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Techniques in Coloproctology Jun 2023Anismus or non-relaxing puborectalis muscle (PRM) on straining may affect over 40% of patients with obstructed defecation (OD). Management is usually with biofeedback,...
Anismus or non-relaxing puborectalis muscle (PRM) on straining may affect over 40% of patients with obstructed defecation (OD). Management is usually with biofeedback, or botulin toxin injection or partial puborectalis muscle myotomy. Such a procedure can be difficult technically. Bleeding and rectal injury may occur when detaching the PRM from the rectum. A partial modification of surgical technique may avoid these complications. The diagnosis should be confirmed with exclusion of sphincter compromise. Through two cutaneous incisions, an Ellis forceps is advanced through the ischio-rectal space, whilst finger pressure per rectum allows the puborectalis to be visualized and grasped by the forceps. Removal of some ischiorectal fat may be necessary to allow division of half the PRM under direct view. From October 2020 to October 2021, 5 patients underwent the modified technique in our department (4 males, median age 43 years [range 34-58 years], median follow-up 6 months [range 2-12 months]). No patients suffered from injury of the rectum or bleeding during or after surgery. Operative time was 30 min less than conventional PRM division, as the time-consuming "blind dissection" of PRM was avoided. Four patients regained appropriate relaxation of the PRM on straining. One male patient had temporary minor anal incontinence for 2 weeks. One male patient with severe mental distress continued to have with anismus and OD after surgery and refused psychiatric support. This modified procedure is feasible and safe and quicker than our conventional technique. More cases with longer follow-up are needed to confirm its efficacy.
Topics: Humans; Male; Child, Preschool; Defecation; Constipation; Anus Diseases; Rectal Diseases; Myotomy
PubMed: 36725753
DOI: 10.1007/s10151-022-02748-0 -
The British Journal of Radiology 2015Total pelvic floor ultrasound is used for the dynamic assessment of pelvic floor dysfunction and allows multicompartmental anatomical and functional assessment. Pelvic... (Review)
Review
Total pelvic floor ultrasound is used for the dynamic assessment of pelvic floor dysfunction and allows multicompartmental anatomical and functional assessment. Pelvic floor dysfunction includes defaecatory, urinary and sexual dysfunction, pelvic organ prolapse and pain. It is common, increasingly recognized and associated with increasing age and multiparity. Other options for assessment include defaecation proctography and defaecation MRI. Total pelvic floor ultrasound is a cheap, safe, imaging tool, which may be performed as a first-line investigation in outpatients. It allows dynamic assessment of the entire pelvic floor, essential for treatment planning for females who often have multiple diagnoses where treatment should address all aspects of dysfunction to yield optimal results. Transvaginal scanning using a rotating single crystal probe provides sagittal views of bladder neck support anteriorly. Posterior transvaginal ultrasound may reveal rectocoele, enterocoele or intussusception whilst bearing down. The vaginal probe is also used to acquire a 360° cross-sectional image to allow anatomical visualization of the pelvic floor and provides information regarding levator plate integrity and pelvic organ alignment. Dynamic transperineal ultrasound using a conventional curved array probe provides a global view of the anterior, middle and posterior compartments and may show cystocoele, enterocoele, sigmoidocoele or rectocoele. This pictorial review provides an atlas of normal and pathological images required for global pelvic floor assessment in females presenting with defaecatory dysfunction. Total pelvic floor ultrasound may be used with complementary endoanal ultrasound to assess the sphincter complex, but this is beyond the scope of this review.
Topics: Defecation; Female; Humans; Pelvic Floor; Pelvic Floor Disorders; Ultrasonography
PubMed: 26388109
DOI: 10.1259/bjr.20150494 -
Digestive Diseases and Sciences Apr 2023The effect of age and gender differences on anorectal function, symptoms severity, and quality of life (QoL) in patients with chronic constipation (CC) is not well...
BACKGROUND
The effect of age and gender differences on anorectal function, symptoms severity, and quality of life (QoL) in patients with chronic constipation (CC) is not well studied. This study examines the impact of age and gender on anorectal function testing (AFT) characteristics, symptoms burden, and QoL in patients with CC.
METHODS
This is a retrospective analysis of prospectively collected data from 2550 adults with CC who completed AFT. Collected data include demographics, sphincter response to simulated defecation during anorectal manometry (ARM), balloon expulsion testing (BET), and validated surveys assessing constipation symptoms and QoL. DD was defined as both the inability to relax the anal sphincter during simulated defecation and an abnormal BET.
RESULTS
2550 subjects were included in the analysis (mean age = 48.6 years). Most patients were female (81.6%) and Caucasian (82%). 73% were < 60 years old (mean = 41) vs. 27% ≥ 60 years old (mean = 69). The prevalence of impaired anal sphincter relaxation on ARM, abnormal BET, and DD in patients with CC was 48%, 42.1%, and 22.9%, respectively. Patients who were older and male were significantly more frequently diagnosed with DD and more frequently had impaired anal sphincter relaxation on ARM, compared to patients who were younger and female (p < 0.05). Conversely, CC patients who were younger and female reported greater constipation symptoms severity and more impaired QoL (p ≤ 0.004).
CONCLUSION
Among patients with CC referred for anorectal function testing, men and those older than 60 are more likely to have dyssynergic defecation, but women and patients younger than 60 experience worse constipation symptoms and QoL.
Topics: Adult; Humans; Female; Male; Middle Aged; Quality of Life; Defecation; Retrospective Studies; Sex Factors; Manometry; Constipation; Anal Canal; Surveys and Questionnaires; Rectum
PubMed: 36173584
DOI: 10.1007/s10620-022-07709-z -
Neurogastroenterology and Motility Jun 2024Even if understanding of neuronal enteropathies, such as Hirschsprung's disease and functional constipation, has been improved, specialized therapies are still missing....
BACKGROUND
Even if understanding of neuronal enteropathies, such as Hirschsprung's disease and functional constipation, has been improved, specialized therapies are still missing. Sacral neuromodulation (SNM) has been established in the treatment of defecation disorders in adults. The aim of the study was to investigate effects of SNM in children and adolescents with refractory symptoms of chronic constipation.
METHODS
A two-centered, prospective trial has been conducted between 2019 and 2022. SNM was applied continuously at individually set stimulation intensity. Evaluation of clinical outcomes was conducted at 3, 6, and 12 months after surgery based on the developed questionnaires and quality of life analysis (KINDL). Primary outcome was assessed based on predefined variables of fecal incontinence and defecation frequency.
KEY RESULTS
Fifteen patients enrolled in the study and underwent SNM (median age 8.0 years (range 4-17 years)): eight patients were diagnosed with Hirschsprung's disease (53%). Improvement of defecation frequency was seen in 8/15 participants (53%) and an improvement of fecal incontinence in 9/12 patients (75%). We observed stable outcome after 1 year of treatment. Surgical revision was necessary in one patient after electrode breakage. Urinary incontinence was observed as singular side effect of treatment in two patients (13%), which was manageable with the reduction of stimulation intensity.
CONCLUSIONS
SNM shows promising clinical results in children and adolescents presenting with chronic constipation refractory to conservative therapy. Indications for patients with enteral neuropathies deserve further confirmation.
Topics: Humans; Adolescent; Child; Female; Male; Constipation; Electric Stimulation Therapy; Child, Preschool; Fecal Incontinence; Prospective Studies; Treatment Outcome; Lumbosacral Plexus; Defecation; Quality of Life; Hirschsprung Disease
PubMed: 38703048
DOI: 10.1111/nmo.14808 -
Neurogastroenterology and Motility Feb 2017The metabolic activity of colonic microbiota is influenced by diet; however, the relationship between metabolism and colonic content is not known. Our aim was to...
BACKGROUND
The metabolic activity of colonic microbiota is influenced by diet; however, the relationship between metabolism and colonic content is not known. Our aim was to determine the effect of meals, defecation, and diet on colonic content.
METHODS
In 10 healthy subjects, two abdominal MRI scans were acquired during fasting, 1 week apart, and after 3 days on low- and high-residue diets, respectively. With each diet, daily fecal output and the number of daytime anal gas evacuations were measured. On the first study day, a second scan was acquired 4 hours after a test meal (n=6) or after 4 hours with nil ingestion (n=4). On the second study day, a scan was also acquired after a spontaneous bowel movement.
RESULTS
On the low-residue diet, daily fecal volume averaged 145 ± 15 mL; subjects passed 10.6 ± 1.6 daytime anal gas evacuations and, by the third day, non-gaseous colonic content was 479 ± 36 mL. The high-residue diet increased the three parameters to 16.5 ± 2.9 anal gas evacuations, 223 ± 19 mL fecal output, and 616 ± 55 mL non-gaseous colonic content (P<.05 vs low-residue diet for all). On the low-residue diet, non-gaseous content in the right colon had increased by 41 ± 11 mL, 4 hours after the test meal, whereas no significant change was observed after 4-hour fast (-15 ± 8 mL; P=.006 vs fed). Defecation significantly reduced the non-gaseous content in distal colonic segments.
CONCLUSION & INFERENCES
Colonic content exhibits physiologic variations with an approximate 1/3 daily turnover produced by meals and defecation, superimposed over diet-related day-to-day variations.
Topics: Adult; Colon; Defecation; Diet; Dietary Fiber; Feces; Female; Humans; Magnetic Resonance Imaging; Male; Meals; Middle Aged
PubMed: 27545449
DOI: 10.1111/nmo.12930 -
PloS One 2019Open defecation is ongoing in Nepal despite the rise in efforts for increasing latrine coverage and its use. Understanding the reasons for open defecation would...
INTRODUCTION
Open defecation is ongoing in Nepal despite the rise in efforts for increasing latrine coverage and its use. Understanding the reasons for open defecation would complement the ongoing efforts to achieve the 'open defecation free' status in Nepal. This study aimed at exploring different motivations of people who practice open defecation in a village in Nepal.
METHODS
This study was conducted among the people from the Hattimudha village in Morang district of eastern Nepal, who practiced open defecation. Maximum variation sampling method was used to recruit participants for 20 in-depth interviews and 2 focus group discussions. We adopted a content analysis approach to analyze the data.
RESULTS
We categorized different reasons for open defecation as motivation by choice and motivation by compulsion. Open defecation by choice as is expressed as a medium for socializing, a habit and an enjoyable outdoor activity that complies with spiritual and religious norms. Open defecation by compulsion include reasons such as not having a latrine at home or having an alternative use for the latrine structures. Despite having a private latrine at home or access to a public latrine, people were compelled to practice open defecation due to constraints of norms restricting latrine use and hygiene issues in general. For women the issues with privacy and issues refraining women to use the same latrine as men compelled women to look for open defecation places.
CONCLUSION
Open defecation is either a voluntary choice or a compulsion. This choice is closely linked with personal preferences, cultural and traditional norms with special concerns for privacy for women and girls in different communities. The ongoing campaigns to promote latrine construction and its use needs to carefully consider these factors in order to reduce the open defecation practices and increase the use of sanitary latrines.
Topics: Adult; Aged; Compulsive Behavior; Culture; Defecation; Family Characteristics; Female; Habits; Health Knowledge, Attitudes, Practice; Humans; Hygiene; Male; Middle Aged; Motivation; Nepal; Qualitative Research; Rural Population; Sanitation; Socioeconomic Factors; Surveys and Questionnaires; Toilet Facilities; Young Adult
PubMed: 31260506
DOI: 10.1371/journal.pone.0219246 -
Current Opinion in Gastroenterology Jan 2018To summarize the advances in diagnostic modalities and management options for defecatory dysfunction and highlight the areas in need of further research. (Review)
Review
PURPOSE OF REVIEW
To summarize the advances in diagnostic modalities and management options for defecatory dysfunction and highlight the areas in need of further research.
RECENT FINDINGS
The diagnostic utility of high-resolution anorectal manometry (ARM), which has emerged as a promising tool for the diagnosis of defecatory dysfunction, appears to be questionable in differentiating disease from normal physiology. There also seems to be discrepancy between results of various tests of anorectal function in the diagnosis of defecatory dysfunction. New revisions in diagnostic criteria for defecatory dysfunction by Rome IV consortium, may enhance its diagnostic yield. Biofeedback remains to be the most effective evidence-based treatment option for patients with defecatory dysfunction. Anorectal pressure profile cannot predict or mediate the success of biofeedback. Biofeedback may improve the symptoms through central effects.
SUMMARY
Despite the advances in the ARM and defecography techniques, no one test has been able to be considered as the 'gold standard' for diagnosis of defecatory dysfunction. The mechanism of action of biofeedback in defecatory dysfunction remains poorly understood.
Topics: Anal Canal; Biofeedback, Psychology; Constipation; Defecation; Defecography; Humans; Manometry; Rectum
PubMed: 29064840
DOI: 10.1097/MOG.0000000000000407 -
Neurogastroenterology and Motility May 2022The pathophysiology of bloating is partially understood. We investigated in patients with disorders of gut-brain interaction (DGBI) the relationship between severity of...
BACKGROUND
The pathophysiology of bloating is partially understood. We investigated in patients with disorders of gut-brain interaction (DGBI) the relationship between severity of bloating, abdominal girth changes and defecation pattern, and the efficacy of pelvic floor biofeedback treatment on bloating.
METHODS
Disorders of gut-brain interaction patients with severe bloating as the main complaint were prescribed 2 weeks dietary advice and underwent abdominal girth measurements. At the first visit, all patients underwent a questionnaire on the subjective improvement of bloating, a (0-100) VAS abdominal bloating, and abdominal girth measurement. Patients reporting inadequate bloating relief underwent a standardized balloon expulsion test. Furthermore, they were invited to undergo pelvic floor electromyography and biofeedback treatment previously used for constipation due to dyssynergic defecation. The primary outcome was bloating improvement on a 5-point Likert scale. The secondary outcomes were the effect of diet intervention and pelvic floor biofeedback treatment on bloating severity and quality of life changes as well as the effect of pelvic floor biofeedback treatment on BET and EMG on straining.
KEY RESULTS
One hundred and fifty six patients (129 F, 39.3 ± 11.7 mean age) completed the 2-week run-in period. 105 patients were diet non-responder and underwent balloon expulsion test, with the vast majority (64%) failing the test. Patients who scored higher bloating on VAS had a significant association with failed balloon expulsion test (adjusted B 0.4 [95% CI 10.8-25.7], p < 0.0001). 63% agreed to perform pelvic floor biofeedback treatment at Verona center, 54% became responders reporting fair or major improvement/cure (ITT analysis, McNemar test, p < 0.0001), and all of them showed a 50% decrease in bloating severity.
CONCLUSIONS AND INFERENCES
Disordered defecation is a prevalent etiology in DGBI patients with bloating unresponsive to conservative measures; pelvic floor biofeedback treatment to improve the defecation effort significantly relieved bloating (http://www.isrctn.com, ISRCTN17004079).
Topics: Biofeedback, Psychology; Brain; Constipation; Defecation; Flatulence; Humans; Pelvic Floor; Quality of Life; Treatment Outcome
PubMed: 34532928
DOI: 10.1111/nmo.14264 -
American Journal of Obstetrics and... Apr 2017Posterior vaginal prolapse is thought to cause difficult defecation and splinting for bowel movements. However, the temporal relationship between difficult defecation...
BACKGROUND
Posterior vaginal prolapse is thought to cause difficult defecation and splinting for bowel movements. However, the temporal relationship between difficult defecation and prolapse is unknown. Does posterior vaginal prolapse lead to the development of defecation symptoms? Conversely, does difficult defecation lead to posterior prolapse? This prospective longitudinal study offered an opportunity to study these unanswered questions.
OBJECTIVE
We sought to investigate the following questions: (1) Are symptoms of difficult defecation more likely to develop (and less likely to resolve) among women with posterior vaginal prolapse? (2) Is posterior vaginal prolapse more likely to develop among women who complain of difficult defecation?
STUDY DESIGN
In this longitudinal study, parous women were assessed annually for defecatory symptoms (Epidemiology of Prolapse and Incontinence Questionnaire) and pelvic organ support (POP-Q examination). The unit of analysis for this study was a visit-pair (2 sequential visits from any participant). We created logistic regression models for symptom onset among those women who were symptom-free at the index visit and for symptom resolution among those women who had symptoms at the index visit. To investigate the change in posterior vaginal support (assessed at point Bp) as a function of symptom status, we created a standard regression model that controlled for Bp at the index visit for each visit-pair.
RESULTS
We derived 3888 visit-pairs from 1223 women (each completed 2-7 annual visits). At the index visit, 1143 women (29%) reported difficulty with bowel movements, and 643 women (17%) reported splinting for bowel movements. Posterior vaginal prolapse (Bp≥0) was observed among 80 women (2%). Among those women without symptoms, posterior vaginal prolapse did not significantly increase the odds that defecatory symptoms would develop (difficult bowel movements, P=.378; splinting, P=.765). In contrast, among those with defecatory symptoms, posterior vaginal prolapse reduced the probability of symptom resolution (difficult bowel movements, P<.001; splinting, P=.162). The mean rate of change in posterior wall support was +0.13 cm. Among women without posterior vaginal prolapse, the presence of defecatory symptoms at the index visit did not have an effect on changes in Bp over time; however, among those with posterior vaginal prolapse (Bp≥0), defecatory symptoms were associated with more rapid worsening of posterior support (difficulty with bowel movements, P=.005; splinting, P=.057).
CONCLUSION
Posterior vaginal prolapse did not increase the odds that new defecatory symptoms would develop among asymptomatic women but did increase the probability that defecatory symptoms would persist over time. Furthermore, among those women with established posterior vaginal prolapse, defecatory symptoms were associated with more rapid worsening of posterior vaginal wall descent.
Topics: Adult; Defecation; Female; Humans; Longitudinal Studies; Prospective Studies; Time Factors; Uterine Prolapse
PubMed: 27780707
DOI: 10.1016/j.ajog.2016.10.021 -
Journal of Oncology Pharmacy Practice :... Oct 2019Opioid-induced constipation is a clinically relevant side effect and a cause of potentially avoidable drug-related hospital admissions. (Observational Study)
Observational Study
INTRODUCTION
Opioid-induced constipation is a clinically relevant side effect and a cause of potentially avoidable drug-related hospital admissions.
OBJECTIVES
To describe the presence of laxative co-medication, the reasons for not starting laxatives and to evaluate changes in stool patterns of opioid initiators.
METHODS
In this observational study community pharmacists evaluated the availability of laxative co-medication in starting opioid users and registered reasons for non-use. Two opioid initiators per pharmacy were invited to complete questionnaires ('Bristol stool form scale' and 'Rome III Diagnostic Questionnaire for the Adult Functional Gastrointestinal Disorders') on their defecation prior to and during opioid use. Descriptive statistics and Chi square tests were used to analyse reasons for non-use of laxatives and changes in defecation patterns.
RESULTS
Eighty-one pharmacists collected data from 460 opioid initiators. Of those, 344 (74.8%) used laxatives concomitantly. Main reason not to use laxatives was that either prescribers or patients did not consider them necessary. Sixty-seven (89.3%) of the 75 opioid starters with two questionnaires completed were not constipated at opioid start. Eleven of them (16%) developed constipation during opioid use (Chi square p=0.003). At follow-up within laxative users 10.6% were constipated compared to 20.7% in subjects without laxatives.
CONCLUSION
One in four opioid starters did not dispose of laxative co-medication, mainly because they were not considered necessary by either the prescriber or the patient. The prevalence of constipation doubled during opioid use. A watchful waiting strategy for the use of laxative co-medication might include a monitoring of defecation patterns with validated questionnaires.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Constipation; Defecation; Female; Humans; Laxatives; Male; Middle Aged; Prospective Studies; Surveys and Questionnaires; Young Adult
PubMed: 30260269
DOI: 10.1177/1078155218801066