Responses of anal constipation to biofeedback treatment

Predicting Responsiveness to Biofeedback Therapy Using High-resolution Anorectal Manometry With Integrated Pressurized Volume

Background/Aims

Biofeedback therapy is widely used to treat patients with chronic constipation, especially those with dyssynergic defecation. Yet, the utility of high-resolution manometry with novel parameters in the prediction of biofeedback response has not been reported. Thus, we constructed a model for predicting biofeedback therapy responders by applying the concept of integrated pressurized volume in patients undergoing high-resolution anorectal manometry.

Methods

Seventy-one female patients (age: 48-68 years) with dyssynergic defecation who underwent initial high-resolution anorectal manometry and subsequent biofeedback therapy were enrolled. The manometry profiles were used to calculate the 3-dimensional integrated pressurized volumes by multiplying the distance, time, and amplitude during simulated evacuation. Partial least squares regression was performed to generate a predictive model for responders to biofeedback therapy by using the integrated pressurized volume parameters.

Results

Fifty-five (77.5%) patients responded to biofeedback therapy. The responders and non-responders did not show significant differences in the conventional manometric parameters. The partial least squares regression model used a linear combination of eight integrated pressurized volume parameters and generated an area under the curve of 0.84 (95% confidence interval: 0.76-0.95, P < 0.01), with 85.5% sensitivity and 62.1% specificity.

Conclusions

Integrated pressurized volume parameters were better than conventional parameters in predicting the responsiveness to biofeedback therapy, and the combination of these parameters and partial least squares regression was particularly promising. Integrated pressurized volume parameters can more effectively explain the physiology of the anorectal canal compared with conventional parameters.

Correction of Dyssynergic Defecation, but Not Fiber Supplementation, Reduces Symptoms of Functional Dyspepsia in Patients With Constipation in a Randomized Trial

BACKGROUND & AIMS

Patients with functional dyspepsia are believed to have increased sensitivity of the gastrointestinal tract, and some also have functional constipation. We investigated whether in patients with functional dyspepsia, correction of dyssynergic defecation can reduce postprandial fullness.

METHODS

We performed a parallel trial at 2 referral centers in Spain, from June 2016 through January 2018 of 50 patients who fulfilled the Rome IV criteria for functional dyspepsia with postprandial distress syndrome and functional constipation and dyssynergic defecation. After a 2-week pretreatment phase, the patients were randomly assigned to groups that learned to correct dyssynergic defecation (2-3 sessions of biofeedback combined with instructions for daily exercise; n = 25) or received dietary fiber supplementation (3.5 g plantago ovata per day; n = 25) for 4 weeks. The primary outcome was change in postprandial abdominal fullness, measured daily on a scale of 0-10, during the last 7 days treatment phase vs the last 7 days of the pretreatment phase. Anal gas evacuations were measured (by an event marker) during the last 2 days of the pretreatment vs treatment phases.

RESULTS

Biofeedback treatment corrected dyssynergic defecation in 19/25 patients; corrected dyssynergic defection reduced postprandial fullness by 22%±1% in these patients (P < .001), and reduced the number of anal evacuations by 21%±8% (P = .009). Fiber supplementation did not reduce postprandial fullness or anal evacuations (P ≤ .023 between groups for both parameters in the intent to treat analysis).

CONCLUSIONS

Diagnosis and correction of dyssynergic defecation reduces dyspeptic symptoms by more than 20% in patients with functional dyspepsia and associated constipation. Dietary fiber supplementation does not reduce symptoms in these patients. ClinicalTrials.gov no: NCT02956187.

An investigation into the effect of biofeedback on urinary and fecal incontinence in patients with anal sphincter dysfunction

Introduction:

Fecal incontinence refers to the inability to control bowel movements, causing feces to leak unexpectedly from the rectum. People suffering from this disorder are emotionally distressed. This problem causes social degradation, anxiety, fear, and social isolation. The present study aimed to evaluate the effect of biofeedback (BFB) on fecal incontinence in patients with anal sphincter abnormalities in 2017.

Methods:

This quasi-experimental study was performed on 30 patients with fecal incontinence, referring to the gastroenterology clinic of Taleghani and Mehrad hospitals. Patients were first evaluated by Wexner criteria and then, with the aid of a manometer, information was obtained on the amount of sphincter muscle tone, squeeze pressure, and rectal sensation. Manometric results and Waxner's questionnaire were compared before and after BFB. Data were analyzed using SPSS (version 20).

Findings:

In this study, 18 women and 12 men were studied. There was no significant relationship between fluid intake, fiber, exercise, sex, and incontinence (P < 0.05). According to Wuxner's components, the sphincter muscle tone increased significantly after BFB in patients. The total score of the squeeze pressure increased significantly after the BFB application (P < 0.05). The mean total score of rectal sensation (individual awareness of rectal contents) decreased after the BFB application.

Conclusion:

In addition to the fact that it can improve incontinence in patients with anal sphincter abnormalities, BFB is also helpful for patients whose sphincter and rectum are not seriously affected and only show incontinence symptoms.

Review article: dyssynergic defaecation and biofeedback therapy in the pathophysiology and management of functional constipation

BACKGROUND

Functional constipation is a common clinical presentation in primary care. Functional defaecation disorders are defined as the paradoxical contraction or inadequate relaxation of the pelvic floor muscles during attempted defaecation (dyssynergic defaecation) and/or inadequate propulsive forces during attempted defaecation. Prompt diagnosis and management of dyssynergic defaecation is hindered by uncertainty regarding nomenclature, diagnostic criteria, pathophysiology and efficacy of management options such as biofeedback therapy.

AIM

To review the evidence pertaining to the pathophysiology of functional defaecation disorders and the efficacy of biofeedback therapy in the management of patients with dyssynergic defaecation and functional constipation.

METHODS

Relevant articles addressing functional defaecation disorders and the efficacy of biofeedback therapy in the management of dyssynergic defaecation and functional constipation were identified from a search of Pubmed, MEDLINE Ovid and the Cochrane Library.

RESULTS

The prevalence of dyssynergic defaecation in patients investigated for chronic constipation is as many as 40%. Randomised controlled trials have demonstrated major symptom improvement in 70%-80% of patients undergoing biofeedback therapy for chronic constipation resistant to standard medical therapy and have determined it to be superior to polyethylene glycol laxatives, diazepam or sham therapy. Long-term studies have shown 55%-82% of patients maintain symptom improvement.

CONCLUSIONS

Dyssynergic defaecation is a common clinical condition in patients with chronic constipation not responding to conservative management. Biofeedback therapy appears to be a safe, successful treatment with sustained results for patients with dyssynergic defaecation. Further studies are required to standardise the diagnosis of dyssynergic defaecation in addition to employing systematic protocols for biofeedback therapy.

Long-term efficacy of biofeedback therapy in patients with dyssynergic defecation: results of a median 44 months follow-up

BACKGROUND

The beneficial effect of biofeedback therapy (BFT) over a period of more than 2 years has not been studied in a large group of patients. The aim of this study was to evaluate the long-term efficacy of BFT for dyssynergic defecation (DD).

METHODS

We evaluated the results for 347 consecutive constipated patients with DD who underwent BFT for a median of five sessions between 2004 and 2009. Initial responses were assessed immediately after the completion of BFT. A responder was defined as a subject with at least a three-point improvement from before to after BFT on an 11-point global bowel satisfaction (GBS) scale, or a two-point improvement if the baseline GBS was more than six points. The probability of remaining a responder was estimated by non-parametric maximum likelihood estimation.

KEY RESULTS

The initial response rate to BFT was 72.3% (n = 251), Parkinson's disease and higher baseline GBS scores were associated with initial non-response. The long-term efficacy of BFT was analyzed in 103 patients who were followed up for more than 6 months; the initial effects of BFT were maintained in 85 of the patients (82.5%) during a median of 44 months of follow-up (IQR = 12-68). The probability of remaining a responder was 60% at 2 years, and 58% at 5 years.

CONCLUSIONS & INFERENCES

The efficacy of BFT is maintained for more than 2 years after BFT in a considerable proportion of constipated patients with DD. BFT is effective and durable treatment for managing DD.

How to perform and interpret balloon expulsion test

The balloon expulsion test is a simple and useful method for investigating a defecatory disorder assessing the subject's ability to evacuate a simulated stool. However, there is no standard methodology and varying interpretations have been reported. This review discusses the techniques, interpretation and clinical utility of the balloon expulsion test.

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

BACKGROUND

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

METHODS

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

KEY RESULTS

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

CONCLUSIONS & INFERENCES

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

Postoperative pain after haemorrhoidectomy: role of impaired evacuation

AIM

We hypothesized that obstructive defaecation is associated with more postoperative pain after haemorrhoidectomy.

METHOD

Fifty patients with grade IV haemorrhoids were included in a prospective study. Impaired evacuation was defined as the inability to evacuate a rectal balloon. Perianal sensitivity was evaluated by means of an algometer, and anxiety and depression were assessed by the hospital anxiety and depression (HAD) scale. Over the first 10 days after a Milligan-Morgan haemorrhoidectomy, the following parameters were measured on daily questionnaires: pain (associated with and unrelated to defaecation by means of visual analogue scales), number of bowel movements, faecal consistency and analgesic requirement on demand (tramadol 50 mg p.o., number of doses). Results are expressed as median and interquartile range or mean ± SE.

RESULTS

Patients with impaired evacuation (14 women, eight men; age range 28-61 years) experienced more postoperative pain than patients with nonimpaired evacuation (eight women, 20 men; age range 24-70 years): 3.2 (2.1) vs 2.1 (1.8) defaecatory pain, respectively (P = 0.045), and 2.4 (2.3) vs 1.7 (2.3) nondefecatory pain, respectively (P = 0.048). There was no difference between the groups regarding stool consistency, number of bowel movements [12.5 (7.3) vs 15.5 (7.2), respectively; NS] and analgesic requirement [1.0 (6.1) vs 1.0 (5.2) extra doses on demand, respectively; NS] during the 10 postoperative days. No differences related to age, sex, HAD scores or perianal sensitivity were found.

CONCLUSION

Impaired anal evacuation is predictive of postoperative pain after haemorrhoidectomy.

Predictors of outcome of anorectal biofeedback therapy in patients with constipation

BACKGROUND

Anorectal biofeedback therapy (BFT) is a safe and effective treatment in patients with constipation. Given the high prevalence of constipation and therefore high demand for BFT, there is a need to prioritise patients.

AIMS

To explore clinical features and anorectal physiology which predict success or failure of BFT and to derive a statistical model which helps to predict the success of BFT.

METHODS

A total of 102 patients with constipation referred for BFT were evaluated. All patients underwent comprehensive clinical and anorectal function assessment, including balloon expulsion testing. The BFT protocol consisted of a comprehensive 6-weekly visit programme comprising instruction on toilet behaviour and abdominal breathing, achieving adequate rectal pressure and anal relaxation, and balloon expulsion and rectal sensory retraining. Success of BFT was based on an improvement in global bowel satisfaction.

RESULTS

Harder stool consistency (P=0.009), greater willingness to participate (P<0.001), higher resting anal sphincter pressure (P=0.04) and prolonged balloon expulsion time (P=0.02) correlated with an improvement in bowel satisfaction score. A longer duration of laxative use (P=0.049) correlated with no improvement in bowel satisfaction score. Harder stools, shorter duration of laxative use, higher straining rectal pressure and prolonged balloon expulsion independently predicted successful BFT. A model (S(i) = (p)∑ β(j)X(ij), where β represents a regression coefficient, X is a given predictive variable and S(i) is the weighted index score for each individual) incorporating these four variables enabled prediction of successful BFT, with sensitivity and specificity of 0.79 and 0.81, respectively.

CONCLUSIONS

Important clinical and anorectal physiological features were found to be associated with outcome of anorectal biofeedback therapy in patients with constipation. This information and the predictive model will assist clinicians to prioritise patients for anorectal biofeedback therapy.

Predictive capability of anorectal physiologic tests for unfavorable outcomes following biofeedback therapy in dyssynergic defecation

The purpose of this study is to evaluate the predictive capability of anorectal physiologic tests for unfavorable outcomes prior to the initiation of biofeedback therapy in patients with dyssynergic defecation. We analyzed a total of 80 consecutive patients who received biofeedback therapy for chronic idiopathic functional constipation with dyssynergic defecation. After classifying the patients into two groups (responders and non-responders), univariate and multivariate analyses were performed to determine the predictors associated with the responsiveness to biofeedback therapy. Of the 80 patients, 63 (78.7%) responded to biofeedback therapy and 17 (21.3%) did not. On univariate analysis, the inability to evacuate an intrarectal balloon (P=0.028), higher rectal volume for first, urgent, and maximal sensation (P=0.023, P=0.008, P=0.007, respectively), and increased anorectal angle during squeeze (P=0.020) were associated with poor outcomes. On multivariate analysis, the inability to evacuate an intrarectal balloon (P=0.018) and increased anorectal angle during squeeze (P=0.029) were both found to be independently associated with a lack of response to biofeedback therapy. Our data show that the two anorectal physiologic test factors are associated with poor response to biofeedback therapy for patients with dyssynergic defecation. These findings may assist physicians in predicting the responsiveness to therapy for this patient population.

[The Latin-American Consensus on Chronic Constipation]

The Latin-American Consensus on Chronic Constipation aimed to establish guidelines to improve the identification, diagnosis and treatment of this disorder in the region. Two coordinators and an honorary coordinator established the process and the topics to be discussed, based on a systematic review of the literature published in the previous 10 years, since 1995. Seventeen members participated with the support of their local gastroenterology societies. The members reviewed the different subjects based on the levels of evidence and grades of recommendation; the topics were then discussed in a plenary session. A written report was drafted and the coordinators prepared the final declarations to be submitted to a vote by all the members in October 2006. The consensus concluded that chronic constipation has an estimated prevalence of 5-21% in the region, with a female-to-male ratio of 3:1. Among individuals with constipation, 75% use some type of medication, with more than 50% using home remedies. A diagnosis based on Rome Criteria was recommended and diagnostic testing only in persons older than 50 years or with alarm symptoms. The use of barium enema as an initial investigation was recommended only in countries with a high prevalence of idiopathic megacolon or Chagas' disease. Recommendations on treatment included an increase in dietary fiber of up to 25-30 g/day (grade C). No evidence was found to recommend measures such as exercise, increased water intake, or frequent visits to the toilet. Fiber supplements such as Psyllium received a grade B and pharmacological treatments such as tegaserod and polyethylene glycol, both grade A. There was insufficient evidence to recommend lactulose, but the consensus did not disadvise its use when necessary. Complementary investigations such as colonic transit followed by anorectal manometry and defecography were only recommended to rule out colonic inertia and/or obstructive defecation in patients not responding to treatment. Biofeedback was recommended (grade B) for those with pelvic dyssynergia.

Anal plugs and retrograde colonic irrigation are helpful in fecal incontinence or constipation

AIM: To evaluate the feasibility, clinical effect and predicting factors for favorable outcome of treatment with anal plugs in fecal incontinence and retrograde colonic irrigation (RCI) in patients with fecal incontinence or constipation.

METHODS: Patients who received treatment with an anal plug or RCI between 1980 and 2005 were investigated with a questionnaire.

RESULTS: Of the 201 patients (93 adults, 108 children), 101 (50%) responded. Adults: anal plugs (8), five stopped immediately, one stopped after 20 mo and two used it for 12-15 mo. RCI (40, 28 fecal incontinence, 12 constipation), 63% are still using it (mean 8.5 years), 88% was satisfied. Younger adults (< 40 years) were more satisfied with RCI (94 % vs 65%, P = 0.05). Children: anal plugs (7), 5 used it on demand for an average of 2.5 years with satisfactory results, one stopped immediately and one after 5 years. RCI (26 fecal incontinence, 22 constipation), 90% are still using it (mean time 6.8 years) and felt satisfied. Children tend to be more satisfied (P = 0.001). Besides age, no predictive factors for success were found. There was no difference in the outcome between patients with fecal incontinence or constipation.

CONCLUSION: RCI is more often applied than anal plugs and is helpful in patients with fecal incontinence or constipation, especially for younger patients. Anal plugs can be used incidentally for fecal incontinence, especially in children.

Persistent symptoms of functional outlet obstruction after rectocele repair

BACKGROUND

Rectocele is frequently associated with constipation, but it is not known whether a causal relationship exists.

OBJECTIVE

To determine the effect of rectocele repair on symptoms of constipation.

METHOD

Thirty-five women (28-79 years) consecutively operated for rectocele repair (11 transanal approach and 24 transperineal) were included in the prospective study. Using a structured questionnaire, the following criteria for constipation were evaluated: (a) straining, (b) sensation of anal blockage, (c) sensation of incomplete evacuation, (d) manual manoeuvres to facilitate defecation, (e) stool consistency and (f) stool frequency. The evaluation was performed before and 1 year after rectocele repair.

RESULTS

Before the operation all patients had two or more constipation criteria, including sensation of anal blockage. One year after the operation, the incidence of all symptoms significantly improved (from 3.9 +/- 0.2 to 1.9 +/- 0.3; P < 0.01). However, in 18 patients two or more criteria of constipation persisted, two patients presented one criterion, and only 15 patients became asymptomatic. Neither parity nor the type of surgical approach (endorectal vs transperineal) was related to the response to treatment. In eight patients who had a previous hysterectomy the result was significantly worse.

CONCLUSION

In a considerable proportion of patients, constipation persists after rectocele repair, suggesting that these symptoms are related to an underlying dysfunction.

Darmentleerung, Sauberkeitsentwicklung bei Kindern und ihre Störungen (Obstipation und Enkopresis)

Zusammenfassung. Verstopfung und Stuhlinkontinenz bei Kindern stellen für die Betroffenen und deren Familien eine schwere Belastung dar. In den meisten Fällen liegen funktionelle Störungen ohne organische Erkrankungen zugrunde. Trotzdem muss bei jedem Kind eine zielgerichtete somatische Diagnostik erfolgen. Rein psychische Ursachen für Obstipation und Inkontinenz sind eher selten. Nach Eingrenzen der Diagnose kann durch verschiedene Therapieansätze eine Besserung der Symptomatik erfolgen. Neben medikamentösen und diätetischen Maßnahmen stehen verhaltenstherapeutische Ansätze im Vordergrund. Der vorliegende Text gibt einen Überblick über den aktuellen Stand der wissenschaftlichen Erkenntnisse zu Kontinenzentwicklung, Physiologie und Pathophysiologie der Darmentleerung sowie Diagnostik und Behandlung von Obstipation und Enkopresis aus pädiatrisch-gastroenterologischer Sicht.

Defecación obstructiva. Métodos diagnósticos y tratamiento

Obstructive defecation is observed in approximately half of all patients with functional constipation. Functional constipation has been related to alterations in intestinal motility (slow transit constipation) and to pelvic floor disorders leading to obstructive defecation associated with anatomical alterations of the pelvic floor (rectocele, posterior perineal hernia, enterocele and sigmoidocele, internal rectal intussusception, occult mucosal prolapse, solitary rectal ulcer and descending perineum syndrome), or obstructive defecation without anatomical alterations (pelvic floor dyssynergy or anismus). The diagnostic methods used (history and physical examination, colonic transit time, balloon expulsion test, proctography, anorectal manometry and electromyography) are reviewed. Conservative medical treatment and the indications for surgical treatment and its results are also discussed.