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

Position paper on transanal irrigation in chronic non-organic constipation

The practice of recto-colonic water irrigation to treat constipation has been used since ancient times with different, uncontrolled, and variably performing methods which have been considered interchangeably all alike. The use of better-performing devices with a standardized methodology is relatively recent, and the term Trans Anal Irrigation (TAI) defines a methodology performed with devices able to control the timing, volume, and pressure of the water introduced into the rectum and colon utilizing a catheter or a cone through the anus. Such practice has been implemented with favorable responses in patients with refractory chronic constipation secondary to neurological diseases. However, since the role of Trans Anal Irrigation as a therapeutic aid in chronic functional constipation and functional evacuation disorders is not yet fully clarified and standardized, a group of clinical investigators with recognized expertise in these clinical conditions intends to clarify the elements that characterize a TAI procedure that can benefit patients with functional constipation and functional defecation disorders defined according to the lastly updated Rome Diagnostic Criteria. Finally, the paper deals with adherence and practical implementation of TAI.

Digital Rectal Exams Are Infrequently Performed Prior to Anorectal Manometry

BACKGROUND

Digital rectal examination should be performed prior to anorectal manometry; however, real-world data is lacking.

AIMS

Characterize real world rates of digital rectal and their sensitivity for detecting dyssynergia compared to anorectal manometry and balloon expulsion test.

METHODS

A retrospective single-center study was conducted to examine all patients who underwent anorectal manometry for chronic constipation between 2021 and 2022 at one tertiary center with motility expertise. Primary outcomes consisted of the rate of digital rectal exam prior to anorectal manometry; and secondary outcomes included the sensitivity of digital rectal exam for dyssynergic defecation.

RESULTS

Only 42.3% of 142 patients had digital rectal examinations prior to anorectal manometry. Overall sensitivity for detecting dyssynergic defecation was 46.4%, but significantly higher for gastroenterology providers (p = .004), and highest for gastroenterology attendings (82.6%).

CONCLUSIONS

Digital rectal examination is infrequently performed when indicated for chronic constipation. Sensitivity for detecting dyssynergic defecation may be impacted by discipline and level of training.

Optimizing the Management Algorithm for Adults With Functional Constipation Failing a Fiber/Laxative Trial in General Gastroenterology: Cost-Effectiveness and Cost-Minimization Analysis

INTRODUCTION

Anorectal function testing is traditionally relegated to subspecialty centers. Yet, it is an office-based procedure that appears capable of triaging care for the many patients with Rome IV functional constipation that fail empiric over-the-counter therapy in general gastroenterology, as an alternative to empirical prescription drugs. We aimed to evaluate cost-effectiveness of routine anorectal function testing in this specific population.

METHODS

We performed a cost-effectiveness analysis from the patient perspective and a cost-minimization analysis from the insurer perspective to compare 3 strategies: (i) empiric prescription drugs followed by pelvic floor physical therapy (PFPT) for drug failure, (ii) empiric PFPT followed by prescription drugs for PFPT failure, or (iii) care directed by up-front anorectal function testing. Model inputs were derived from systematic reviews of prospective clinical trials, national cost data sets, and observational cohort studies of the impact of chronic constipation on health outcomes, healthcare costs, and work productivity.

RESULTS

The most cost-effective strategy was upfront anorectal function testing to triage patients to appropriate therapy, in which the subset of patients without anal hypocontractility on anorectal manometry and with a balloon expulsion time of at least 6.5 seconds would be referred to PFPT. In sensitivity analysis, empiric PFPT was more cost effective than empiric prescription drugs except for situations in which the primary goal of treatment was to increase bowel movement frequency. If adopted, gastroenterologists would refer ∼17 patients per year to PFPT, supporting feasibility.

DISCUSSION

Anorectal function testing seems to be an emergent technology to optimize cost-effective outcomes, overcoming testing costs by phenotyping care.