Minimum standards of anorectal manometry

Review article: advances in the diagnosis and management of anorectal motility disorders

BACKGROUND

Anorectal motility disorders such as dyssynergic defecation (DD), faecal incontinence (FI) and anorectal pain affect 40% of the population and are a frequent reason for gastroenterology consultation. They significantly affect the quality of life and lead to psychological distress. Lack of understanding of these problems compounded by a lack of availability and knowledge of diagnostic tools in most medical centres and/or trained physicians has significantly hampered this field.

AIMS

To discuss the latest advances in pathophysiology, diagnostic tests and therapeutic options for these disorders using an evidence-based approach.

METHODS

We reviewed the published literature over the past 20 years on DD, FI and anorectal pain and distilled these into a narrative review.

RESULTS

A detailed history, prospective stool diary and digital rectal exam, together with diagnostic tests such as anorectal manometry, balloon expulsion test, translumbosacral anorectal magnetic stimulation test for assessing neuropathy, defecography and anal ultrasound, can provide detailed mechanistic and structural information. Such knowledge can pave the way for a meaningful and pathophysiologic-based management approach. This could include biofeedback therapy for DD or FI, sensory training for rectal hyposensitivity or sensory adaptation training for rectal hypersensitivity or sphincter bulking agents or neuromodulation therapies. These treatments are effective and safe.

CONCLUSIONS

Anorectal motility disorders are common, but either less well recognized or poorly managed by most gastroenterologists. Equipped with the practical and up-to-date knowledge provided in this review, physicians could provide improved health care for these patients.

Anorectal Manometry in Pediatric Colorectal Surgical Care

BACKGROUND

Pediatric colorectal specialists care for patients with a variety of defecation disorders. Anorectal (AR) manometry testing is a valuable tool in the diagnosis and management of these children. This paper provides a summary of AR manometry techniques and applications as well as a review of AR manometry findings in pediatric patients with severe defecation disorders referred to a pediatric colorectal center. This is the first study describing multi-year experience using a portable AR manometry device in pediatric patients.

METHODS

An electronic medical record review was performed (1/2018 to 12/2023) of pediatric patients with defecation disorders who had AR manometry testing. Demographics, diagnostic findings, and outcomes are described.

KEY RESULTS

A total of 297 unique patients (56.9% male, n = 169) had AR manometry testing. Of these, 72% (n = 188) had dyssynergic defecation patterns, of which 67.6% (n = 127) had fecal soiling prior to treatment. Pelvic rehabilitation (PR) was administered to 35.4% (n = 105) of all patients. A total of 79.5% (n = 58) of the 73 patients that had fecal soiling at initial presentation and completed PR with physical therapy and a bowel management program were continent after therapy. AR manometry was well tolerated, with no major complications.

CONCLUSIONS

AR manometry is a simple test that can help guide the management of pediatric colorectal surgical patients with defecation disorders. As a secondary finding, PR is a useful treatment for patients with dyssynergic stooling.

Latent profile analysis reveals the central role of psychological symptoms in driving disease severity in chronic constipation

BACKGROUND

Chronic constipation (CC) is defined by symptom criteria reflecting heterogenous physiology. However, many patients with CC have significant psychological comorbidities-an alternative definition using a biopsychosocial classification model could be warranted to inform future treatments. We sought to: (1) empirically derive psychological symptom profiles of patients with CC using latent profile analysis and (2) validate these profiles by comparing them on symptom severity, GI-specific anxiety, body mass index (BMI), and anorectal manometry findings.

METHODS

Participants included adults presenting for anorectal manometry for CC (N = 468, 82% female, Mage = 47). Depression/anxiety symptoms and eating disorder (ED) symptoms (EAT-26) were used as indicators (i.e., variables used to derive profiles) representing unique psychological constructs. Constipation symptoms, GI-specific anxiety, BMI, and anorectal manometry results were used as validators (i.e., variables used to examine the clinical utility of the resulting profiles).

KEY RESULTS

A 5-profile solution provided the best statistical fit, comprising the following latent profiles (LPs): LP1 termed "high dieting, low bulimia;" LP2 termed "high ED symptoms;" LP3 termed "moderate ED symptoms;" LP4 termed "high anxiety and depression, low ED symptoms;" and LP5 termed "low psychological symptoms." The low psychological symptom profile (61% of the sample) had lower abdominal and overall constipation severity and lower GI-specific anxiety compared to the four profiles characterized by higher psychological symptoms (of any type). Profiles did not significantly differ on BMI or anorectal manometry results.

CONCLUSIONS AND INFERENCES

Profiles with high psychological symptoms had increased constipation symptom severity and GI-specific anxiety in adults with CC. Future research should test whether these profiles predict differential treatment outcomes.

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

BACKGROUND & AIMS

Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings.

METHODS

Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations.

RESULTS

ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices.

CONCLUSIONS

Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.

Study on 3D High-Resolution Anorectal Manometry Interrater Agreement in the Evaluation of Dyssynergic Defecation Disorders

Anorectal manometry measurements exhibit significant interrater variability. Newer techniques like 3D high-resolution anorectal manometry (3D-HRAM) have the potential to enhance diagnostic accuracy and our understanding of defecation disorders. However, the extent of interrater variability in 3D-HRAM is still unknown. Between January 2020 to April 2022, patients referred for pelvic floor physical therapy (PFPT) due to functional defecation complaints underwent 3D-HRAM testing. In a retrospective analysis, three expert raters independently evaluated the 3D-HRAM results in a blinded matter to assess interrater agreement. The evaluation also determined the level of agreement concerning dyssynergic patterns during simulated defecation. The 3D-HRAM results of 50 patients (37 females) were included. Twenty-nine patients had complaints of fecal incontinence, eleven patients had chronic constipation, and ten patients had several other complaints. There was a substantial agreement (kappa 0.612) between the raters concerning the 3D images on dyssynergic patterns during simulated defecation. Our study emphasizes the need for standardized guidelines in evaluating 3D-HRAM test results to reduce subjectivity and further improve agreement among raters. Implementing these guidelines could improve diagnostic consistency and enhance personalized treatment strategies, increasing the reliability and usefulness of 3D-HRAM testing in clinical practice.

Association of delivery mode and number of pregnancies with anorectal manometry data in patients with postpartum constipation

OBJECTIVE

To explore the association of delivery mode and the number of pregnancies with anorectal manometry data in patients with postpartum constipation.

METHODS

This retrospective study included women with postpartum constipation treated at the pelvic floor rehabilitation department of Huzhou Maternity & Child Health Care Hospital between January 2018 and December 2019.

RESULTS

Among 127 patients included, 55 (43.3%) had one pregnancy, 72 (56.7%) had two pregnancies, 96 (75.6%) delivered spontaneously, 25 (16.7%) underwent Cesarean section, and six (4.7%) needed a Cesarean section despite spontaneous labor. The median duration of constipation was 12 months (range, 6-12). There were no differences between the two groups for any manometry parameters (all P > 0.05). The patients with a spontaneous delivery had a lower change in maximal contracting sphincter pressure compared with those with Cesarean section (14.3 (4.5-25.0) vs. 19.6 (13.4-40.0), P = 0.023). Only the delivery mode (Cesarean vs. spontaneous) independently affected the changes in contracting sphincter pressure (B = 10.32, 95%CI: 2.95-17.69, P = 0.006); age (P = 0.201), number of pregnancies (P = 0.190), and constipation duration (P = 0.161) were not associated.

CONCLUSION

The patients with a spontaneous delivery had a lower change in maximal contracting sphincter pressure compared with those with a Cesarean section, suggesting that patients with Cesarean may retain a better "push" function during defecation.

Intra-subject Variability in High Resolution Anorectal Manometry Using the London Classification: Diagnostic and Therapeutic Implications

This retrospective pilot study conducted on a community-based cohort of both men and women of various ages and underlying clinical presentations examined the durability and reproducibility of HR-ARM findings influencing their potential impact on clinical decision-making at the point of care (Jameson et al. in Br J Surg 81:1689-1692, 1994). The key finding of our study was that only a minority of patients who underwent repeat anorectal manometry as analyzed by the London Classification had stable manometric findings, raising questions regarding the validity of a single manometric measurement, as currently analyzed, for clinical decision-making.

Optimizing techniques for measuring anal resting and squeeze pressures with high-resolution manometry

BACKGROUND

The optimal methods for measuring and analyzing anal resting and squeeze pressure with high-resolution manometry (HRM) are unclear.

METHODS

Anal resting and squeeze pressures were measured with HRM in 90 healthy women, 35 women with defecatory disorders (DD), and 85 with fecal incontinence (FI). Pressures were analyzed with Manoview™ software and a customized approach. Resting pressures measured for 20, 60, and 300 s were compared. During the squeeze period, (3 maneuvers, 20 s each), the squeeze increment, which was averaged over 5, 10, 15, and 20 s, and squeeze duration were evaluated.

RESULTS

Compared to healthy women, the anal resting pressure, squeeze pressure increment, and squeeze duration were lower in FI (p ≤ 0.04) but not in DD. The 20, 60, and 300 s resting pressures were strongly correlated (concordance correlation coefficients = 0.96-0.99) in healthy and DD women. The 5 s squeeze increment was the greatest; 10, 15, and 20 s values were progressively lower (p < 0.001). The squeeze pressure increment and duration differed (p < 0.01) among the three maneuvers in healthy and DD women but not in FI women. The upper 95th percentile limit for squeeze duration was 19.5 s in controls, 19.9 s in DD, and 19.3 s in FI. Adjusted for age, resting pressure, and squeeze duration, a greater squeeze increment was associated with a lower risk of FI versus health (OR, 0.96; 95% CI, 0.94-0.97).

CONCLUSIONS

These findings suggest that anal resting and squeeze pressures can be accurately measured over 20 s. In most patients, one squeeze maneuver is probably sufficient.

Review of the indications, methods, and clinical utility of anorectal manometry and the rectal balloon expulsion test

BACKGROUND

Anorectal manometry (ARM) comprehensively assesses anorectal sensorimotor functions.

PURPOSE

This review examines the indications, techniques, interpretation, strengths, and weaknesses of high-resolution ARM (HR-ARM), 3-dimensional high-resolution anorectal manometry (3D-HR-ARM), and portable ARM, and other assessments (i.e., rectal sensation and rectal balloon expulsion test) that are performed alongside manometry. It is based on a literature search of articles related to ARM in adults. HR-ARM and 3D-HR-ARM are useful for diagnosing defecatory disorders (DD), to identify anorectal sensorimotor dysfunction and guide management in patients with fecal incontinence (FI), constipation, megacolon, and megarectum; and to screen for anorectal structural (e.g., rectal intussusception) abnormalities. The rectal balloon expulsion test is a useful, low-cost, radiation-free, outpatient assessment tool for impaired evacuation that is performed and interpreted in conjunction with ARM. The anorectal function tests should be interpreted with reference to age- and sex-matched normal values, clinical features, and results of other tests. A larger database of technique-specific normal values and newer paradigms of analyzing anorectal pressure profiles will increase the precision and diagnostic utility of HR-ARM for identifying abnormal mechanisms of defecation and continence.

Utility of postoperative anorectal manometry in children with anorectal malformation: a systematic review

Children with anorectal malformation (ARM) often continue to have disturbances in bowel function long after reconstructive surgery. Anorectal manometry may be utilized to evaluate bowel function in these children. We aimed to describe the reported protocols and manometric findings in children with ARM post-reconstructive surgery and to investigate the correlation between manometric evaluation and bowel functional outcome. PubMed, EMBASE, and Google Scholar databases were searched from 1980 to 2021. Data were reviewed and extracted independently by two authors, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Included studies were English articles reporting postoperative assessment of children (≤ 18 years) with ARM using anorectal manometry. From 128 articles obtained in the initial search, five retrospective cohort studies and one prospective study fulfilled inclusion criteria. The rectoanal inhibitory reflex and mean anal resting pressure were parameters most often reported to correlate with postoperative bowel function. The least reported parameters among the studies were high-pressure zone, rectal volume, and rectal sensation. Anorectal manometry could be an objective method providing important information for personalized management of postoperative ARM patients with bowel function issues, but lack of standardized protocols limits a comprehensive analysis of their utility.

THE FATIGUE RATE INDEX IS HIGHER IN CHILDREN WITH FUNCTIONAL CONSTIPATION AND RETENTIVE FECAL INCONTINENCE

BACKGROUND

The Fatigue Rate Index (FRI) is a parameter in anorectal manometry (ARM) to assess sustained voluntary contraction, considering the squeeze pressure and fatigability of the external anal sphincter. It is used in adults to detect fecal incontinence even in patients who present normal squeeze pressures. The FRI in adult patients with functional constipation is similar to controls.

OBJECTIVE

The aim of this study was to evaluate the feasibility and values of FRI in children in relation to the values previously established in adults and comparing children with functional constipation and retentive fecal incontinence to children without retentive fecal incontinence.

METHODS

This retrospective study evaluated 105 ARM performed from Jan 2014 to Apr 2015. 42 patients were selected (were able to perform a voluntary contraction and had no co-morbidities other than functional constipation). 14 (33.3%) of those collaborated in sustaining contraction for 40 seconds (s), allowing the evaluation of the FRI. Patients with retentive fecal incontinence secondary to functional constipation (n=7, aged 6 to 13 years, six boys) were our interest group. Patients with functional constipation without fecal incontinence (n=7, aged 6 to 13 years, four boys) were considered a reference group. The ARM were performed with a radial eight-channel perfusion catheter (DynamedTM, São Paulo, Brazil) and the FRI was calculated (Proctomaster 6.4) in the first 20 s and overall 40 s of sustained voluntary contraction.

RESULTS

14 of the selected 42 collaborated in sustaining contraction for 40 s, allowing the evaluation of the FRI. In the first 20 s of contraction, the fecal incontinence group showed a significantly higher mean FRI (2.48±1.39 min) compared to the reference group (1.13±0.72 min, P=0.042), which was not observed in the 40 s interval due to less uniform contraction. The anal resting pressure was higher in the fecal incontinence group (76.83 mmHg) than in the reference group (54.13 mmHg), but the statistical study did not reach significance (P=0.051).

CONCLUSION

The FRI is feasible in children. The mean FRI obtained in this study is lower than the reported in constipated adults. The mean FRI among children with functional constipation and retentive fecal incontinence is higher than among constipated children without retentive fecal incontinence.

Transcutaneous Electrical Acustimulation Improves Constipation by Enhancing Rectal Sensation in Patients With Functional Constipation and Lack of Rectal Sensation

INTRODUCTION

Reduced rectal sensation is involved in the pathophysiology of constipation. The aim of this study was to investigate the effects of transcutaneous electrical acustimulation (TEA) at acupuncture point ST36 on constipation and rectal sensation as well as autonomic functions in patients with constipation and reduced rectal sensation.

METHODS

In an acute study, anorectal motility and sensation tests were performed in constipation patients (N = 53) who were treated with TEA at ST36 or sham points. In a chronic study, patients (N = 18) underwent 2 weeks of TEA or sham-TEA in a crossover design.

RESULTS

Chronic TEA increased spontaneous bowel movements (3.72 vs 2.00 per week with sham-TEA, P < 0.0001) and significantly reduced constipation symptoms and increased quality of life in comparison with sham-TEA (P < 0.05). Acute TEA reduced the sensation threshold in response to rectal distention for the urge of defecation and maximum tolerable volume (P < 0.05, vs baseline); chronic TEA reduced the sensation thresholds for first sensation and desire of defecation, and decreased the threshold volume to an elicit rectal anal inhibitory reflex (P < 0.05). Both acute and chronic TEA increased parasympathetic activity (P < 0.05).

DISCUSSION

TEA at ST36 improves chronic constipation by enhancing rectal sensation possibly mediated by the reinforcement of parasympathetic activity in patients with functional constipation and reported lack/absence of rectal sensation.

Rectal Evacuation Disorders are Associated With Poor Bowel Preparation in Patients With Chronic Constipation: Results From Two Centers

INTRODUCTION

We evaluated factors that can predict the adequacy of bowel preparation in patients with chronic constipation undergoing colonoscopy.

MATERIALS AND METHODS

We identified patients with chronic constipation who underwent anorectal manometry and at least 1 colonoscopy at 2 tertiary referral centers from 2003 to 2019. We also identified a subgroup of patients who underwent colonic transit testing through radiopaque marker testing. We determined demographic, medical, and constipation-related factors associated with poor bowel preparation and their effect on standardized quality metrics using univariate and multivariate analyses.

RESULTS

We identified 274 patients with chronic constipation who underwent anorectal manometry testing. Both outlet dysfunction (prolonged balloon expulsion) and slow-transit constipation were associated with suboptimal bowel preparation. Outlet dysfunction was also associated with decreased cecal intubation rates, adenoma detection rates, and sessile serrated polyp detection rates. In multivariable analyses controlling for demographics and known factors associated with poor bowel preparation, outlet dysfunction was associated with an almost 3-fold odds of suboptimal bowel preparation [odds ratio (OR): 2.9; 95% confidence interval (CI): 1.6-5.1] and a 3-fold reduction in cecal intubation rates (OR: 0.3; 95% CI: 0.1-0.8). Among those with radiopaque marker colonic transit testing available, slow-transit constipation was associated with a >2-fold odds of suboptimal bowel preparation (OR: 2.2; 95% CI: 1.1-4.4).

CONCLUSIONS

Among a cohort of patients with chronic constipation undergoing colonoscopy, outlet dysfunction was associated with suboptimal bowel preparation and other quality metrics. Constipated patients with a rectal evacuation disorder may represent a subgroup of patients that could benefit from individualized strategies for better bowel preparation.

Systematic review and meta-analysis of anal motor and rectal sensory dysfunction in male and female patients undergoing anorectal manometry for symptoms of faecal incontinence

AIM

Manometry is the best established technique to assess anorectal function in faecal incontinence. By systematic review, pooled prevalences of anal hypotonia/hypocontractility and rectal hypersensitivity/hyposensitivity in male and female patients were determined in controlled studies using anorectal manometry.

METHODS

Searches of MEDLINE and Embase were completed. Screening, data extraction and bias assessment were performed by two reviewers. Meta-analysis was performed based on a random effects model with heterogeneity evaluated by I² .

RESULTS

Of 2116 identified records, only 13 studies (2981 faecal incontinence patients; 1028 controls) met the inclusion criteria. Anal tone was evaluated in 10 studies and contractility in 11; rectal sensitivity in five. Only three studies had low risk of bias. Pooled prevalence of anal hypotonia was 44% (95% CI 32-56, I² = 96.35%) in women and 27% (95% CI 14-40, I² = 94.12%) in men. The pooled prevalence of anal hypocontractility was 69% (95% CI 57-81; I² = 98.17%) in women and 36% (95% CI 18-53; I² = 96.77%) in men. Pooled prevalence of rectal hypersensitivity was 10% (95% CI 4-15; I² = 80.09%) in women and 4% (95% CI 1-7; I² = 51.25%) in men, whereas hyposensitivity had a pooled prevalence of 7% (95% CI 5-9; I² = 0.00%) in women compared to 19% (95% CI 15-23; I² = 0.00%) in men.

CONCLUSIONS

The number of appropriately controlled studies of anorectal manometry is small with fewer still at low risk of bias. Results were subject to gender differences, wide confidence intervals and high heterogeneity indicating the need for international collective effort to harmonize practice and reporting to improve certainty of diagnosis.

A Guide to Establishing a Pediatric Neurogastroenterology and Motility Program

ABSTRACT

The purpose of this document is to provide guidance for establishing a pediatric neurogastroenterology and motility (PNGM) program, including considerations for personnel, equipment, and physical space requirements, and business planning, from members of the neurogastroenterology and motility (NGM) Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) who have developed PNGM programs at various institutions. A business plan defining the needs for required personnel, dedicated physical space, procedures, clinical care, and equipment storage is a prerequisite. Thoughtful logistical planning should address provider schedules, clinical visits, procedure coordination, and prior authorization processes. A business-plan outlining equipment purchase with projected costs, revenue generation, and goals for future growth is desirable for obtaining institutional support, which is imperative to building a successful PNGM program.

Barostat or syringe-assisted sensory biofeedback training for constipation with rectal hyposensitivity: A randomized controlled trial

BACKGROUND

Rectal hyposensitivity (RH) is a well-known pathophysiological dysfunction in chronic constipation. Whether biofeedback training improves RH and restores bowel function is unknown.

AIM

To investigate the efficacy of barostat-assisted sensory training (BAST) with syringe-assisted sensory training (SAST) in patients with RH in a randomized controlled trial.

METHODS

Patients with RH and chronic constipation (Rome III) were randomized to receive 6 biweekly sessions of BAST or SAST. Verbal/visual feedback was provided during repeated rectal distensions to improve defecation desire/urge and first sensations with either 10-cm balloon connected to barostat (BAST) or 4-cm balloon connected to syringe and manometry probe (SAST). Sensory thresholds, bowel symptoms, and therapist and patient's rating of treatments were compared. The primary outcome (responders) was the improvement in ≥2 sensory thresholds.

RESULTS

Sixty-six patients were enrolled: 32 received BAST, 34 received SAST, and 56 completed study. There were significantly more responders in BAST group than SAST (78% vs. 53%, p = 0.0320). Rectal sensation normalized in 81% with BAST compared to 56% with SAST (p = 0.0270). When compared to baseline, desire and urge to defecate thresholds and bowel satisfaction improved with BAST (p = 0.0013; p = 0.0002; p = 0.0001) and SAST (p = 0.0012; p = 0.0001; p < 0.0001) and number of complete spontaneous bowel movements with BAST (p = 0.0029) but without inter-group differences. Therapists rated BAST as superior to SAST (p < 0.0001), but patients rated both equally.

CONCLUSIONS

Sensory biofeedback training was effective and significantly improved rectal sensation and constipation symptoms. Although both techniques were useful, the novel BAST was more efficacious and easier to administer for treating RH.

Redundancy in the International Anorectal Physiology Working Group Manometry Protocol: A Diagnostic Accuracy Study in Fecal Incontinence

BACKGROUND

Anorectal manometry (ARM) is essential for identifying sphincteric dysfunction. The International Anorectal Physiology Working Group (IAPWG) protocol and London Classification provide a standardized format for performing and interpreting ARM. However, there is scant evidence to support timing and number of constituent maneuvers.

AIMS

To assess the impact of protocol modification on diagnostic accuracy in patients with fecal incontinence.

METHODS

Retrospective analysis of high-resolution ARM recordings from consecutive patients based on the current IAPWG protocol and modifications thereof: (1) baseline rest period (60 vs. 30 vs. 10 s); (2) number of abnormal short squeezes (SS) out of 3 (SS1/SS2/SS3) based on maximal incremental squeeze pressures over 5 s; (3) resting anal pressures (reflecting recovery) at 25-30 versus 15-20 s after SS1.

RESULTS

One hundred patients (86 F, median age 55 [IQR: 39-65]; median St. Mark's incontinence score 14 [10-17]) were studied. 26% and 8% had anal hypotonia and hypertonia, respectively. Compared with 60-s resting pressure, measurements had perfect correlation (κ = 1.0) over 30 s, and substantial correlation (κ = 0.85) over 10 s. After SS1, SS2, and SS3, 43%, 49%, and 46% had anal hypocontractility, respectively. Correlation was substantial between SS1 and SS2 (κ = 0.799) and almost perfect between SS2 and SS3 (κ = 0.9). Compared to resting pressure of 5 s before SS1, pressure recordings at 25-30 and 15-20 s after SS1 were significantly correlated.

CONCLUSIONS

A 30-s resting anal pressure, analysis of 2 short-squeezes with a 20-s between-maneuver recovery optimizes study duration without compromising diagnostic accuracy. These findings indicate the IAPWG protocol has redundancy.

Diagnostic Strategy and Tools for Identifying Defecatory Disorders

This article reviews the indications, techniques, interpretation, strengths, and weaknesses of tests (anal manometry, anal surface electromyography, rectal balloon expulsion test, barium and MRI defecography, assessment of rectal compliance and sensation, and colonic transit) that are used diagnose defecatory disorders in constipated patients. The selection of tests and the sequence in which they are performed should be individualized to and interpreted in the context of the clinical features. Because anorectal functions are affected by age, results should be interpreted with reference to age- and sex-matched normal values for the same technique.

New Internet of Medical Things for Home-Based Treatment of Anorectal Disorders

Home-based healthcare provides a viable and cost-effective method of delivery for resource- and labour-intensive therapies, such as rehabilitation therapies, including anorectal biofeedback. However, existing systems for home anorectal biofeedback are not able to monitor patient compliance or assess the quality of exercises performed, and as a result have yet to see wide spread clinical adoption. In this paper, we propose a new Internet of Medical Things (IoMT) system to provide home-based biofeedback therapy, facilitating remote monitoring by the physician. We discuss our user-centric design process and the proposed architecture, including a new sensing probe, mobile app, and cloud-based web application. A case study involving biofeedback training exercises was performed. Data from the IoMT was compared against the clinical standard, high-definition anorectal manometry. We demonstrated the feasibility of our proposed IoMT in providing anorectal pressure profiles equivalent to clinical manometry and its application for home-based anorectal biofeedback therapy.

Volumetric Rectal Perception Testing: Is It Clinically Relevant? Results From a Large Patient Cohort

INTRODUCTION

Rectal perception testing is a recommended component of anorectal physiology testing. Although recent consensus (London) guidelines suggested criteria for categorizing hyporectal and hyper-rectal sensitivity, these were based on scant evidence. Moreover, data regarding diagnostic capabilities and clinical utility of rectal perception testing are lacking. The aims of this study were to determine the association between rectal perception testing and both clinical and physiological variables to enhance the analysis and interpretation of real-life test results.

METHODS

Prospectively documented data from 1,618 (92% female) patients referred for anorectal physiology testing were analyzed for 3 rectal perception thresholds (first, urge, and maximal tolerated). Normal values derived from healthy female subjects were used to categorize each threshold into hyposensitive and hypersensitive to examine the clinical relevance of this categorization.

RESULTS

There was poor to moderate agreement between the 3 thresholds. Older age, male sex, and constipation were associated with higher perception thresholds, whereas irritable bowel syndrome, fecal incontinence, connective tissue disease, and pelvic radiation were associated with lower perception thresholds to some, but not all, thresholds (P < 0.01 on multivariate analysis for all). The clinical utility and limitations of categorizing thresholds into "hypersensitivity" and "hyposensitivity" were determined.

DISCUSSION

Commonly practiced rectal perception testing is correlated with several disease states and thus has clinical relevance. However, most disease states were correlated with 2 or even only 1 abnormal threshold, and agreement between thresholds was limited. This may suggest each threshold measures different pathophysiological pathways. We suggest all 3 thresholds be measured and reported separately in routine clinical testing.

Randomized controlled trial of home biofeedback therapy versus office biofeedback therapy for fecal incontinence

BACKGROUND

Biofeedback therapy is useful for treatment of fecal incontinence (FI), but is not widely available and labor intensive. We investigated if home biofeedback therapy (HBT) is non-inferior to office biofeedback therapy (OBT).

METHODS

Patients with FI (≥1 episode/week) were randomized to HBT or OBT for 6 weeks. HBT was performed daily using novel device that provided resistance training and electrical stimulation with voice-guided instructions. OBT consisted of six weekly sessions. Both methods involved anal strength, endurance, and coordination training. Primary outcome was change in weekly FI episodes. FI improvement was assessed with stool diaries, validated instruments (FISI, FISS, and ICIQ-B), and anorectal manometry using intention-to-treat analysis.

KEY RESULTS

Thirty (F/M = 26/4) FI patients (20 in HBT, 10 in OBT) participated. Weekly FI episodes decreased significantly after HBT (Δ ± 95% confidence interval: 4.7 ± 1.8, compared with baseline, p = 0.003) and OBT (3.7 ± 1.6, p = 0.0003) and HBT was non-inferior to OBT (p = 0.2). The FISI and FISS scores improved significantly in HBT group (p < 0.02). Bowel pattern, bowel control, and quality of life (QOL) domains (ICIQ-B) improved significantly in HBT arm (p < 0.023). Resting and maximum squeeze sphincter pressures significantly improved in both HBT and OBT groups and sustained squeeze pressure in HBT, without group differences.

CONCLUSIONS & INFERENCES

Home biofeedback therapy is non-inferior to OBT for FI treatment. Home biofeedback is safe, effective, improves QOL, and through increased access could facilitate improved management of FI.

The Effect of a Didactic Course on Gastroenterology Nurses' Knowledge and Interest in Anorectal Manometry

Anorectal manometry may be performed by a nurse or physician, yet little has been written about what training is needed. Additionally, many gastroenterology nurses receive little exposure to motility studies such as anorectal manometry, limiting their ability to learn these procedures. We therefore sought to evaluate whether a short didactic course on anorectal manometry would increase nurses' knowledge about the procedure and stimulate their interest in becoming trained to perform it. To accomplish this, gastroenterology nurses attended a series of three lectures on anorectal manometry. A 15-question quiz was given as a pre-test and again as a post-test after completing the course. Thirteen nurses participated (11 female, mean age 46). None had experience performing anorectal manometry. Due to the course, test scores increased from a mean of 8.4 (55.9%) correct to 13.3 (88.7%) (p < .001), with improvements noted in 12 of 13 participants (92.3%). All of the nurses felt that the course increased their knowledge of anorectal manometry and reported that they would recommend it to other nurses. Most (61.5%) also expressed an interest in becoming trained to perform anorectal manometry. In conclusion, a short didactic course has been shown to increase nurses' knowledge and interest in performing anorectal manometry.

Normal values for high-resolution anorectal manometry in healthy young adults: evidence from Vietnam

BACKGROUND

High-resolution anorectal manometry (HRAM) has been developed to improve measurement of anorectal functions. This study aims to identify normal HRAM values in healthy young Vietnamese adults.

METHODS

We conducted a cross-sectional study at the National Hospital of Traditional Medicine (Hanoi, Vietnam) from July through December 2014. Healthy young adults were invited to participate in the study. All anorectal measurement values were performed using the ISOLAB high-resolution manometry system. Differences between groups were analyzed using Student's t-tests.

RESULTS

Thirty healthy young adults, including 15 males and 15 females aged 19-26 years, were recruited. Mean functional anal canal length was 3.4 ± 0.5 cm (range: 2.4-4.8 mm). Mean maximum resting pressure, mean maximum squeezing pressure, mean maximum coughing pressure, and mean maximum strain pressure were 65.5, 168.0, 125.9, and 84.2 mm Hg, respectively. All anal pressure values were significantly different between males and females. For rectal sensation measurements, only the volume at first sensation was significantly higher in males than in females.

CONCLUSIONS

This study provides normal HRAM value for healthy young adults in Vietnam. Sex may influence anal pressure and first rectal sensation values in this cohort. Further studies should be conducted in order to improve the quality of HRAM normal values and to confirm the effects of sex.

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

Background:

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

Aim:

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

Methods:

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

Results:

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

Conclusions:

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

Review article: diagnosis, management and patient perspectives of the spectrum of constipation disorders

BACKGROUND

Chronic constipation is a common, heterogeneous disorder with multiple symptoms and pathophysiological mechanisms. Patients are often referred to a gastroenterology provider after laxatives fail. However, there is limited knowledge of the spectrum and management of constipation disorders.

AIM

To discuss the latest understanding of the spectrum of constipation disorders, tools for identifying a pathophysiologic-based diagnosis in the specialist setting, treatment options and the patient's perspective of constipation.

METHODS

Literature searches were conducted using PubMed for constipation diagnostic criteria, diagnostic tools and approved treatments. The authors provided insight from their own practices.

RESULTS

Clinical assessment, stool diaries and Rome IV diagnostic criteria can facilitate diagnosis, evaluate severity and distinguish between IBS with constipation, chronic idiopathic constipation and dyssynergic defecation. Novel smartphone applications can help track constipation symptoms. Rectal examinations, anorectal manometry and balloon expulsion, assessments of neuromuscular function with colonic transit time and colonic manometry can provide mechanistic understanding of underlying pathophysiology. Treatments include lifestyle and diet changes, biofeedback therapy and pharmacological agents. Several classes of laxatives, as well as prokinetic and prosecretory agents, are available; here we describe their mechanisms of action, efficacy and side effects.

CONCLUSIONS

Constipation includes multiple overlapping subtypes identifiable using detailed history, current diagnostic tools and smartphone applications. Recognition of individual subtype(s) could pave the way for optimal, evidence-based treatments by a gastroenterology provider.

Anorectal manometry in pediatric settings: A systematic review of 227 studies

BACKGROUND

There is wide variation in the clinical use of diagnostic tools for children with chronic constipation and functional/structural fecal incontinence (CCFSFI). Anorectal manometry (ARM) is a well-recognized technique to assess the function of the anorectum.

PURPOSE

Our aim was to perform an up-to-date review on ARM in pediatric patients with CCFSFI, with specific focus on the indication of use and protocol. Variation of its use in pediatrics will be explored.

METHODS

A systematic search was conducted for empirical studies utilizing ARM with a pediatric sample. A keyword search of literature published in English before July 2018 was conducted and updated to October 2019. Data on demographics, clinical information, study aims, ARM parameters and use of sedation/anesthesia were collected.

KEY RESULTS

A total of 227 studies were included in this systematic review. The age of study participants at the time of ARM ranged from birth to 18 years. ARM was most commonly used in patients with organic conditions (65%) compared to functional constipation (41%). In almost half [108/227 (48%)] of the studies, ARM was performed awake. The ARM parameters most frequently assessed were the rectoanal inhibitory reflex, which was evaluated in 198/227 studies (87%) and the anal resting pressure [166/227 studies (73%)].

CONCLUSIONS AND INFERENCES

This systematic review has highlighted the vast variation of ARM use within pediatrics and the need to strive toward standardization and use of consensus guidelines. We anticipate this will further advance our understanding of the pathophysiological mechanisms involved in children with defecation disorders.

Modified colonic transit test in healthy subjects and constipated patients: A triple-phase, two-center prospective study

BACKGROUND AND AIM

Classic daily-ingestion single-film protocol using radiopaque markers for colonic transit time (CTT) is unsuitable for Chinese patients because of rapid colonic motility. A new modified method needs to be established.

METHODS

The triple-phase study was performed. In Phase I, the classic protocol was assessed to evaluate its feasibility for Chinese subjects. In Phase II, a modified protocol was performed in two centers on 180 healthy subjects and 90 constipated patients to determine optimal conditions. In Phase III, the simplified protocol was validated on 90 constipated patients.

RESULTS

All the subjects of the Phase I expelled more than 95% of the markers during the examination period, which means that the classic protocol is unsuitable for Chinese patients. The 20.9-h mean total CTT for healthy Chinese subjects was much faster than that seen in Western countries. As shown by Phase II, the numbers of subjects went beyond the upper limit were 22 in P1TCTT and 10 in P2TCTT (8.14% vs 3.70%, P = 0.029). The percentage of values fall outside of the measurement range of excretion ratio was around half of our study subjects (45-70%), whereas this percentage was only 3.70% using P2TCTT. The simplified protocol had a diagnostic accuracy for constipation of 0.81, with a sensitivity and specificity of 0.46 and 0.97, respectively.

CONCLUSIONS

Colon movement in Chinese individuals is significantly faster than that of Western populations. The modified protocol generated in this study is appropriate for diagnosis of constipation in population with rapid colon motility.

Systematic evaluation of cough-anorectal pressure responses in health and in fecal incontinence: A high-resolution anorectal manometry study

BACKGROUND

Anorectal manometry is the most commonly performed test of anorectal function. The cough-anorectal response is frequently assessed as part of a routine manometric investigation but has not previously been the subject of detailed analysis. This study systematically examined anorectal pressure responses to cough in health and evaluated the impact of parity and symptoms of fecal incontinence (FI) on measurements.

METHODS

High-resolution anorectal manometry (HR-ARM) traces from nulliparous (n = 25) and parous (n = 25) healthy volunteers (HV: aged 41, range 18-64), and 57 parous patients with FI (age 47, range 28-72) were retrospectively reviewed. Cough-anorectal pressure responses were analyzed between groups by qualitative and quantitative approaches.

KEY RESULTS

In health, traditional anal pressure measurements ("rest" and "squeeze") were similar between nulliparous and parous women. In contrast, incremental anal-rectal pressure difference during cough significantly differed: nulliparous 42 mm Hg (95% CI: 21-64) vs. parous 6 mm Hg (-14-25), P < 0.036). This measure also differed significantly between nulliparous HVs and patients with FI (-2 mm Hg (95% CI: -15-12), P < 0.001), but not between parous HVs and FI. Qualitatively, a color-contour trace resembling a "spear" in the upper anal canal was observed uniquely in FI. Of 25 patients with normal anal function by traditional measures, cough parameters were abnormal in 52%.

CONCLUSIONS AND INFERENCES

Novel HR-ARM measures during coughing revealed differences in anal function between nulliparous and parous HV, and patients with FI, which were not detected by traditional measures. Cough-anorectal measurements may improve manometric yield, though clinical utility would require assessment by longitudinal studies.

The Role of Traditional Acupuncture in Patients with Fecal Incontinence-Mini-Review

OBJECTIVE

Fecal incontinence affects up to 15% of the general population, with higher rates of incidence among women and the elderly. Acupuncture is an old practice of Traditional Chinese Medicine that might be used to treat fecal incontinence. The aim of this mini review was to assess the effect of acupuncture for fecal incontinence.

MATERIALS AND METHODS

Cochrane Library, Web of Science, Embase, PubMed, and CENTRAL electronic databases were searched until August 2020. The following keywords were used: acupuncture, electroacupuncture, moxibustion, fecal incontinence, diarrhea, irritable bowel syndrome, and bowel dysfunction. In addition, references were searched. Five studies (two randomized controlled trials), out of 52,249 predefined publications after an electronic database search, were included into the review.

RESULTS

Overall, 143 patients were included. All studies report significant improvements in continence, although they all apply different acupuncture regimens. Randomized controlled trials show significant differences in experimental groups treated with acupuncture in improving continence. Significant improvement in quality of life scores was reported. In addition, improvement in fecal continence remained significantly improved after 18 months of follow-up.

CONCLUSION

Acupuncture is a promising treatment alternative for fecal incontinence. Based on small, low-quality studies, it might be a safe, inexpensive, and efficient method. However, more high-quality studies are needed in order to apply this treatment technique routinely.

Kegel Exercises, Biofeedback, Electrostimulation, and Peripheral Neuromodulation Improve Clinical Symptoms of Fecal Incontinence and Affect Specific Physiological Targets: An Randomized Controlled Trial

Background/Aims

Fecal incontinence (FI) is a prevalent condition among community-dwelling women, and has a major impact on quality of life (QoL). Research on treatments commonly used in clinical practice—Kegel exercises, biofeedback, electrostimulation, and transcutaneous neuromodulation—give discordant results and some lack methodological rigor, making scientific evidence weak. The aim is to assess the clinical efficacy of these 4 treatments on community-dwelling women with FI and their impact on severity, QoL and anorectal physiology.

Methods

A randomized controlled trial was conducted on 150 females with FI assessed with anorectal manometry and endoanal ultrasonography, and pudendal nerve terminal motor latency, anal/rectal sensory-evoked-potentials, clinical severity, and QoL were determined. Patients were randomly assigned to one of the following groups Kegel (control), biofeedback + Kegel, electrostimulation + Kegel, and neuromodulation + Kegel, treated for 3 months and re-evaluated, then followed up after 6 months.

Results

Mean age was 61.09 ± 12.17. Severity of FI and QoL was significantly improved in a similar way after all treatments. The effect on physiology was treatment-specific Kegel and electrostimulation + Kegel, increased resting pressure (P < 0.05). Squeeze pressures strongly augmented with biofeedback + Kegel, electrostimulation + Kegel and neuromodulation + Kegel (P < 0.01). Endurance of squeeze increased in biofeedback + Kegel and electrostimulation + Kegel (P < 0.01). Rectal perception threshold was reduced in the biofeedback + Kegel, electrostimulation + Kegel, and neuromodulation + Kegel (P < 0.05); anal sensory-evoked-potentials latency shortened in patients with electrostimulation + Kegel (P < 0.05).

Conclusions

The treatments for FI assessed have a strong and similar efficacy on severity and QoL but affect specific pathophysiological mechanisms. This therapeutic specificity can help to develop more efficient multimodal algorithm treatments for FI based on pathophysiological phenotypes.

The Prevalence of Enteropathy Symptoms from the Lower Gastrointestinal Tract and the Evaluation of Anorectal Function in Diabetes Mellitus Patients

Complications affecting the gastrointestinal tract often occur in the course of diabetes mellitus (DM). The aim of this study was to evaluate enteropathy symptoms and anorectal function using high-resolution anorectal manometry (HRAM). Fifty DM patients and 20 non-DM controls were enrolled into the study. Clinical data and laboratory tests were collected, physical examination and HRAM were performed. Symptoms in the lower gastrointestinal tract were reported by 72% of patients. DM patients with a long disease duration reported anal region discomfort (p = 0.028) and a sensation of incomplete evacuation (p = 0.036) more often than patients with shorter diabetes duration. Overall, DM patients had a lower maximal squeeze pressure (MSP) (p = 0.001) and a higher mean threshold of minimal rectal sensation (p < 0.01) than control subjects. They presented with enhanced features of dyssynergic defection than the control group. MSP and maximal resting pressure (MRP) were significantly lower in the group of long-term diabetes (p = 0.024; p = 0.026 respectively) than in patients with a short-term diabetes. The same observation was noted for patients with enteropathy symptoms that control for MSP (p < 0.01; p < 0.01; p = 0.03) and MRP (p < 0.001; p = 0.0036; p = 0.0046), respectively, for incontinence, constipation, and diarrhea. Symptoms in the lower gastrointestinal tract are often reported by DM patients. All DM patients have impaired function of the external anal sphincter and present enhanced features of dyssynergic defecation and also impaired visceral sensation. Patients with long-standing DM and patients with enteropathy symptoms have severely impaired function of both anal sphincters.

Anorectal Physiology Testing for Prolapse-What Tests are Necessary?

Rectal prolapse frequently occurs in conjunction with functional and anatomic abnormalities of the bowel and pelvic floor. Prolapse surgery should have as its goal not only to correct the prolapse, but also to improve function to the greatest extent possible. Careful history-taking and physical exam continue to be the surgeon's best tools to put rectal prolapse in its functional context. Physiologic testing augments this and informs surgical decision-making. Defecography can identify concomitant middle compartment prolapse and pelvic floor hernias, potentially targeting patients for urogynecologic consultation or combined repair. Other tests, including manometry, ultrasound, and electrophysiologic testing, may be of utility in select cases. Here, we provide an overview of available testing options and their individual utility in rectal prolapse.

Translumbosacral Neuromodulation Therapy for Fecal Incontinence: A Randomized Frequency Response Trial

INTRODUCTION

Treatments for fecal incontinence (FI) remain unsatisfactory because they do not remedy the underlying multifactorial dysfunction(s) including anorectal neuropathy. The aim of this study was to investigate the optimal dose frequency, clinical effects, and safety of a novel treatment, translumbosacral neuromodulation therapy (TNT), aimed at improving neuropathy.

METHODS

Patients with FI were randomized to receive 6 sessions of weekly TNT treatments consisting of 600 repetitive magnetic stimulations over each of 2 lumbar and 2 sacral sites with either 1, 5, or 15 Hz frequency. Stool diaries, FI severity indices, anorectal neurophysiology and sensorimotor function, and quality of life were compared. Primary outcome measure was the change in FI episodes/week. Responders were patients with ≥50% decrease in weekly FI episodes.

RESULTS

Thirty-three patients with FI participated. FI episodes decreased significantly (∆ ±95% confidence interval, 4.2 ± 2.8 (1 Hz); 2 ± 1.7 (5 Hz); 3.4 ± 2.5 (15 Hz); P < 0.02) in all 3 groups when compared with baseline. The 1 Hz group showed a significantly higher (P = 0.04) responder rate (91 ± 9.1%) when compared with the 5 Hz group (36 ± 18.2%) or 15 Hz (55 ± 18.2%); no difference was found between the 5 and 15 Hz groups (P = 0.667). Anal neuropathy, squeeze pressure, and rectal capacity improved significantly only in the 1 Hz (P < 0.05) group compared with baseline, but not in other groups. Quality of life domains improved significantly (P < 0.05) with 1 and 5 Hz groups. No device-related serious adverse events were noted.

DISCUSSION

TNT significantly improves FI symptoms in the short term, and the 1 Hz frequency was overall better than 5 and 15 Hz. Both anorectal neuropathy and physiology significantly improved, demonstrating mechanistic improvement. TNT is a promising, novel, safe, efficacious, and noninvasive treatment for FI (see Visual Abstract, Supplementary Digital Content 3, http://links.lww.com/AJG/B598).

[Recommendations for the Protocol of functional examination of the anorectal zone and disorders classification: the International Anorectal Physiology Working Group consensus and Russian real-world practice]

This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed. Aim to provide information about methods of diagnosis and new classification of functional anorectal disorders to a wide range of specialists general practitioners, therapists, gastroenterologists, coloproctologists all who face the manifestations of these diseases in everyday practice and determine the diagnostic and therapeutic algorithm. Current paper provides agreed statements of IAPWG Consensus and comments (in italics) of Russian experts on real-world practice, mainly on methodology of examination. These comments in no way intended to detract from the provisions agreed by the international group of experts. We hope that these comments will help to improve the quality of examination based on the systematization of local experience with the use of the methods discussed and the results obtained. Key recommendations: the International Anorectal Physiology Working Group protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia.

Placement of a fine-bore rectal balloon catheter in the anal canal does not affect anal sphincter pressures: improving our understanding of physiological function with anal acoustic reflectometry

AIM

The recto-anal inhibitory reflex (RAIR) is currently measured using anorectal manometry catheters, which may distort the anal canal. Anal acoustic reflectometry (AAR) is considered a catheter-free technique for evaluating the physiological function of the anal canal; however, it has yet to be used to elicit the RAIR. For the RAIR to be measured with AAR, the effect of placing an additional rectal balloon catheter on the measured AAR parameters needs to be investigated: that is the aim of this work.

METHOD

Patients aged over 18 years attending hospital for the investigation of pelvic floor disorders were included. AAR parameters were obtained before and after a rectal balloon catheter was placed alongside the AAR catheter. The following parameters were measured: opening pressure (Op, cmH₂ O), opening elastance (Oe, cmH₂ O/mm² ), closing pressure (Cp, cmH₂ O), closing elastance (Ce, cmH₂ O/mm² ), hysteresis (Hys, %), squeeze opening pressure (SqOp, cmH₂ O) and squeeze opening elastance (SqOe, cmH₂ O/mm² ).

RESULTS

Thirty-five patients were included in the analysis, of whom 28 were women. The median age was 58 years. Comparison of median AAR parameters before and after catheter placement showed no significant difference: Op (36.36 vs 33.42, P = 0.09), Oe (1.27 vs 1.39, P = 0.19), Cp (18.62 vs 19.73, P = 0.13), Ce (1.2 vs 1.28, P = 0.33), Hys (41.08 vs 40.11, P = 0.17), SqOp (81.85 vs 81.65, P = 0.93) and SqOe (1.44 vs 1.49, P = 0.55).

DISCUSSION

Placement of a rectal balloon catheter alongside the AAR catheter has no significant effect on the measured AAR parameters. The results of this study add to the fundamental basic science and understanding of the physiological function of the anal canal.

Frequency of Eating Disorder Pathology Among Patients With Chronic Constipation and Contribution of Gastrointestinal-Specific Anxiety

BACKGROUND & AIMS

Individuals with eating disorders (EDs) frequently have constipation-related symptoms, although the mechanisms of this relationship are not clear. We examined the frequency of and relation between EDs and constipation in patients with chronic constipation referred for anorectal manometry.

METHODS

We analyzed data from 279 patients with chronic constipation (79.2% female) evaluated at a tertiary center from June 2017 through September 2018. Participants completed a standardized psychometric assessment (patient assessment of constipation symptoms questionnaire and hospital anxiety and depression scale and visceral sensitivity index analyses) and anorectal manometry. A subset of patients completed colonic transit testing. Participants with clinically significant ED pathology were identified based on scores of 20 or higher on the Eating Attitudes Test-26. We performed a logistic regression analysis to examine factors associated with the likelihood of having ED pathology. Odds ratios were calculated based on continuous variables. We examined the contribution of anxiety to the relationship between severity of ED pathology and symptoms of constipation (such as abdominal pain) using a regression-based bootstrapping approach.

RESULTS

Of the study participants, 53 (19.0%) had clinically significant ED pathology. The presence of ED pathology was associated with greater general anxiety scores, based on the hospital anxiety and depression scale (odds ratio, 1.20; 95% CI, 1.05-1.38), and greater gastrointestinal-specific anxiety scores, based on the visceral sensitivity index (odds ratio, 1.06; 95% CI, 1.03-1.09). Gastrointestinal-specific anxiety fully mediated the relationship between the severity of ED pathology and constipation (standardized β, 0.11-0.16; P = .026-.024). We found no differences in anorectal manometry or colonic transit between patients with vs without ED pathology.

CONCLUSIONS

In an analysis of patients with chronic constipation, we found that 19% had clinically significant ED pathology. Our preliminary finding indicated that ED pathology might contribute to constipation via gastrointestinal-specific anxiety. Clinicians should consider screening patients with chronic constipation for EDs-especially patients who report symptoms such as bloating and abdominal pain.

Dyssynergic Defecation and Anal Sphincter Disorders in Children in High-Resolution Anorectal Manometry Investigation

OBJECTIVES

Dyssynergic defecation is a common disorder in children with functional constipation (FC) because of relaxation disorders of the sphincter apparatus and intra-rectal pressure during defecation. The aim of the study was to determine frequency and type of dyssynergic defecation and to assess pressure in the anal canal poles during simulated evacuation and function of puborectalis muscle in defecation in children with FC.

METHODS

Three-dimensional (3D) high-resolution anorectal manometries (3D HRAM) were performed in 131 children with FC. In the manometric test, resting pressure measurements were assessed in 4 measuring poles of the anal canal.

RESULTS

One hundred thirty-one children ages 5 to 17 years (mean age 10.2; SD ± 3.8; median 10) were involved in the study (69 girls and 62 boys). Dyssynergic defecation was shown in 106/131 (80.9%) examined children. A statistically significant difference between the age of examined children (P < 0.02) and intrarectal pressures at the anal canal measuring points (left P < 0.009, right P < 0.005, anterior P < 0.01) was found. Correlation between the residual pressure values in lateral anal canal measurement poles and intrarectal pressure was demonstrated in all types of dyssynergy (left: r = 0.69, P < 0.0005; right: r = 0.74, P < 0.0005). In a group of 53/131 (40.5%) children, 3D HRAM showed a rectal pressure increase during simulated defecation, because of the dysfunction of the puborectalis muscle.

CONCLUSION

The increase in sphincter pressure in lateral and posterior poles in I and II types of dyssynergia and in lateral poles in other types of dyssynergia may depend on relaxation disorders of the puborectalis muscle during defecation.

The London Classification: Improving Characterization and Classification of Anorectal Function with Anorectal Manometry

PURPOSE OF REVIEW

Objective measurement of anorectal sensorimotor function is a requisite component in the clinical evaluation of patients with intractable symptoms of anorectal dysfunction. Regrettably, the utility of the most established and widely employed investigations for such measurement (anorectal manometry (ARM), rectal sensory testing and the balloon expulsion test) has been limited by wide variations in clinical practice.

RECENT FINDINGS

This article summarizes the recently published International Anorectal Physiology Working Group (IAPWG) consensus and London Classification of anorectal disorders, together with relevant allied literature, to provide guidance on the indications for, equipment, protocol, measurement definitions and results interpretation for ARM, rectal sensory testing and the balloon expulsion test. The London Classification is a standardized method and nomenclature for description of alterations in anorectal motor and sensory function using office-based investigations, adoption of which should bring much needed harmonization of practice.

Assessing Anorectal Function in Constipation and Fecal Incontinence

Constipation and fecal incontinence are commonly encountered complaints in the gastrointestinal clinic. Assessment of anorectal function includes comprehensive history, rectal examination, and prospective stool diary or electronic App diary that accurately captures bowel symptoms, evaluation of severity, and quality of life of measure. Evaluation of a suspected patient with dyssynergic constipation includes anorectal manometry, balloon expulsion test, and defecography. Investigation of a suspected patient with fecal incontinence includes high-resolution anorectal manometry; anal ultrasound or MRI; and neurophysiology tests, such as translumbosacral anorectal magnetic stimulation or pudendal nerve latency. This article provides an approach to the assessment of anorectal function.

Comparison between high-resolution water-perfused anorectal manometry and THD® Anopress anal manometry: a prospective observational study

AIM

Anorectal physiology tests provide a functional assessment of the anal canal. The aim of this study was to compare the results generated by standard high-resolution water-perfused manometry (WPM) with the newer THD^® Anopress manometry system.

METHOD

This was a prospective observational study. Conventional manometry was carried out using a water-perfused catheter with high-resolution manometry and compared with the Anopress system with air-filled catheters. All patients underwent the two procedures successively in a randomized order. Time to arrive at the resting pressure plateau, resting, squeeze, straining pressure and visual analogue scale (VAS) scores for pain were recorded. A qualitative analysis of the two devices was performed.

RESULTS

Between 2016 and 2017, 60 patients were recruited. The time from insertion of the catheter to arriving at the resting pressure plateau was significantly lower with the Anopress compared with WPM: 12 s [interquartile range (IQR) 10-17 s] versus 100 s (IQR 67-121 s) (P < 0.001). A strong correlation between the manometric values of WPM and the Anopress was observed. Both procedures were well tolerated, although the VAS score for insertion of the WPM catheter was significantly higher. The Anopress was easier to use and more time-efficient than the WPM.

CONCLUSION

The pressure values obtained with Anopress correlated well with those of conventional manometry. The Anopress has the advantage of being less time-consuming, user-friendly and better tolerated by patients.

Specific Changes in Manometric Parameters are Associated with Non-improvement in Symptoms after Rectocele Repair

INTRODUCTION AND HYPOTHESIS

The present study aimed to assess the changes in manometric parameters after transperineal repair (TPR) of rectocele and interpret failure of symptom improvement in light of these changes.

METHODS

This was an observational cohort study on patients with anterior rectocele who underwent TPR in the period of February 2016 to February 2019. Data collected included patients' demographics, rectocele size, Wexner constipation and incontinence scores, anal pressures, and rectal sensation before and 12 months after TPR. Analysis of data was done by paired t-test and chi-square test.

RESULTS

Forty-six female patients with a mean age of 43.2 ± 10.7 years were included. After a mean follow-up of 13.9 ± 2.7 months, 30 (65.2%) patients reported clinical improvement and 16 (34.8%) had no significant improvement. At 12 months after rectocele repair, the entire cohort studied showed an insignificant increase in the mean anal pressures and a significant decrease in the thresholds of first rectal sensation, first urge, intense urge, and maximum tolerable volume (MTV). Patients who clinically improved showed similar physiologic changes to the entire cohort examined, whereas patients who had no clinical improvement showed significant increases in the mean anal pressures and insignificant decreases in rectal sensation and MTV.

CONCLUSION

Patients who showed clinical improvement showed insignificant increases in anal pressures and significant decreases in thresholds of first rectal sensation, first urge, intense urge, and MTV. Contrarily, patients who did not show clinical improvement showed significant increases in anal pressures and insignificant reduction in sensory thresholds.

Anorectal manometry in children with defecation disorders BSPGHAN Motility Working Group consensus statement

Defecatory disorders in children, including chronic constipation (CC) and fecal incontinence (FI), are common conditions worldwide and have a significant impact on children, their families, and the healthcare system. Anorectal manometry (ARM) and high-resolution anorectal manometry (HRAM) are relatively novel tools for the assessment of anal sphincter function and rectal sensation and have contributed significantly to improving the understanding of the anorectum as a functional unit. ARM has been recognized as the investigation of choice for adults with symptoms of defecation disorders, including fecal incontinence (FI), evacuation difficulties, and constipation. Although it is the gold standard tool in adults, it has yet to be formally accepted as a standardized diagnostic tool in the pediatric age, with limited knowledge regarding indications, protocol, and normal values. ARM/HRAM is slowly becoming recognized among pediatricians, but given that there are currently no agreed guidelines there is a risk that will lead to diversity in practice. The British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN)-Motility Working Group (MWG) therefore has taken the opportunity to provide guidance on the use of ARM/HRAM in children with CC and/or FI.

High resolution anorectal manometry. Recommendations on russian-language terminology based on interdisciplinary consensus

The aim of the paper — is to present the results of the consensus on the terminology used to describe data of high-resolution anorectal manometry.

Methods: Online survey was conducted with the help of the public platform “Google forms” with the aim to harmonize the terms, which are used to conduct high-resolution anorectal manometry (HRAM), to agree the conformity of the proposed Russian-language terms to those used in English-language literature, and their abbreviations.

Results: According to the aim, 56 specialists of different medical specialties who perform and use the results of HRAM in clinical practice and research were invited to participate in the survey. We received 45 answers from the respondents (42.2% coloproctologists, 22.2% gastroenterologists, 15.6% surgeons, 20% — representatives of other specialties). The response rate was 80.3%. According to the survey, 95.6% of respondents supported the need for harmonization of terms. Ten out of the 11 terms reached consensus level C1 (excellent), 1 term level of consistency was C2 (moderate). 90.9% of respondents (consensus level C1) were in favor of the appropriateness of using common abbreviations. However, the proposed abbreviations of the terms used in the conduct and description of the results of the HRAM can be accepted with reservations (in 10 cases out of 11 consensus level was C2).

Conclusions: The agreed in interdisciplinary consensus terms can be approved and recommended for the use in clinical practice and when research data are published in Russian-language scientific literature.

Predictors of permanent stoma creation in patients with mid or low rectal cancer: results of a multicentre cohort study with preoperative evaluation of anal function

AIM

Preoperative factors predictive of permanent stoma creation were investigated in a long-term follow-up of patients with mid or low rectal cancer.

METHOD

We included patients who underwent radical resection for mid or low rectal cancer with available data for preoperative anal function measured by manometry and Faecal Incontinence Severity Index questionnaire between January 2005 and December 2015 in three tertiary referral hospitals. A permanent stoma was defined as a stoma present until the patient's last follow-up visit or death. Preoperative factors that predicted permanent stoma creation were analysed.

RESULTS

Over a median follow-up of 57.4 months (range 12-143 months), a permanent stoma was created in 144/577 (25.0%) patients, including 89 (15.4%) who underwent abdominoperineal resection, one (0.2%) who underwent Hartmann's operation without reversal, 15 (2.6%) with a diverting ileostomy at the time of initial sphincter-preserving surgery without undergoing stoma reversal, and 39 (6.8%) who underwent permanent ileostomy formation after sphincter-preserving surgery. Patients with permanent stoma creation had a shorter tumour distance from the anal verge (P < 0.001), larger tumour size (P = 0.020) and higher preoperative Faecal Incontinence Severity Index score (P = 0.020). On multivariable analysis, tumour distance from the anal verge predicted permanent stoma formation (relative risk 0.53 per centimetre increase; 95% confidence interval 0.46-0.60; P < 0.001) but preoperative anal function did not.

CONCLUSION

Tumour distance from the anal verge was the only preoperative determinant of permanent stoma creation in rectal cancer patients. These data may help mid and low rectal cancer patients understand the need for permanent stoma.

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.

The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function

BACKGROUND

This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed.

METHODS

Twenty-nine working group members (clinicians/academics in the field of gastroenterology, coloproctology, and gastrointestinal physiology) were invited to six face-to-face and three remote meetings to derive consensus between 2014 and 2018.

KEY RECOMMENDATIONS

The IAPWG protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia.

CONCLUSIONS AND INFERENCES

This framework introduces the IAPWG protocol and the London classification for disorders of anorectal function based on objective physiological measurement. The use of a common language to describe results of diagnostic tests, standard operating procedures, and a consensus classification system is designed to bring much-needed standardization to these techniques.

Predictive value of colonic transit time indices for differentiating nonnormal from normal sensation in children with chronic functional constipation identified by anorectal manometry

BACKGROUND

Constipation is a common disorder in pediatrics, although the underlying pathogenesis is not fully understood. The current study aimed at evaluating the efficacy of different colonic transit time (CTT) indices for differentiating normal from nonnormal sensation in children with chronic functional constipation identified by anorectal manometry (ARM).

MATERIALS AND METHODS

In this cross-sectional study, 47 children with chronic idiopathic constipation, aged 5-15 years, were studied. The total and segmental CTTs were estimated by administering multiple radiopaque markers for 6 days and performing a single abdominal radiograph on day 7. Anorectal function was evaluated using manometry with an Arhan probe. The predictive value of CTT indices was evaluated by receiver operating characteristic curve analysis. Area under the curve (AUC) along with 95% confidence interval (CI) as well as sensitivity and specificity was calculated.

RESULTS

The mean age of the participants was 8.30 ± 2.99 years, with a mean constipation duration of 2.90 ± 0.46; 28 children were identified with nonnormal sensation. The mean values of CTT indices were statistically significantly longer in the nonnormal sensation patients than that in the normal group (P < 0.001). In addition, the mean values of manometry parameters were statistically significantly higher in nonnormal sensation patients than that in normal group (P < 0.01). Among CTT indices, rectosigmoid CTT (AUC [95% CI] =0.999 [0.99-1]; P < 0.001) with sensitivity = 100% and specificity = 94.7% and total CTT (AUC [95% CI] =0.972 [0.93-1] P < 0.001) with sensitivity = 82.3% and specificity = 100% had the highest predictive values for differentiating nonnormal from normal sensation patients.

CONCLUSION

CTT is a simple and noninvasive technique for classifying patients with constipation. It can be used for identifying children suffering from chronic constipation with nonnormal sensation reliably, instead of ARM. Colonic inertia may be a manifestation of global motility dysfunction. Children with delayed distal colonic transits are more likely to have abnormal defecation dynamics.

Defective Conduction of Anorectal Afferents Is a Very Prevalent Pathophysiological Factor Associated to Fecal Incontinence in Women

Background/Aims

Fecal incontinence (FI) is a prevalent condition among women. While biomechanical motor components have been thoroughly researched, anorectal sensory aspects are less known. We studied the pathophysiology of FI in community-dwelling women, specifically, the conduction through efferent/afferent neural pathways.

Methods

A cross-sectional study was conducted on 175 women with FI and 19 healthy volunteers. The functional/structural study included anorectal manometry/endoanal ultrasound. Neurophysiological studies including pudendal nerve terminal motor latency (PNTML) and sensory-evoked-potentials to anal/rectal stimulation (ASEP/RSEP) were conducted on all healthy volunteers and on 2 subgroups of 42 and 38 patients, respectively.

Results

The main conditions associated with FI were childbirth (79.00%) and coloproctological surgery (37.10%). Cleveland score was 11.39 ± 4.09. Anorectal manometry showed external anal sphincter and internal anal sphincter insufficiency in 82.85% and 44.00%, respectively. Sensitivity to rectal distension was impaired in 27.42%. Endoanal ultrasound showed tears in external anal sphincter (60.57%) and internal anal sphincter disruptions (34.80%). Abnormal anorectal sensory conduction was evidenced through ASEP and RSEP in 63.16% and 50.00% of patients, respectively, alongside reduced activation of brain cortex to anorectal stimulation. In contrast, PNTML was delayed in only 33.30%. Stools were loose/very loose in 56.70% of patients.

Conclusions

Pathophysiology of FI in women is mainly associated with mechanical sphincter dysfunctions related to either muscle damage or, to a lesser extent, impaired efferent conduction at pudendal nerves. Impaired conduction through afferent anorectal pathways is also very prevalent in women with FI and may play an important role as a pathophysiological factor and as a potential therapeutic target.