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

Therapeutic effects of Bombax ceiba flower aqueous extracts against loperamide-induced constipation in mice

CONTEXT

Bombax ceiba Linnaeus (Bombacaceae) is known as silk cotton tree, the flowers of which are used in many medicinal applications.

OBJECTIVE

To investigate the therapeutic effect of B. ceiba flower aqueous extracts (BCE) against loperamide-induced constipation and characterize the chemical composition of BCE.

MATERIALS AND METHODS

Sixty male Kunming mice were divided into control (saline), model (10 mg/kg loperamide + saline), phenolphthalein (10 mg/kg loperamide + 10 mg/kg phenolphthalein) and different dosage of BCE (10 mg/kg loperamide + 40, 80 and 160 mg/kg BCE, respectively) groups, and received intragastric administrations for eight days. Faecal water content, number of faeces, first black-stool defecation time and gastrointestinal transit rates were evaluated. Various biochemical and molecular biomarkers were assessed in blood and colon. UPLC-ESI-QTOF-MS/MS was used to tentatively identify the composition of the BCE.

RESULTS

BCE treatment (160 mg/kg) could increase faecal water (15.75%), faeces number (11.65%), gastrointestinal transit rate (25.37%) and decrease first black-stool defecation time (24.04%). The BCE (80 mg/kg) increased the serum level of motilin (30.62%), gastrin (54.46%) and substance P (18.99%), and decreased somatostatin (19.47%). Additionally, the BCE (160 mg/kg) reduced the mucosal damage, restored colonic goblet cell function, down-regulated the protein expression of AQP₃ (33.60%) and increased c-kit protein expression (11.63%). Twelve known compounds, including protocatechuic acid, chlorogenic acid and rutin, previously reported in B. ceiba, were identified in the BCE.

DISCUSSION AND CONCLUSIONS

This study suggested that BCE is a promising agent for the treatment of constipation.

The Relevance of the Excessive Perineal Descent in the Obstructed Defecation Syndrome: A Prospective Study of 141 Patients

BACKGROUND

Despite the widely accepted association between excessive straining and perineal descent, the clinical significance of perineal descent in patients with obstructed defecation syndrome is still unclear.

OBJECTIVE

This study aimed to evaluate the prevalence of pathological perineal descent in patients with obstructed defecation syndrome and the impact of perineal descent on symptoms severity.

DESIGN

This was a prospective multicenter uncontrolled study.

SETTINGS

The study involved 3 hospital pelvic-care centers and was conducted from January 2018 to January 2022.

PATIENTS

The study included 141 consecutive adult patients with an obstructed defecation syndrome score of 9 or more and no evidence of organic GI pathology. All the patients underwent dynamic pelvic MRI and, in case of suspected paradoxical puborectalis contraction, anal manometry.

MAIN OUTCOME MEASURES

Main outcome measures were the prevalence of excessive perineal descent and the correlation between perineal descent and obstructed defecation syndrome score.

RESULTS

One hundred twenty-eight patients (90.7%) completed magnetic resonance examination and were included in the analysis. Of these, 18 patients (14.1%) had a physiological perineal descent and 110 (85.9%) had an excessive perineal descent. Excessive perineal descent was found in 46.1% of patients (12/26) with MRI signs of paradoxical puborectalis contraction and in 96% of patients (98/102) with normal puborectalis relaxation. In this latter group of patients, a good correlation between obstructed defecation syndrome score and maximum perineal descent during straining was found (Spearman r test: 0.68; p < 0.0001).

LIMITATIONS

The study was limited by the small sample size and by the strong selection of the study population.

CONCLUSIONS

Excessive perineal descent is a common finding in patients with obstructed defecation syndrome and high symptoms score, occurring almost consistently in patients without paradoxical puborectalis contraction. In these patients, the maximum perineal descent seems to be well correlated with symptoms severity. See Video Abstract at http://links.lww.com/DCR/C135 .

LA RELEVANCIA DEL DESCENSO PERINEAL EXCESIVO EN EL SNDROME DE DEFECACIN OBSTRUIDA UN ESTUDIO PROSPECTIVO DE PACIENTES

ANTECEDENTES:A pesar de la asociación ampliamente aceptada entre el esfuerzo excesivo y el descenso perineal, la importancia clínica del descenso perineal en pacientes con síndrome de defecación obstruida aún no está clara.OBJETIVO:Evaluar la prevalencia del descenso perineal patológico en pacientes con síndrome de defecación obstruida y el impacto del descenso perineal en la severidad de los síntomas.DISEÑO:Este fue un estudio prospectivo multicéntrico no controladoENTORNO CLINICO:El estudio involucró a tres centros hospitalarios de atención pélvica y se llevó a cabo entre enero de 2018 y enero de 2022.PACIENTES:El estudio incluyó a 141 pacientes adultos consecutivos con puntuación del síndrome de defecación obstruida ≥ 9 y sin evidencia de patología gastrointestinal orgánica. A todas las pacientes se les realizó resonancia magnética pélvica dinámica y, en caso de sospecha de contracción puborrectal paradójica, manometría anal.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado fueron la prevalencia del descenso perineal excesivo y la correlación entre el descenso perineal y la puntuación del síndrome de defecación obstruida.RESULTADOS:Ciento veintiocho (90,7%) pacientes completaron el examen de resonancia magnética y fueron incluidos en el análisis. De estos, 18 (14,1%) presentaron descenso perineal fisiológico y 110 (85,9%) descenso perineal excesivo. Se encontró descenso perineal excesivo en el 46,1% (12/26) de los pacientes con signos de contracción puborrectal paradójica en la resonancia magnética y en el 96% (98/102) de los pacientes con relajación puborrectal normal. En estos últimos pacientes se encontró una buena correlación entre la puntuación del síndrome de defecación obstruida y el descenso perineal máximo durante el esfuerzo (prueba r de Spearman: 0,68; p < 0,0001).LIMITACIONES:El estudio estuvo limitado por el pequeño tamaño de la muestra y por la fuerte selección de la población de estudio.CONCLUSIONES:El descenso perineal excesivo es un hallazgo común en pacientes con síndrome de defecación obstruida y alto puntaje de síntomas, ocurriendo casi constantemente en pacientes sin contracción puborrectal paradójica. En estos últimos pacientes el descenso perineal máximo parece estar bien correlacionado con la severidad de los síntomas. Consulte Video Resumen en http://links.lww.com/DCRC135 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Research progress in the treatment of slow transit constipation by traditional Chinese medicine

ETHNOPHARMACOLOGICAL RELEVANCE

Slow transit constipation (STC) is a common gastrointestinal disorder seriously impacting patients' quality of life. At present, although conventional chemical drugs effectively control STC symptoms in the short term, the long-term effects are poor, and the side effects are significant. In this regard, traditional Chinese medicine (TCM) offers an opportunity for STC treatment. Many pharmacological and clinical studies have confirmed this efficacy of TCM with multiple targets and mechanisms.

AIM OF THE STUDY

This review attempted to summarize the characteristics of TCM (compound prescriptions, single Chinese herbs, and active ingredients) for STC treatment and discussed their efficacy based on analyzing the pathogenesis of STC.

MATERIALS AND METHODS

The information was acquired from different databases, including PubMed, Web of Science, China National Knowledge Infrastructure, and Wanfang databases. We then focused on the recent research progress in STC treatment by TCM. Finally, the future challenges and trends are proposed.

RESULTS

TCM has good clinical efficacy in the treatment of STC with multi-mechanisms. Based on the theory of syndrome differentiation, five kinds of dialectical treatment for STC by compound TCM prescriptions were introduced, namely: Nourishing Yin and moistening the intestines; Promoting blood circulation and removing blood stasis; Warming Yang and benefiting Qi; Soothing the liver and regulating Qi; and Benefiting Qi and strengthening the spleen. In addition, six single Chinese herbs and eight active ingredients also show good efficacy in STC treatment.

CONCLUSIONS

TCM, especially compound prescriptions, has bright prospects in treating STC attributed to its various holistic effects.

Translating Fecobionics Into a Technique That Addresses Clinical Needs for Objective Perineal Descent Measurements

INTRODUCTION

Perineal descent is a phenomenon associated with anorectal dysfunction. It is diagnosed by defecography but subjected to manual measurements on the images/videos and interobserver bias. Fecobionics is a simulated feces for assessing important physiological parameters during defecation. Here, we translate Fecobionics into a new method for estimation of perineal descent based on electronic signals from the embedded inertial measurement units (IMUs).

METHODS

A displacement measurement method by a combined zero-velocity update and gravity compensation algorithm from IMUs was developed. The method was verified in a robot model, which mimicked perineal descent motion.

RESULTS

The method correlated well with the reference (R = 0.9789) and had a deviation from the peak displacement (range 0.25-2.5 cm) of -0.04 ± 0.498 cm. The method was further validated in 5 human experiments with comparison to the benchmark defecography technology (R = 0.79).

DISCUSSION

The proposed technology is objective, i.e., electronic measurements rather than by fluoroscopy or MRI. The development may impact clinical practice by providing a resource-saving and objective technology for diagnosing perineal descent in the many patients suffering from anorectal disorders. The technology may also be used in colon experiments with Fecobionics and for other gastrointestinal devices containing IMUs such as ingestible capsules like the Smartpill.

Clinical Features and Associations of Descending Perineum Syndrome in 300 Adults with Constipation in Gastroenterology Referral Practice

BACKGROUND

Outlet obstruction constipation accounts for about 30% of chronic constipation (CC) cases in a referral practice.

AIMS

To assess the proportion of patients with CC diagnosed with descending perineum syndrome (DPS) by a single gastroenterologist and to compare clinical, radiological, and associated features in DPS compared to patients with constipation.

METHODS

We conducted a review of records of 300 consecutive patients evaluated for constipation by a single gastroenterologist from 2007 to 2019, including medical, surgical, and obstetrics history, digital rectal examination, anorectal manometry, defecation proctography (available in 15/23 with DPS), treatment, and follow-up. DPS was defined as > 3 cm descent of anorectal junction on imaging or estimated perineal descent on rectal examination. Logistic regression with univariate and multivariate analysis compared factors associated with DPS to non-DPS patients.

RESULTS

Twenty-three out of 300 (7.7%, all female) patients had DPS; these patients were older, had more births [including more vaginal deliveries (84.2% vs. 31.2% in non-DPS, p < 0.001)], more instrumental or traumatic vaginal deliveries, more hysterectomies, more rectoceles on proctography (86.7% vs. 28.6% non-DPS, p = 0.014), lower squeeze anal sphincter pressures (p < 0.001), and lower rectal sensation (p = 0.075) than non-DPS. On univariate logistic regression, history of vaginal delivery, hysterectomy, and Ehlers-Danlos syndrome increased the odds of developing DPS. Vaginal delivery was confirmed as a risk factor on multivariate analysis.

CONCLUSIONS

DPS accounts for almost 10% of tertiary referral patients presenting with constipation. DPS is associated with age, female gender, and number of vaginal (especially traumatic) deliveries.

Laxative Effects of Yangyin Tongmi Capsule on a Model of Diphenoxylate-Induced Constipation in Mice

Constipation is characterized by reduced number of bowel movements, dry stools, and difficult defecation. Yangyin Tongmi capsule (YTC), a traditional Chinese formula, is used in the treatment of constipation, while the underlying mechanisms remain unknown. Herein, this work attempted to prove the effects of YTC on constipation treatment and its possible mechanisms. KM mice were randomly divided into four groups (n = 10/group) and treated with double distilled water (Control), diphenoxylate (Model: 10 mg/kg), or diphenoxylate plus low-dose YTC (L-YTC: 0.6 g/kg) or high-dose YTC (H-YTC: 1.2 g/kg). The data indicated that YTC can significantly shorten the discharge time of the first black stool, improve intestinal propulsion rate, and increase the water content and quantity of feces in mice. ELISA suggested that YTC regulate the content of intestinal hormones and neurotransmitters, such as motilin (MTL), gastrin (GT), somatostatin (SST), substance P (SP), acetylcholine (Ach), and nitric oxide (NO). The expression levels of aquaporin 3 (AQP3) and aquaporin 8 (AQP8) in the colon were examined by immunohistochemistry. In the meantime, the expression levels of P2X2, C-kit, and stem cell factor (SCF) in the colon were examined by western blot analysis. The results of this study suggest that YTC has mitigative effects on diphenoxylate-induced constipation by regulating the content of intestinal hormones and neurotransmitters and regulating the expression of related proteins in the colon.

Bacterial Cellulose Relieves Diphenoxylate-Induced Constipation in Rats

This study was to probe the effects of bacterial cellulose (BC) on diphenoxylate-induced constipation in rats. Administration with BC at 500 mg/kg of body weight in diphenoxylate-induced constipation rats distinctly improved the carmine propulsion rate (83.5 ± 5.2%), shortened the defecating time of the first red feces (249.0 ± 23.3 min), and increased the weight of carmine red feces within 5 h (2.7 ± 1.3 g). The levels of aquaporins (AQP-2, AQP-3, and AQP-4) and inhibitory neurotransmitters (nitric oxide, nitric oxide synthetase, vasoactive intestinal peptide, and arginine vasopressin) in the BC-treated groups reduced by 31.9-40.0% ( p < 0.01) and 21.1-67.7% ( p < 0.01) compared to those in the constipation group, respectively. However, the secretion of excitability neurotransmitters (substance P and motilin) in the BC-treated groups was increased by 20.0-39.9% ( p < 0.01). The activities of ATPases in the colon of constipation rats were significantly weakened by BC administration ( p < 0.01). Histological morphology of the colon showed that BC supplementation could effectively increase the length of villus cells and the thickness of colonic mucosa and muscle ( p < 0.01). Moreover, BC supplementation could protect colonic smooth muscle cells against apoptosis. All of the findings suggest that BC supplementation effectively relieves constipation in rats and BC would be used as a great promising dietary fiber for alleviating constipation.