Update on the Pathophysiology and Management of Anorectal Disorders

Characterization of obstructive defecation from a structural and a functional perspective

BACKGROUND/AIMS

Defecation disorders can occur as a consequence of functional or structural anorectal dysfunctions during voiding. The aims of this study is to assess the prevalence of structural (SDD) vs functional (FDD) defecation disorders among patients with clinical complaints of obstructive defecation (OD) and their relationship with patients' expulsive capacity.

PATIENTS AND METHODS

Retrospective study of 588 patients with OD studied between 2012 and 2020 with evacuation defecography (ED), and anorectal manometry (ARM) in a subgroup of 294.

RESULTS

90.3% patients were women, age was 58.5±12.4 years. Most (83.7%) had SDD (43.7% rectocele, 45.3% prolapse, 19.3% enterocele, and 8.5% megarectum), all SDD being more prevalent in women except for megarectum. Functional assessments showed: (a) absence of rectification of anorectal angle in 51% of patients and poor pelvic descent in 31.6% at ED and (b) dyssynergic defecation in 89.9%, hypertonic IAS in 44%, and 33.3% rectal hyposensitivity, at ARM. Overall, 46.4% of patients were categorized as pure SDD, 37.3% a combination of SDD+FDD, and 16.3% as having pure FDD. Rectal emptying was impaired in 66.2% of SDD, 71.3% of FDD and in 78% of patients with both (p=0.017).

CONCLUSIONS

There was a high prevalence of SDD in middle-aged women with complaints of OD. Incomplete rectal emptying was more prevalent in FDD than in SDD although FDD and SDD frequently coexist. We recommend a stepwise therapeutic approach always starting with therapy directed to improve FDD and relaxation of striated pelvic floor muscles.

Effect of intracutaneous pyonex therapy on postoperative pain management following perianal surgery: A systematic review and meta-analysis

Intracutaneous pyonex therapy (IPT), a novel acupuncture technique also known as intradermal thumbtack needle embedding therapy, has been reported to optimize postoperative pain management following perianal surgery. This meta-analysis aimed to analyze the efficacy of IPT for postoperative pain management following perianal surgery. The Cochrane Library, PubMed, EMBASE, Web of Science, CNKI, SinoMed, Wanfang, and VIP databases were systematically searched for randomized controlled trials (RCTs) on IPT as a treatment for postoperative pain management following perianal surgery from inception until June 15, 2022. The analyzed outcomes from the eleven RCTs included in this meta-analysis were as follows: postoperative visual analogue scale(VAS), analgesic duration, ineffective cases following treatment, and adverse events. Subgroup analyses were conducted according to different time points. Risk-of-bias assessment, publication bias analysis, sensitivity analysis, and trial sequential analysis were performed. Of the 895 patients, 450 and 445 were included in the IPT and control groups, respectively. The IPT group showed a better analgesic effect[standard mean difference (SMD) = -0.77, 95% CI: -1.00 to -0.53, P < 0.00001; P for heterogeneity = 0.009, I2 = 59%] and longer analgesic duration [SMD = 0.56, 95% CI: 0.31 to 0.82, P < 0.0001; P for heterogeneity = 0.6, I2 = 0%], fewer ineffective cases following treatment [risk ratio(RR) = 0.23; 95% CI: 0.13 to 0.39, P < 0.00001; P for heterogeneity = 0.76, I2 = 0%], and lower overall occurrence of postoperative complications [RR = 0.35; 95% CI: 0.17 to 0.70; P = 0.003; P for heterogeneity = 0.85, I2 = 0%] than the control group. Thus, our findings indicated that IPT can provide better pain management following perianal surgery compared to controls. This novel approach complements a reasonable modality for postoperative multimodal analgesia and is worth promoting.

Defecation Symptoms in Relation to Stool Consistency Significantly Reflect the Dyssynergic Pattern in High-resolution Anorectal Manometry in Constipated Patients

GOALS

To evaluate the usefulness of a 2-week patient-completed bowel habit and symptom diary as a screening tool for disordered rectoanal coordination (DRC).

BACKGROUND

DRC is an important subgroup of chronic constipation that benefits from biofeedback treatment. Diagnosis of DRC requires a dyssynergic pattern (DP) of attempted defecation in high-resolution anorectal manometry (HRAM) and at least 1 other positive standardized examination, such as the balloon expulsion test or defecography. However, HRAM is generally limited to tertiary gastroenterology centres and finding tools for selecting patients for referral for further investigations would be of clinical value.

STUDY

Retrospective data from HRAM and a 2-week patient-completed bowel habit and symptom diary from 99 chronically constipated patients were analyzed.

RESULTS

Fifty-seven percent of the patients had a DP pattern during HRAM. In the DP group, 76% of bowel movements with loose or normal stool resulted in a sense of incomplete evacuation compared with 55% of the non-DP group ( P =0.004). Straining and sensation of incomplete evacuation with the loose stool were significantly more common in the DP group ( P =0.032). Hard stool was a discriminator for non-DP ( P =0.044). Multiple logistic regression including incomplete evacuation and normal stool predicted DP with a sensitivity of 82% and a specificity of 50%.

CONCLUSIONS

The sensation of incomplete evacuation with loose or normal stool could be a potential discriminator in favor of DP in chronically constipated patients. The bowel habit and symptom diary may be a useful tool for stratifying constipated patients for further investigation of suspected DRC.

The current state of gastrointestinal motility evaluation in cystic fibrosis: a comprehensive literature review

Background and Objective

As life expectancy in cystic fibrosis (CF) has increased over the years, a shift in focus toward extra-pulmonary comorbidities such as gastrointestinal (GI) disease has become a topic of particular importance. Although not well-defined in the current literature, GI dysmotility is thought to significantly contribute to GI symptomatology in the CF population. The objective of this article was to provide a comprehensive review of diagnostic modalities at the disposal of the clinician in the evaluation of patients with CF (pwCF) presenting with GI complaints. Furthermore, we aimed to highlight the available literature regarding utilization of these modalities in CF, in addition to their shortcomings, and emphasize areas within the motility literature where further research is essential.

Methods

A comprehensive review of all available literature in the English language through December 1, 2022 utilizing PubMed was conducted. Our search was limited to GI motility/transit and dysmotility in pwCF. Two researchers independently screened references for applicable articles and extracted pertinent data.

Key Content and Findings

Several diagnostic imaging and manometry options exist in the evaluation of dysmotility; however, the literature is lacking in high-quality, prospective studies to validate such testing in pwCF. Common symptoms experienced and diagnostic motility tools available based on segment of the GI tract as related to pwCF are explored in the current review. Shortcomings in the current literature are identified and future direction to enhance research efforts within the field of CF-related dysmotility is provided.

Conclusions

The influence of CF on GI integrity and motility is far-reaching. Despite improvements in longevity and advancement of pulmonary-specific treatment strategies, further high-quality research targeting the evaluation and management of GI dysmotility in pwCF is needed.

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.

Pelvic floor physical therapy in patients with chronic anal fissure: long-term follow-up of a randomized controlled trial

BACKGROUND

Chronic anal fissure is a common benign anorectal disease with a high recurrence rate. Pelvic floor physical therapy has been proven effective in the short-term management in patients with chronic anal fissure and pelvic floor dysfunction (PAF-trial). The aim of this study was to determine the outcomes of the PAF-trial and fissure recurrence in patients who completed the 2 months of pelvic floor physical therapy at 1-year follow-up.

METHODS

Electromyographic registration of the pelvic floor, digital rectal examination, visual analog scales, patient-related outcome measurements, and quality of life were assessed at baseline and at 1-year after inclusion. The primary outcome was muscle tone at rest during electromyographic registration of the pelvic floor at baseline and at 1-year follow-up. Secondary outcomes contained fissure recurrence, pain ratings, pelvic floor dysfunction, complaint reduction measured with a proctology specific patient-reported outcome measurement, and quality of life.

RESULTS

The treatment protocol was followed by 137 patients. Ninety-seven patients (71%) completed the 1-year follow-up, 48 women (49.5%) and 49 men (50.5%) with a mean age of 44.4 ± 11.6 years (range 19-68). In the total group of patients, mean resting electromyographic values of the pelvic floor significantly improved from baseline to follow-up at 1 year (mean estimated difference 2.20 μV; 95% CI, 1.79 to 2.61; p < 0.001). After 1 year, the fissure recurred in 15 patients (15.5%). VAS-pain significantly decreased from baseline to follow-up (mean estimated difference 4.16; 95% CI, 3.75 to 4.58; p < 0.001). Dyssynergia was found in 72.9% at baseline and decreased to 14.4% at 1-year follow-up (p < 0.001). Complaint reduction measured with the Proctoprom significantly improved from baseline to 1-year follow-up (p < 0.001). Quality of life (RAND-36) significantly improved in eight of nine domains at 1-year follow-up. No significant improvement was found in the domain vitality.

CONCLUSIONS

In the PAF-trial, we demonstrated that pelvic floor physical therapy yields a significant and clinical benefit in the time course and therefore should be advocated as adjuvant conservative treatment in patients with chronic anal fissure.

TRIAL REGISTRATION

The trial is registered at the Dutch Trial registry (NTR7581)  https://trialsearch.who.int.

Anorectal manometry for the diagnosis of pelvic floor disorders in patients with hypermobility spectrum disorders and hypermobile Ehlers-Danlos syndrome

INTRODUCTION

Functional gastrointestinal disorders (FGID) including impaired rectal evacuation are common in patients with Hypermobility Spectrum Disorder (HSD) or Hypermobile Ehlers-Danlos Syndrome (hEDS). The effect of connective tissue pathologies on pelvic floor function in HSD/hEDS remains unclear. We aimed to compare clinical characteristics and anorectal pressure profile in patients with HSD/hEDS to those of age and sex matched controls.

METHODS

We conducted a retrospective review of all FGID patients who underwent high resolution anorectal manometry (HR-ARM) and balloon expulsion test (BET) for evaluation of impaired rectal evacuation. Patients with HSD/hEDS were age and sex matched to a randomly selected cohort of control patients without HSD/hEDS. An abnormal BET was defined as the inability to expel a rectal balloon within 2 minutes. Wilcoxon rank sum test and Fisher's exact test were used to make comparisons and logistic regression model for predictive factors for abnormal evacuation.

RESULTS

A total of 144 patients (72 with HSD/hEDS and 72 controls) were analyzed. HSD/hEDS patients were more likely to be Caucasian (p < 0.001) and nulliparous. Concurrent psychiatric disorders; depression, and anxiety (p < 0.05), and somatic syndromes; fibromyalgia, migraine and sleep disorders (p < 0.001) were more common in these patients. Rate of abnormal BET were comparable among the groups. HDS/hEDS patients had significantly less anal relaxation and higher residual anal pressures during simulated defecation, resulting in significantly more negative rectoanal pressure gradient. The remaining anorectal pressure profile and sensory levels were comparable between the groups. While diminished rectoanal pressure gradient was the determinant of abnormal balloon evacuation in non HSD/hEDS patients, increased anal resting tone and maximum volume tolerated were independent factors associated with an abnormal BET in HSD/hEDS patients. Review of defecography data from a subset of patients showed no significant differences in structural pathologies between HSD/hEDS and non HSD/hEDS patients.

CONCLUSIONS

These results suggest anorectal pressure profile is not compromised by connective tissue pathologies in HSD patients. Whether concurrent psychosomatic disorders or musculoskeletal involvement impact the pelvic floor function in these patients needs further investigation.

Tailoring surgery for obstructed defecation syndrome to the 'iceberg diagram': Long-term results

BACKGROUND

Patients with obstructed defecation syndrome may present with a wide spectrum of disorders. The iceberg diagram, which focuses on the underlying occult diseases, has been proposed for an accurate diagnosis. The iceberg diagram deals with lesions, which, if neglected, may worsen the prognosis. The aim of this study was to evaluate the effect of using the iceberg diagram on the clinical results.

METHODS

Patients operated for obstructed defecation syndrome based on the iceberg diagram between 2008 and 2018 were evaluated pre- and postsurgery. All patients underwent psychosomatic assessment, abdominal and perineal examination, proctoscopy, vaginoscopy, transanal ultrasound, and defecography. Postoperative complications were also evaluated.

RESULTS

Of the 80 operated patients, 73 were females; median age was 47 (range 26-78) years. All had a rectal internal mucosal prolapse and 85% had a rectocele. The most frequent occult diseases were functional (mental distress [46%]) or organic (colpo-cysto-enterocele [44%]). Surgery was tailored according to the iceberg diagram with prolapsectomy and rectocele repair the most commonly used among 8 different procedures. A total of 14% of patients had a postoperative complication. Median follow-up was 72 months. Obstructed defecation syndrome score significantly decreased from 10.5 ± 4.8 (mean + standard deviation) to 3.4 ± 3.6 (P < .01) and 68% of patients reported to be either improved or cured.

CONCLUSION

The use of the iceberg diagram in obstructed defecation syndrome patients assists in identifying latent "submerged lesions' that may negatively impact the functional outcome of surgery. A clinical approach to patients with obstructed defecation syndrome tailored according to the iceberg diagram allows the identification of occult lesions and to achieve good long-term results.

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.

Clinical value of positive BET and pelvic floor dyssynergia in Chinese patients with functional defecation disorder

BACKGROUND

Functional defecation disorder (FDD) is a common subtype of functional constipation (FC). Balloon expulsion test (BET) and high resolution anorectal manometry (HR-ARM) are significant tools but their results are not always consistent.

AIMS

To investigate the characteristics of patients with positive BET and pelvic floor dyssynergia (PFD) and explore the value of both positive results in FDD diagnosis.

METHODS

We retrospectively diagnosed FC subtypes and enrolled FDD patients based on Rome-IV criteria. They underwent HR-ARM, BET and CTT tests. Then they were classified to two groups and further stratified by FDD subtypes. Validated questionnaires were applied to investigate patients' constipation, anxiety/depression and quality of life.

RESULTS

335 FDD patients were finally enrolled. They were classified into two groups according to whether BET and PFD were both positive (consistent or not). 84.48% showed consistent results. These patients had significantly higher anal residual pressure, lower anal relaxation rate, manometric defecation index (MDI) and a more negative rectoanal pressure gradient (RAPG) (Ps < .05). The specific distribution of FDD phenotypes in two groups showed significant difference (p = .021). Males suffered a more negative RAPG (p < .001) and age was correlated with anal relaxation rate (p < .001). A subset (177 individuals) was investigated with validated questionnaires. Scores for Defecation Symptoms, Physical Discomfort and GAD-7 score were significantly high in Consistent Group (Ps < .05). GAD-7 score was associated with Defecation Symptoms (p < .001) while anal residual pressure, GAD-7 and Defecation Symptoms score were linked to Physical Discomfort (Ps < .05). The diagnostic specificity and PPV for FDD rose significantly with positive BET and PFD.

CONCLUSION

FDD patients with positive BET and PFD suffered from severe defecation symptoms, anxiety and impaired QOL. Positive BET and PFD could be an ideal tool for screening FDD.

Pelvic floor physical therapy in patients with chronic anal fissure: a randomized controlled trial

Background

A chronic anal fissure is a common, painful condition with great impact on daily life. The exact pathogenesis has not been fully elucidated and treatment varies. A large percentage of patients experience pelvic floor dysfunction (dyssynergia and increased pelvic floor muscle tone). The aim of our study was to investigate the effect of pelvic floor physical therapy in patients with chronic anal fissure.

Methods

Between December 2018 and July 2021, at the Proctos Clinic in the Netherlands, patients with chronic anal fissure and pelvic floor dysfunction were randomly assigned to an intervention group, receiving 8 weeks of pelvic floor physical therapy including electromyographic biofeedback or assigned to a control group receiving postponed pelvic floor physical therapy. The primary outcome was muscle tone at rest during electromyographic registration of the pelvic floor before and after pelvic floor physical therapy. Secondary outcomes contained healing of the fissure, pain ratings, improvement of pelvic floor function, and complaint reduction measured with a proctology-specific patient-reported outcome measurement. Endpoints were measured at 8- and 20-week follow-up.

Results

One hundred forty patients were included in the study, 68 men (48.6%) and 72 women (51.4%) with a mean age of 44.5 ± 11.1 (range 19–79) years. Mean resting electromyographic values of the pelvic floor in the intervention group significantly improved from pre- to post-treatment (p < 0.001) and relative to controls (mean estimated difference between groups − 1.88 µV; 95% CI, − 2.49 to − 1.27 (p < 0.001) at first follow-up and remained significant from baseline at 20-week follow-up (p < 0.001). The intervention group performed better compared to the control group on all secondary outcomes, i.e., healing of the fissure (55.7% of the patients vs 21.4% in control, pain ratings (p < 0.001), diminished dyssynergia (p < 0.001), complaint reduction (p < 0.001), and decrease of pelvic floor muscle tone (p < 0.05) at first follow-up.

Conclusions

The findings of this study provide strong evidence that pelvic floor physical therapy is effective in patients with chronic anal fissure and pelvic floor dysfunction and supports its recommendation as adjuvant treatment besides regular conservative treatment.

The role of rectal redundancy in the pathophysiology of rectal prolapse: a pilot study

Purpose

Rectal prolapse is hypothesized to be caused due to weakness of the pelvic floor which is related to childbearing. However, half of the female patients with rectal prolapse were reported to be nulliparous and this hypothesis doesn't explain the prolapse in males. The aim of this study is to evaluate the role of rectal redundancy in rectal prolapse pathophysiology.

Methods

This study was conducted prospectively. Fourteen patients who underwent rectopexy were included in the study group. A total of 17 patients who underwent laparotomy for another reason and who have no symptoms regarding rectal prolapse were included in the control group. In order to measure the redundancy of the rectum, we have calculated the ratio of length of intraperitoneal rectum (R) to length of distance between promontorium and peritoneal reflection (PRx). The primary outcome of this study was to evaluate whether the R/PRx ratio is higher in patients with rectal prolapse compared to the control group.

Results

Comparing the anatomic features showed that the length of sigmoid colon and length of PRx were not significantly different between the two groups. However, the length of intraperitoneal rectum was significantly higher in the prolapse group. Furthermore, the median R/PRx ratio in the prolapse group was significantly higher than in the control group.

Conclusion

This study showed that intraperitoneal rectum in patients with rectal prolapse is significantly more redundant than in the normal population. This could be considered reasonable evidence for the role of rectal redundancy on rectal prolapse pathophysiology.

Investigation of HPLF-111624 in Modified Experimental Models of Ulcerative Proctitis and Anal Fissure in Rats

Background

Although ulcerative proctitis (UP) and anal fissure (AF) are common anorectal diseases, there are no appropriate experimental models to screen the drugs intended for these conditions. In this context, existing experimental models mimicking these diseases were modified and the polyherbal formulation, HPLF-111624 was evaluated in these models.

Objective

To establish animal model for UP and AF and to evaluate polyherbal formulation, HPLF-111624 in these disease models.

Methods

An experimental model of UP was selected based on the modification of the ulcerative colitis model using different concentrations of acetic acid. The concentration used for induction were 2.5%, 5% and 10% v/v and different weights used to induce AF were 25 g, 50 g and 100 g, which were selected based on the severity of inflammation, fecal score, gross pathology, and histopathological evaluation. Furthermore, these animal models were used to evaluate the efficacy of HPLF-111624, a polyherbal formulation known to be beneficial in anal diseases.

Results

Acetic acid at 5% produced typical pathological changes that resembled UP, with a significant increase in the fecal score, gross lesion, and histopathological changes. Similarly, among the three weights, physical injury with a 100 g weight produced significant changes in the histopathological score in the model of AF. Intervention with HPLF-111624 at doses of 250 and 500 mg/kg b.wt., showed a reduction in the inflammatory cytokines and a significant improvement in the histopathological findings in both the conditions.

Conclusion

The results showed that the modified experimental models for UP and AF resemble the human pathological conditions and are simple, versatile and may be used for screening drugs intended for these conditions. Intervention with HPLF-111624 was found to be effective in improving the pathological state of UP and AF.

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

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

Management of chronic anal fissure: results of a national survey among gastrointestinal surgeons in the Netherlands

BACKGROUND

Chronic anal fissure (CAF) is a common, bothersome condition frequently accompanied by pelvic floor complaints. Despite current guidelines, optimal management is challenging. The aim of this study is to evaluate current management of CAF among gastrointestinal surgeons in the Netherlands.

METHODS

Dutch gastrointestinal surgeons and residents were sent a survey invitation by email, which was available online between June 2021 and September 2021. The questionnaire consisted of 21 questions concerning work experience, physical examination, diagnostic and surgical techniques, and follow-up.

RESULTS

Overall, 106 (33%) respondents completed the survey. Most respondents (59%) had at least 10 years of experience in treating CAF. Only 23% always addressed pelvic floor complaints. Fifty-one percent performed digital rectal examination and 22% always, or almost always, examined the pelvic floor muscles. Most respondents started treatment with fibers and/or laxatives and ointment (96%). Diltiazem was in 90% the preferred ointment. Twenty-two percent referred patients for pelvic floor physical therapy. Botulinum toxin was in 54% performed under general or spinal anesthesia or sedation. The surgical procedure of choice was fissurectomy (71%) followed by lateral internal sphincterotomy (27%). Fissurectomy was in 51% always combined with botulinum toxin. Fifty-seven percent of the respondents preferred a physical follow-up appointment.

CONCLUSION

Guideline recommendations are largely followed in the Netherlands, starting with conservative measures followed by surgical procedures. Surgeons do not consistently assess pelvic floor complaints, nor do they routinely examine the pelvic floor muscles. Awareness of pelvic floor dysfunctions is important to refer patients for pelvic floor physical therapy.

Management of irreducible giant rectal prolapse: A case report and literature review

INTRODUCTION AND IMPORTANCE

Rectal prolapse is defined as herniation of mucosa or full-thickness of the rectal wall through the anal canal. It has a negative impact on the quality of life and therefore, it should be treated as soon as diagnosis is confirmed. Definitive treatment is surgical and it depends on the clinical characteristics of the patients. We aimed to present the one of the largest rectal prolapse case in the literature.

CASE PRESENTATION

A 32- years- old male patient with a history of severe constipation was admitted to our institution with a giant rectal prolapse. The prolapsed segment was incarcerated, and a semi-emergent procedure was performed though a mid-line laparotomy. The sigmoid colon was redundant and therefore sigmoid colon and the upper two thirds of rectum were resected and end to end anastomosis was performed. The patient was discharged postoperative day 7 without any complication.

CLINICAL DISCUSSION

Rectal prolapse has a negative impact on quality of life and should be operated as soon as the diagnosis is reached. The surgical strategy depends on the compliance of the patient as well as the experience of the surgical team.

CONCLUSION

Clinicians should know that chronic constipation together with other factors may result in rectal prolapse which may become disproportionately large in size.

Digital Rectal Examination Is a Valuable Bedside Tool for Detecting Dyssynergic Defecation: A Diagnostic Study and a Meta-Analysis

BACKGROUND

Accurate dyssynergic defecation (DD) diagnosis depends on anorectal physiological tests that are not widely available.

AIM

The purpose of this study is to evaluate the diagnostic yield of digital rectal examination (DRE) compared with anorectal physiological tests in diagnosing DD in patients with constipation.

METHODS

A total of 218 chronic constipation patients who fulfilled the Rome IV diagnostic criteria for functional constipation (FC) and underwent a standardized DRE and high-resolution anorectal manometry (HRAM) test were enrolled in this study. The diagnostic accuracy of DRE compared with HRAM was evaluated, and the agreement between DRE and HRAM was calculated. Furthermore, a comprehensive literature search on PubMed, Web of Science, Cochrane Library, and Embase database was conducted to further elucidate the pooled diagnostic accuracy of DRE in DD patients.

RESULTS

A total of 101 patients (46.33%) had a DD pattern using HRAM, while 117 patients (53.67%) were diagnosed without DD. The sensitivity of DRE in diagnosing dyssynergia was 71.3%, and the specificity was 76.1%. There was a moderate agreement between DRE and HRAM for diagnosing DD (κ-coefficient = 0.474, P < 0.001). Meanwhile, six studies (including our study) comprising 964 constipated patients were included in our meta-analysis. The outcomes demonstrated that the AUC was 0.85 (95% CI 0.82-0.88) with 77% summary sensitivity (95% CI 65-86) and 80% summary specificity (95% CI 71-86) to diagnose DD.

CONCLUSIONS

DRE could be a valuable tool for screening DD. Our study revealed acceptable sensitivity and specificity of DRE in detecting dyssynergia compared with the physiological tests. Meanwhile, our study highlights that DRE remains an important tool in clinical practice.

An experimental study on the pathophysiology of rectal prolapse

Objective: For decades, rectal prolapse has been hypothesized to be caused due to laxity or weakness of the pelvic floor muscles which is often sup- posed to be related to childbearing in females. However, 50% of females with rectal prolapse have been reported to be nulliparous and this hypothesis does not explain the incidence of rectal prolapse in males. The aim of this study was to evaluate the role of rectal redundancy in rectal prolapse patho- physiology.

Material and Methods: Nineteen female Sprague Dawley rats (250-300 g) at 16 weeks of age were obtained from the animal center. Rats were divided into two groups as rectal mobilization (study) group (n= 9) and sham-operated control (n= 10) group. In the study group, soft dissection was applied and rectum were mobilized up from the pelvic floor to create a redundant or hypermobilized rectum.The primary outcome was the rate of rectal pro- lapse after rectal mobilization.

Results: As compared to the sham-operated control group, in which none of the rats had rectal prolapse throughout the post-surgical period, rectal prolapse was observed in four of the rats in the rectal mobilization group (0% vs. 44%; p= 0.006). Being unable to increase the length of the rectums of the rats, but using only mobilization to create the redundancy, and the lack of data regarding any adhesions after surgery are the main limitations of this study.

Conclusion: This study showed the role of rectal redundancy on the rectal prolapse pathophysiology.

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.

Prevalence and Clinical Characteristics of Dyssynergic Defecation and Slow Transit Constipation in Patients with Chronic Constipation

Patients with chronic constipation who do not respond to initial treatments often need further evaluation for dyssynergic defecation (DD) and slow transit constipation (STC). The aims of this study are to characterize the prevalence of DD and STC in patients referred to a motility center with chronic constipation and correlate diagnoses of DD and STC to patient demographics, medical history, and symptoms. High-resolution ARM (HR-ARM), balloon expulsion testing (BET) and whole gut transit scintigraphy (WGTS) of consecutive patients with chronic constipation were reviewed. Patients completed questionnaires describing their medical history and symptoms at the time of testing. A total of 230 patients completed HR-ARM, BET, and WGTS. Fifty (22%) patients had DD, and 127 (55%) patients had STC. Thirty patients (13%) had both DD and STC. There were no symptoms that were suggestive of STC vs. DD; however, patients with STC and DD reported more severe constipation than patients with normal transit and anorectal function. Patients with chronic constipation often need evaluation for both DD and STC to better understand their pathophysiology of symptoms and help direct treatment.

Imaging and clinical assessment of functional defecatory disorders with emphasis on defecography

Functional defecation disorders (FDD) encompass causes of constipation associated with anorectal dysfunction, which include dyssynergia or inadequate defecatory propulsion. FDD are frequently encountered in clinical practice and may affect up to 33-50% of patients with chronic constipation. The etiology of FDD is unclear, however, it has been defined as an acquired, but subliminal behavioral disorder. Pathophysiologic mechanisms may include discoordination of rectoanal muscles, paradoxical contraction or insufficient relaxation of puborectalis and/or anal sphincter during defecation, and sluggish colonic transit. A combination of comprehensive clinical assessment, digital rectal examination and a battery of physiologic tests are needed to make an accurate diagnosis of FDD. Defecography may play a crucial role in the evaluation of FDD, especially when a balloon expulsion test (BET) and/or anorectal manometry (ARM) are equivocal or demonstrate contradictory results. In this review, we provide a thorough overview of the epidemiology, pathophysiology, diagnostic criteria, clinical and imaging evaluation, and treatment options for FDD, with an emphasis on available diagnostic imaging tools such as defecography and conventional fluoroscopic methods.

External Anal Sphincter Fatigability: An Electromyographic and Manometric Study in Patients With Anorectal Disorders

Background/Aims

External anal sphincter (EAS) plays an important role in fecal and gas voluntary continence. Like every muscle, it can be affected by repeated efforts due to fatigability (physiological response) and/or fatigue (pathological response). No standardized fatiguing protocol and measure method to assess EAS fatigability has existed. The aim is to test a simple, standardized protocol for fatiguing and measuring EAS fatigability and fatigue to understand better the part of EAS fatigability in the pathophysiology of fecal incontinence.

Methods

Patients with anorectal disorders evaluated with anorectal manometry were included. They had to perform 10 repetitions of maximum voluntary contraction (MVC) of 20 seconds. Measurement was made with an anorectal manometry catheter and a surface recording electromyography (EMG). The primary outcome was the difference in EMG root mean square between the first and the last MVC. Secondary outcomes were differences in other EMG and manometry parameters between the first and the last MVC. Difficulties and adverse effects were recorded.

Results

Nineteen patients underwent the fatiguing protocol. All patients completed the entire protocol and no complications were found. No difficulty was declared by the examiner. A significant decrease in root mean square was found between the first and last MVC (0.01020 ± 0.00834 mV vs 0.00661 ± 0.00587 mV; P = 0.002), in maximum anal pressure area under the curve of continuous recordings of anal pressure and mean and total EMG power (P < 0.05).

Conclusions

This protocol is simple and minimally invasive to measure EAS fatigue and fatigability. We highlighted a fatigue of EAS in many patients with anorectal disorders.

Surgical management of the rectocele - An update

Rectocele is defined as a hernia of the rectum with protrusion of the anterior rectal wall through the posterior wall of the vagina. This condition occurs commonly, with an estimated prevalence of 30-50% of women over age 50. The symptomatology that leads to consultation is variable but consists predominantly of anorectal and/or gynecological complaints such as dyschezia, requiring digital disimpaction maneuvers, pelvic heaviness, anal incontinence, or dyspareunia. Rectocele may be isolated or associated with other disorders of pelvic stasis involving cystocele and uterine prolapse. Complementary exams (dynamic imaging and anorectal manometry) are essential before deciding on the surgical management of this condition. The indications for surgical management of rectocele are based on the intensity of symptoms and the resulting deterioration in quality of life, and surgery should be discussed after failure of medical treatment. Different approaches are possible, although there is currently no real consensus in the literature. The initial approach depends on the type of rectocele: if it involves the low or mid rectum or is isolated, an approach from below (transanal, transperineal, or transvaginal approach) can be proposed, while, in the presence of a high rectocele and/or associated with various disorders of pelvic stasis, transabdominal rectopexy is more suitable.

Physiotherapy for Prevention and Treatment of Fecal Incontinence in Women-Systematic Review of Methods

Fecal incontinence (FI) affects approximately 0.25-6% of the population, both men and women. The most common causes of FI are damage to/weakness of the anal sphincter muscle and/or pelvic floor muscles, as well as neurological changes in the central or peripheral nervous system. The purpose of this study is to report the results of a systematic review of the possibilities and effectiveness of physiotherapy techniques for the prevention and treatment of FI in women. For this purpose, the PubMed, Embase, and Web of Science databases were searched for 2000-2020. A total of 22 publications qualified for detailed analysis. The studies showed that biofeedback (BF), anal sphincter muscle exercises, pelvic floor muscle training (PFMT), and electrostimulation (ES) are effective in relieving FI symptoms, as reflected in the International Continence Society recommendations (BF: level A; PFMT and ES: level B). Research has confirmed that physiotherapy, by improving muscle strength, endurance, and anal sensation, is beneficial in the prevention of FI, both as an independent method of conservative treatment or in pre/post-surgery treatment. Moreover, it can significantly improve the quality of life of patients. In conclusion, physiotherapy (in particular, BF, PFMT, or ES, as effective methods) should be one of the key elements in the comprehensive therapy of patients with FI.

Efficacy and safety of Buzhong Yiqi decoction combined with surgery for rectal prolapse: A protocol for systematic review and meta analysis

BACKGROUND

It is extremely easy for rectal prolapse to relapse with surgery alone. Clinical practice indicates that Buzhong Yiqi decoction combined with surgery has certain therapeutic advantages, while there is a lack of evidence-based medicine support. This study aimed to systematically investigate the efficacy and safety of Buzhong Yiqi decoction combined with surgery in the treatment of rectal prolapse.

METHODS

The English databases (PubMed, Embase, Web of Science, the Cochrane Library) and Chinese databases (China National Knowledge Infrastructure [CNKI], Wanfang, China Science and Technology Journal Database [VIP], China Biology Medicine disc) were searched by computer. In addition, Baidu Scholar and Google Scholar were searched manually. A randomized controlled clinical study of Buzhong Yiqi decoction combined with surgery in the treatment of rectal prolapse was performed from the establishment of databases to September 2020. Two investigators independently conducted data extraction and assessed the literature quality of the included studies. The Revman5.3 software was used for meta-analysis of the included literature.

RESULTS

The efficacy and safety of Buzhong Yiqi decoction combined with surgery in the treatment of rectal prolapse were evaluated in terms of efficiency, symptom score, recurrence rate, adverse reaction rate, and so on.

CONCLUSIONS

Thisstudy provides reliable evidence-based support for the clinical application of Buzhong Yiqi decoction combined with surgery in the treatment of rectal prolapse.

OSF REGISTRATION NUMBER

DOI: 10.17605/OSF.IO/K3PJX.

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.

Anorectal Disorders: An Update

Anorectal disorders encompass structural, neuromuscular, and functional disorders. They are common, often distressing, and in some cases debilitating, and significantly add to the health care burden. They present with multiple, overlapping symptoms that can often obscure the underlying pathology and can pose significant diagnostic and management dilemmas. A meticulous history and comprehensive digital rectal examination can provide clarity on the diagnosis, appropriate testing, and management of these conditions. Today, with the development of sophisticated diagnostic tools such as high-resolution and high-definition (3-D) anorectal manometry, 3-D anal ultrasonography, magnetic resonance defecography and imaging, and neurophysiological tests such as translumbosacral anorectal magnetic stimulation, it is possible to more accurately define and characterize the underlying structural and functional abnormalities. In this review, we present a succinct update on the latest knowledge with regards to the pathophysiology, diagnosis and management of anal fissure, hemorrhoids, rectal prolapse, intussusception, rectocele, solitary rectal ulcer syndrome, levator ani syndrome, dyssynergic defecation and fecal incontinence.

Clinical presentation and characteristics of pelvic floor myofascial pain in patients presenting with constipation

BACKGROUND

Patients with pelvic floor myofascial pain (PFMP) have puborectalis tenderness on digital rectal examination (DRE). Little is known about its significance to anorectal function in patients presenting with constipation.

AIM

To characterize demographics, clinical characteristics, findings on anorectal manometry (ARM), diagnosis of rectal evacuation disorder (RED), colonic transit [normal (NTC) or slow (STC)], and imaging in constipated patients with PFMP and compare these features to constipation without PFMP.

METHODS

We performed an electronic medical records review of patients with constipation evaluated by a single gastroenterologist between January 2008 and February 2019. Patients with PFMP were compared to controls with constipation but without PFMP (1:2 ratio).

KEY RESULTS

A total of 98 PFMP cases and 196 controls were identified. Constipated patients with PFMP were more likely to have RED [OR 7.59 (3.82-15.09), P < .01]; controls were more likely to have either NTC [OR 4.25 (1.45-12.42), P < .01] or STC [OR 3.57 (1.45-8.78), P < .01]. RED in patients with PFMP is supported by comparison to controls: On DRE, they had increased resting tone [OR 2.25 (1.33-3.83), P < .01] and paradoxical contraction of the puborectalis upon simulated evacuation [OR 3.41 (1.94-6.00), P < .01]; on ARM, they had higher maximum resting pressure (102.9 mmHg vs 90.7 mmHg, P < .01) and lower rectoanal pressure gradient (-39.4 mmHg vs -24.7 mmHg, P < .01).

CONCLUSIONS/INFERENCES

In constipated patients, PFMP is highly associated with RED. Its presence provides a valuable clue regarding the etiology of a patient's constipation; it should be assessed in all patients with constipation and should also be an additional target for management.

Improvement of Patient Satisfaction and Anorectal Manometry Parameters After Biofeedback Therapy in Patients with Different Types of Dyssynergic Defecation

Biofeedback is a well-known and effective treatment for patients with fecal evacuation disorder (FED). The main purpose of this study was to investigate the outcome and the effects of biofeedback therapy on physiological parameters as assessed by manometry in patients with FED. Data from 114 consecutive patients with FED who underwent biofeedback therapy in Sara Gastrointestinal clinic in Tehran, Iran during 2015-2018 were retrospectively reviewed and analyzed. All participants underwent a comprehensive evaluation of anorectal function that included anorectal manometry and a balloon expulsion test at the baseline and after biofeedback therapy. Maximum anal squeeze pressure and sustained anal squeeze pressure were improved up to 100% and 94.7% of normal values in the patients after biofeedback, respectively (P < 0.001). First rectal sensation, was significantly decreased (25 ± 18.5 vs. 15.5 ± 5.2) while the maximum tolerable volume was significantly increased (233.6 ± 89.7 vs. 182.4 ± 23.1) after biofeedback therapy (P < 0.001). Type I dyssynergia was the most common type, effecting 82 cases (71.9%) of our patients. Dyssynergia parameters were improved 50-80% in 34 (41.5%) and 10 (31.3%) type I and non-type I patients, respectively. Over 80% improvement of dyssynergia parameters occurred in 48 (58.5%) and 22 (68.8%) type I and non-type I patients, respectively. These differences were not statistically significant between the two groups (P = 0.3). In addition, the ability to reject the balloon was significantly better in post intervention measurements (P < 0.001). Biofeedback not only improves the symptoms in patients of FED but also reverses more than 80% the dyssynergic parameters of defecation. However, due to the general effectiveness of biofeedback treatment in different types of DD, there were no significant differences between their improvement scores.

Acupuncture therapy for postoperative pain of anorectal diseases: A systematic review protocol

BACKGROUND

The incidence of anorectal diseases has been increasing year by year, and the acupuncture treatment for postoperative pain of anorectal diseases has the excellent therapeutic effect. Currently, there are no relevant articles for systematic review.

METHODS

We will search the randomized controlled trials related to acupuncture therapy and postoperative anorectal diseases from inception to January 2020. The following database is our focus area: PubMed, EMBASE, Springer, EBSCO, Web of Science, Cochrane, Controlled Trials Register (CENTRAL), the Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI), Wan-Fang Database and Chinese Scientific Journal Database (VIP database). The primary outcome is the pain of visual analogue scale (VAS). The secondary outcomes are the Symptom Checklist, Wong-Baker Faces Pain Rating (WB) Scale, verbalrating scale (VRS), and 36-Item Short Form Health Survey (SF-36) scale. We will use Review Manager Software (RevMan) V.5.2 for data analysis and quantitative data synthesis. The Cochrane collaborative tool will be used to assess the risk of bias in the included studies.

RESULTS

Given the available evidence, this study will provide high level results for acupuncture therapy in treating postoperative pain of anorectal diseases.

CONCLUSION

The conclusions of this study will provide evidence for whether acupuncture is effective in treating postoperative pain of anorectal diseases.

PROSPERO REGISTRATION NUMBER

CRD42020150015.

Pelvic floor rehabilitation for defecation disorders

Pelvic floor rehabilitation is frequently recommended for defecation disorders, in both constipation and fecal incontinence. However, the lack of patient selection, together with the variety of rehabilitation methods and protocols, often jeopardize the results of this approach, causing difficulty in evaluating outcomes and addressing proper management, and above all, in obtaining scientific evidence for the efficacy of these methods for specific indications. The authors represent different gastroenterological and surgical scientific societies in Italy, and their aim was to identify the indications and agree on treatment protocols for pelvic floor rehabilitation of patients with defecation disorders. This was achieved by means of a modified Delphi method, utilizing a working team (10 members) which developed the statements and a consensus group (15 members, different from the previous ones) which voted twice also suggesting modifications of the statements.

The Role of Botox in Colorectal Disorders

PURPOSE OF REVIEW

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

RECENT FINDINGS

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