term. Unfortunately, management of proctalgia fugax remains challenging and treatment outcomes modest at best. A number of therapies to relax the pelvic floor may be employed to improve symptoms in functional anorectal pain syndromes; however, only biofeedback to improve defaecatory dynamics in patients with levator ani syndrome has proven effectiveness in a randomized setting. Further investigation of treatment approaches in proctalgia fugax is required.

An International Survey of Commonly Used Interventions for Management of Pelvic Pain

Background

Pelvic pain (PP) is a debilitating condition that is challenging to manage. Despite differences in suspected etiologies of different PP conditions, common clinical signs and symptoms make it appropriate to group these diagnoses. The presence of neuro-musculoskeletal impairments in PP suggests that physical therapists are ideally situated to be included as part of the health care team managing this condition; however, little information is available to guide physical therapist management of PP.

Objectives

As a first step to developing management guidelines, we sought to determine common interventions currently used by physical therapists to manage PP.

Study Design

Descriptive survey.

Methods

A modified Delphi approach was used to identify broad categories of interventions that were then used to build a survey. Purposeful selection with snowball recruiting methods was used to collect responses from practitioners. Frequency data were collected for survey responses. Chi-square analysis determined associations among responses based on practitioner training.

Results

A total of 984 responses from 17 different countries were analyzed. The primary responses were from physical therapists in the USA and Canada. The majority of respondents were board-certified clinical specialists. More than 80% of physical therapist respondents indicated that they "frequently used" education, exercise, and manual therapy for patients with PP. The most common interventions considered effective but not frequently used were cognitive-behavioral therapy, dry needling, acupuncture, topical medications, and internal pelvic manual therapy techniques. Geographical differences in patterns of usespecific manual therapy and exercise interventions were noted. Differences were also noted on the basis of the levels of advanced postprofessional training.

Conclusion

Physical therapists routinely use education, manual therapy, and exercise to manage pelvic pain conditions.

Treatment Outcome of Acute Sacral Nerve Stimulation in Functional Anorectal Pain

BACKGROUND

Sacral nerve stimulation (SNS) has revolutionized the management of certain intractable cases of fecal and urinary incontinence; however, the management of functional anorectal pain (FAP) has been addressed in only a few studies.

OBJECTIVE

The aim of this study was to evaluate the treatment effect of SNS in improving FAP symptoms.

METHODS

A total of 120 patients with FAP who had undergone temporary SNS probe placement were investigated at Qianfoshan Hospital between January 2014 and December 2016. Pre- and post-SNS treatment outcomes were assessed using the VAS, anorectal manometry, and the 36-item short-form health survey (SF-36) medical outcomes study instrument.

RESULTS

A total of 120 patients proceeded to insertion of an SNS probe at the S3 nerve root (2 Hz, 1.50 mA, 0.10 milliseconds). Of these, 75 patients were cured, 41 improved, and 4 had an ineffective outcome. The total effectiveness rate was 96.7% 1 year after treatment. There was a significant reduction in the median VAS score pre-SNS and post-SNS, from 8 to 3, respectively. Patients post-SNS had lower anal maximum contraction pressure and anal rest pressure than did patients pre-SNS. Compared with the pretreatment group, there were no substantial differences between anal longest contraction time and rectal rest pressure. In addition to general health, there was a substantial improvement in the remaining dimension scores of the SF-36.

CONCLUSION

The effect of SNS in treating FAP was positive, and the improvement of symptoms was substantial and worthy of clinical promotion.

The Role of Botox in Colorectal Disorders

PURPOSE OF REVIEW

To overview the current medical literature on the efficacy of botulism toxin treatment (BTX-A) for lower gastrointestinal disorders (GIT).

RECENT FINDINGS

BTX-A was found to have a short-term efficacy for the treatment of dyssynergic defecation. Surgical treatment was found to be more effective than BTX-A for the healing of chronic anal fissures, and BTX-A can be considered when surgery is undesirable. Data regarding the effects of BTX-A injection for the treatment of chronic anal pain is limited. Beneficial effects were observed only in a minority of patients. BTX-A treatment was found to be effective for the treatment of obstructive symptoms after surgery for Hirsprung's disease as well as for the treatment of internal anal sphincter achalasia. BTX-A treatment has a short-term efficacy and is safe. Further research is still needed in order to establish the exact place of BTX-A treatment of lower GIT disorders.

Role of three-dimensional endoanal ultrasound in assessing the anal sphincter morphology of female patients with chronic proctalgia

AIM

To assess the role of three-dimensional endoanal ultrasound (3D-EAUS) for morphological assessment of the anal sphincter of female patients with chronic proctalgia (CP).

METHODS

In this unmatched case control study, 30 consecutive female patients with CP and 25 normal women (control group) were enrolled. 3D-EAUS was performed in all subjects. Thickness and length of internal anal sphincter (IAS), thickness of puborectalis muscle (PR), length of the external anal sphincter (EAS) plus PR, and puborectalis angle were measured and compared between the two groups.

RESULTS

Patients with CP had significantly shorter IAS length and greater PR thickness, as compared to those in normal individuals (26.28 ± 3.59 mm vs 28.87 ± 4.84 mm, P < 0.05 and 9.67 ± 1.57 mm vs 8.85 ± 0.97 mm, P < 0.05, respectively). No significant between-group differences were observed with respect to IAS thickness and the EAS plus PR length (P > 0.05). Puborectalis angle in the CP group was significantly decreased, both in resting (88.23° ± 1.81° vs 89.94° ± 2.07° in control group, P < 0.05) and straining (88.47° ± 3.32° vs 90.72° ± 1.87° in control group, P < 0.05) phases, which suggest the presence of paradoxical contraction of PR in patients with CP. In the CP group, no significant difference in puborectalis angle was observed between the resting and straining phases (88.23° ± 1.81° vs 88.47° ± 3.32° respectively, P > 0.05).

CONCLUSION

The association of greater PR thickness and paradoxical contraction of PR with CP suggest their potential value as markers of CP.

The Clinical Characteristics of Patients with Chronic Idiopathic Anal Pain

The aim of this study was to investigate the clinical characteristics, treatment outcomes and psychological distress in patients with chronic idiopathic anal pain. The study was conducted on patients referred to Hangzhou Third Hospital for chronic anal pain from January, 2010 to December, 2014. Patient demographics, clinical history, anorectal physiology, and radiological imaging data were recorded for all patients. The treatment outcome was noted for patients treated and followed up for more than 6 month at the present unit. Ninety-six patients with mean age of 45.1 years (range, 17-82) were studied. Seventy-one patients (74.0%) had functional anorectal pain(FARP). The main complaints were dull, sharp, stabbing, or spasm pain. Among all patients, 34.3% reported that their pain radiated into other locations. Fifty-one patients (53.1%) had bowel dysfunction, while 28.1% patients had urinary dysfunction. The common factors associated with pain relief were day time, lying down and warm water baths; the factors that contributed to aggravated pain were night time, defecation or sitting. 92.7% (89/96) of patients reported symptoms of psychological disturbance. FARP patients exhibited increased depression than non-FARP patients(P<0.05). In addition, female patients were more likely to have depression than male patients (P<0.05). The overall pain treatment success rate was 55.2% (53/96). The pain treatment outcome was better in non-FARP patients than in FARP patients(χ2=3.85, P<0.05). Conclusively, chronic idiopathic anal pain is a complex clinical symptom, involving pelvic floor muscles, the nervous system, endocrine system, and the patients' psychological conditions. Further research is needed to improve diagnosis and treatment for patients with chronic idiopathic anal pain.

Incidence and risk factors for rectal pain after laparoscopic rectal cancer surgery

Objective This study was performed to investigate the incidence of and potential risk factors for rectal pain after laparoscopic rectal cancer surgery. Methods We retrospectively analyzed data from 300 patients who underwent laparoscopic rectal cancer surgery. We assessed the presence of rectal pain and categorized patients into Group N (no rectal pain) or Group P (rectal pain). Results In total, 288 patients were included. Of these patients, 39 (13.5%) reported rectal pain and 14 (4.9%) had rectal pain that persisted for >3 months. Univariate analysis revealed that patients in Group P had more preoperative chemoradiotherapy, more ileostomies, longer operation times, more anastomotic margins of <2 cm from the anal verge, more anastomotic leakage, and longer hospital stays. Multivariate analysis identified an anastomotic margin of <2 cm from the anal verge and a long operation time as risk factors. The presence of diabetes mellitus was a negative predictor of rectal pain. Conclusions In this study, the incidence of rectal pain after laparoscopic rectal cancer surgery was 13.5%. An anastomotic margin of <2 cm from the anal verge and a long operation time were risk factors for rectal pain. The presence of diabetes mellitus was a negative predictor of rectal pain. Thus, the possibility of postoperative rectal pain should be discussed preoperatively with patients with these risk factors.

Anorectal and Pelvic Pain

Although pelvic pain is a symptom of several structural anorectal and pelvic disorders (eg, anal fissure, endometriosis, and pelvic inflammatory disease), this comprehensive review will focus on the 3 most common nonstructural, or functional, disorders associated with pelvic pain: functional anorectal pain (ie, levator ani syndrome, unspecified anorectal pain, and proctalgia fugax), interstitial cystitis/bladder pain syndrome, and chronic prostatitis/chronic pelvic pain syndrome. The first 2 conditions occur in both sexes, while the latter occurs only in men. They are defined by symptoms, supplemented with levator tenderness (levator ani syndrome) and bladder mucosal inflammation (interstitial cystitis). Although distinct, these conditions share several similarities, including associations with dysfunctional voiding or defecation, comorbid conditions (eg, fibromyalgia, depression), impaired quality of life, and increased health care utilization. Several factors, including pelvic floor muscle tension, peripheral inflammation, peripheral and central sensitization, and psychosocial factors, have been implicated in the pathogenesis. The management is tailored to symptoms, is partly supported by clinical trials, and includes multidisciplinary approaches such as lifestyle modifications and pharmacological, behavioral, and physical therapy. Opioids should be avoided, and surgical treatment has a limited role, primarily in refractory interstitial cystitis.

Painful intercourse is significantly associated with evoked pain perception and cognitive aspects of pain in women with pelvic pain

Introduction

Evidence suggests that painful intercourse, pain-related psychosocial factors, and altered pain processing magnify the pain experience, but it is not clear how these factors are related to each other.

Aim

The aims were to (i) characterize differences between women with pelvic pain and pain-free women using a battery of pain-related psychosocial measures, clinical pain ratings, and evoked local and remote pain sensitivity; and (ii) examine the relationship between intercourse pain, clinical pain, and local and remote evoked pain sensitivity.

Methods

Women with pelvic pain lasting at least 3 months and pain-free women completed questionnaires and underwent pain sensitivity testing. Self-report measures included clinical pain intensity, pain catastrophizing, pain-related fear, pain anxiety, depression, sexual function, and self-efficacy. Pain sensitivity measures included threshold and tolerance and temporal summation of pain. Separate analyses of variance (anova) were used to test group differences in self-report and pain sensitivity measures. Correlations were calculated among dyspareunia, psychosocial factors, and evoked pain.

Main Outcome Measures

Self-reported pain and pain sensitivity measures.

Results

Twenty-eight pain-free women and 14 women with pelvic pain participated in this study. Women with pelvic pain reported greater pain intensity and greater psychosocial involvement compared with pain-free women. No differences existed between groups for thermal or pressure measures, but women with pelvic pain rated their pain with pain testing significantly higher than pain-free women. Intercourse pain was significantly associated with affective and sensory pain and pressure pain ratings at the puborectalis, vulvar vestibule, adductor longus tendons, and tibialis anterior muscle.

Conclusions

Differences in local pain ratings suggest that women with pelvic pain perceive stimuli in this region as more painful than pain-free women although the magnitude of stimuli does not differ. Alappattu MJ, George SZ, Robinson ME, Fillingim RB, Moawad N, LeBrun EW, and Bishop MD. Painful intercourse is significantly associated with evoked pain perception and cognitive aspects of pain in women with pelvic pain. Sex Med 2015;3:14–23.

Sacral nerve stimulation for faecal incontinence and constipation: a European consensus statement

AIM

In Europe during the last decade sacral nerve stimulation (SNS) or sacral neuromodulation (SNM) has been used to treat faecal incontinence (FI) and constipation. Despite this, there is little consensus on baseline investigations, patient selection and operative technique. A modified Delphi process was conducted to seek consensus on the current practice of SNS/SNM for FI and constipation.

METHOD

A systematic literature search of SNS for FI and constipation was conducted using PubMed. A set of questions derived from the search and expert opinion were answered on-line on two occasions by an international panel of specialists from Europe. A 1-day face-to-face meeting of the experts finalized the discussion.

RESULTS

Three hundred and ninety-three articles were identified from the literature search, of which 147 fulfilled the inclusion criteria. Twenty-two specialists in FI and constipation from Europe participated. Agreement was achieved on 43 (86%) of 50 domains including the set-up of service, patient selection, baseline investigations, operative technique and programming of the device. The median of agreement was 95% (35-100%).

CONCLUSION

Consensus was achieved on the majority of domains of SNS/SNM for FI and constipation. This should serve as a benchmark for safe and quality practice of SNS/SNM in Europe.

Diagnostic value of pelvic floor surface electromyography in functional anorectal pain

AIM: To assess the diagnostic value of pelvic floor surface electromyography (sEMG) in functional anorectal pain (FARP) using receiver operating characteristic (ROC) curve analysis.

METHODS: The parameters of pelvic floor sEMG in 118 patients with FARP and 103 normal controls were measured according to the Glazer protocol. Parameters included amplitude (AVG), coefficient of variance (CV), onset time and median frequency (MF). The ROC curve was plotted to assess the diagnostic value of pelvic floor sEMG.

RESULTS: Compared with the control group, the FARP group had a lower AVG (23.81 ± 13.75 vs 30.55 ± 16.14, P < 0.05) and a higher CV (0.43 ± 0.12 vs 0.30 ± 0.07, P < 0.05) during the tonic phase and a higher CV during the endurance phase (0.40 ± 0.15 vs 0.28 ± 0.09, P < 0.05). The critical value of CV during the tonic and endurance phases were 0.35 and 0.31, respectively, and the areas under ROC curve were 0.813 and 0.761.

CONCLUSION: CV during the tonic and endurance phases has better diagnostic value in FARP.

Treatment of chronic anorectal pain by acupuncture

Chronic anorectal pain is a common functional anorectal disease. Currently, there are still some difficulties in diagnosing and treating this disease. Acupuncture has advantages in treating chronic anorectal pain. This article will summarize the progress in treatment of chronic anorectal pain by acupuncture.

Chronic pelvic pain

Chronic pelvic pain is pain lasting longer than 6 months and is estimated to occur in 15% of women. Causes of pelvic pain include disorders of gynecologic, urologic, gastroenterologic, and musculoskeletal systems. The multidisciplinary nature of chronic pelvic pain may complicate diagnosis and treatment. Treatments vary by cause but may include medicinal, neuroablative, and surgical treatments.

Managing gastrointestinal symptoms after cancer treatment: a practical approach for gastroenterologists

The percentage of the population living with a diagnosis of cancer is rising. By 2030, there will be 4 million cancer survivors in the UK. One quarter of cancer survivors are left with physical symptoms, which affect their quality of life. Gastrointestinal (GI) symptoms are the most common of all chronic physical side-effects of cancer treatment and have the greatest impact on daily activity. Cancer therapies induce long-term changes in bowel function due to alterations to specific GI physiological functions. In addition, the psychological effect of a cancer diagnosis, new GI disease or pre-existing underlying conditions, may also contribute to new symptoms. Twenty-three upper GI symptoms have been identified as occurring after pelvic radiotherapy. After upper GI cancer treatment, the most troublesome symptoms include reflux, abdominal pain, indigestion, diarrhoea and fatigue. Often, several symptoms are present simultaneously and women experience more symptoms than men. The symptoms which patients rate as most difficult are urgency, wind, diarrhoea, incontinence, abdominal pain and rectal bleeding. Recent UK Guidance on managing GI symptoms suggests that these symptoms can be treated especially if gastroenterological advice is combined with dietetic and nursing input to optimise investigations and management. However, as different pathological processes can result in identical symptoms; a systematic, 'algorithmic' approach to assess and treat these symptoms is required. This paper aims to illustrate the value of such an approach to investigate and treat the most common GI symptoms that trouble patients. The algorithm allows clinicians to institute a comprehensive medical management plan.

Treatment approaches of gastrointestinal dysfunction in Parkinson's disease, therapeutical options and future perspectives

Gastrointestinal (GI) dysfunction is a common but underestimated feature in Parkinson's disease (PD). Out of the multimodal spectrum of treatment options, there currently are only a few pharmacological treatments available to improve gastrointestinal motility and symptoms. Because enteric nervous function is mainly regulated by transmitters different from those involved in the brain, dopamine replacement is not a treatment option in PD patients. This article focuses on the known regulative mechanism of GI function and presents known and upcoming treatment options for GI dysfunction in PD.