Anal Sphincter Pressure Research Articles

Intestinal Pseudo-obstruction: Initial Manifestation of Systemic Lupus Erythematosus

A 20-year-old man was hospitalized for 2 months after the onset of vomiting, cramping abdominal pain and dysuria. He had been diagnosed as IgA nephropathy 4 months ago. His mother was recently diagnosed as systemic lupus erythematosus (SLE). Physical examination revealed hypoactive bowel sounds and distended abdomen with diffuse tenderness. There was no rash on the face and body. The laboratory investigations showed hemoglobin 11.2 g/dL, leukocyte 10,500/µL, platelet 160,000/µL and albumin 3.2 g/dL. Antinuclear antibody (titer of 1:320 with speckled pattern), anti-Sm and ribonucleotide protein antibodies were positive. The 24 hour urine protein was 1,100 mg/day. Abdominal X-ray demonstrated multiple air-fluid levels of small bowel (Fig. 1). Abdominal CT showed fluid-filled dilatation of small bowel, bilateral hydronephrosis and thickened bladder wall. There was no abnormality on esophagogastroduodenoscopy and colonoscopy. Anorectal manometry showed decreased anal sphincter pressure and intact anaorectal inhibitory reflex. Figure 1 Simple abdominal erect view. Simple abdominal erect film shows extensive dilatation of the small bowel and multiple air-fluid levels. He was treated with empirical prednisolone 30 mg/day for 3 days but abdominal pain was worsened and plain X-ray showed aggravation of ileus. To find out the underlying cause of intestinal pseudo-obstruction (IPO), subtotal colectomy was performed. Grossly there was no mass, ulcer or mechanical obstruction. Histopathology demonstrated diffuse muscular degeneration with little vasculitis suggestive of SLE (Fig. 2). Steroid and azathiopurine were started after surgery and he became well. Figure 2 Microscopic findings of colon. (A) There is diffuse muscular degeneration, fibrosis and multifocal eosinophil infiltration. (B) The vascular lumen is intact and few inflammatory cells are infiltrated around the vessel. (C) Ganglinoic cells are increased ... After IPO in SLE was first described in 1993,1 few cases have been reported thereafter.2-4 As in this case, IPO may appear as the initial presentation of SLE2 and be associated with interstitial cystitis.3-5 The pathophysiology of IPO in SLE is dysmotility of the intestinal muscle, caused by neuropathy, vasculitis or primary myopathy.3-5 As IPO usually respond to high-dose steroid and additional immunosuppressant, early diagnosis and timely initiation of treatment are important to avoid unnecessary surgery.6

Treatment of fecal incontinence - review of observational studies (OS) and randomized controlled trials (RCT) related to injection of bulking agent into peri-anal tissue.

PURPOSE: Novel treatments are needed to augment medical therapy for fecal incontinence. METHODS: Medline and Google search (fecal incontinence and injection treatment), English publications. RESULTS: Twenty-two observational studies and 4 randomized controlled trials were identified. OS mostly with limited sample sizes reported promising results. Repeated injection was necessary in some patients. Effect on anal sphincter pressures was highly variable. Significant improvements in the length of anal high-pressure zone, asymmetry index and maximum tolerable rectal volume were suggested. Four randomized controlled trials (n=176) revealed: 1. Short-term benefits from injection of Bioplastique under ultrasound guidance compared with digital guidance; 2. Silicone biomaterial (PTQ) provided some advantages and was safer than carbon-coated beads (Durasphere); 3. PTQ did not demonstrate clinical benefit compared to control injection of saline; 4. There was significant improvement at 6 weeks post injection, but no difference between Bulkamid and Permacol. A 2010 Cochrane review, however, noted that these data were inconclusive due to limited number and methodological weaknesses. CONCLUSION: Further studies are warranted to assess patient-centered outcomes (e.g. adequate relief) in addition to the attenuation of severity of incontinence symptoms in ambulatory patients. In nursing home residents, cost-effectiveness studies combining injection treatment and prompted voiding (to mitigate constraints of immobility and dementia) in preventing peri-anal skin complications deserves to be considered.

Reinnervation of urethral and anal sphincters with femoral motor nerve to pudendal nerve transfer

Lower motor neuron damage to sacral roots or nerves can result in incontinence and a flaccid urinary bladder. We showed bladder reinnervation after transfer of coccygeal to sacral ventral roots, and genitofemoral nerves (L1, 2 origin) to pelvic nerves. This study assesses the feasibility of urethral and anal sphincter reinnervation using transfer of motor branches of the femoral nerve (L2-4 origin) to pudendal nerves (S1, 2 origin) that innervate the urethral and anal sphincters in a canine model. Sacral ventral roots were selected by their ability to stimulate bladder, urethral sphincter, and anal sphincter contraction and transected. Bilaterally, branches of the femoral nerve, specifically, nervus saphenous pars muscularis [Evans HE. Miller's anatomy of the dog. Philadelphia: W.B. Saunders; 1993], were transferred and end-to-end anastomosed to transected pudendal nerve branches in the perineum, then enclosed in unipolar nerve cuff electrodes with leads to implanted RF micro-stimulators. Nerve stimulation induced increased anal and urethral sphincter pressures in five of six transferred nerves. Retrograde neurotracing from the bladder, urethral sphincter, and anal sphincter using fluorogold, fast blue, and fluororuby, demonstrated urethral and anal sphincter labeled neurons in L2-4 cord segments (but not S1-3) in nerve transfer canines, consistent with reinnervation by the transferred femoral nerve motor branches. Controls had labeled neurons only in S1-3 segments. Postmortem DiI and DiO labeling confirmed axonal regrowth across the nerve repair site. These results show spinal cord reinnervation of urethral and anal sphincter targets after sacral ventral root transection and femoral nerve transfer (NT) to the denervated pudendal nerve. These surgical procedures may allow patients to regain continence.

Evidence for Altered Anorectal Function in Irritable Bowel Syndrome Patients with Sleep Disturbance

Background/Aims: Sleep dysfunction is associated with altered gastrointestinal functioning and the presence of irritable bowel syndrome (IBS). We aimed to investigate whether sleep dysfunction would influence anorectal motility in IBS patients. Methods: A total of 16 healthy volunteers and 15 IBS patients underwent anorectal manometry. The anorectal parameters included resting and squeeze sphincter pressure, sensory thresholds in response to balloon distension, and rectoanal inhibitory reflex. Sleep dysfunction was assessed by using the Pittsburgh Sleep Quality Index (PSQI). Results: IBS patients had a lower threshold volume for urge (p = 0.04) and pain (p = 0.002) as compared with the controls. IBS patients with sleep dysfunction had a significantly lower threshold volume for urge (p = 0.04) and anal sphincter pressure for maximal squeeze (p = 0.048) as compared with those without sleep dysfunction. In IBS patients, the PSQI score significantly correlated with threshold volume for first sensation (r = –0.55; p = 0.03), urge (r = –0.56; p = 0.03) and pain (r = –0.58; p = 0.03). Conclusions: IBS patients with sleep dysfunction are characterized by lower thresholds for rectal perception. Sleep disturbance might be associated with anorectal dysfunction and appears to create some degree of rectal hyperalgesia in patients with IBS.

Male faecal incontinence presents as two separate entities with implications for management

In contrast to females, male faecal incontinence has received little attention. We investigate its pattern and management at a large UK teaching hospital. Men presenting with faecal incontinence between January 2006 and December 2008 were identified from a gastrointestinal physiology database and classified into faecal leakage or faecal incontinence on the basis of symptomatology. Demographics, Cleveland Clinic incontinence score (CCIS), aetiological factors, investigations and treatments were collected by case note review and compared to clinical outcomes. Forty-three symptomatic patients were identified with faecal incontinence, in which 33 were classified as having faecal leakage (FL) and ten as faecal incontinence (FI). The mean CCIS was 10.7 (range, 4-14) and 14.2 (8-20) for FL and FI, respectively. The FL group had normal anal sphincter pressures, whilst the FI group had significantly lower mean resting pressure, 45mmHg (8-90mmHg), and mean squeeze pressure, 62.1mmHg (18-110mmHg). Thirteen out of 33 patients in the FL group and seven out of ten in the FI group had undergone previous anorectal surgery and had demonstrable sphincter defects whilst in the remainder, no definite aetiological factor could be identified. All patients in the FL group improved with lifestyle changes (28/33) or biofeedback (5/33). Six patients in the FI group required surgical intervention (3/6, collagen injection; 1/6, graciloplasty; 1/6, sacral nerve stimulation; 1/6, rectopexy). Patients presenting with FL characteristically have normal anorectal physiology and respond to non-operative measures, as compared to patients with FI who tend to have weakened anal sphincters, previous history of anorectal surgery, and more often require surgical intervention.

Local transdermal delivery of phenylephrine to the anal sphincter muscle using microneedles

We propose pretreatment using microneedles to increase perianal skin permeability for locally targeted delivery of phenylephrine (PE), a drug that increases resting anal sphincter pressure to treat fecal incontinence. Microneedle patches were fabricated by micromolding poly-lactic-acid. Pre-treatment of human cadaver skin with microneedles increased PE delivery across the skin by up to 10-fold in vitro. In vivo delivery was assessed in rats receiving treatment with or without use of microneedles and with or without PE. Resting anal sphincter pressure was then measured over time using water-perfused anorectal manometry. For rats pretreated with microneedles, topical application of 30% PE gel rapidly increased the mean resting anal sphincter pressure from 7 ± 2 cmH 2O to a peak value of 43 ± 17 cmH 2O after 1 h, which was significantly greater than rats receiving PE gel without microneedle pretreatment. Additional safety studies showed that topically applied green fluorescent protein—expressing E. coli penetrated skin pierced with 23- and 26-gauge hypodermic needles, but E. coli was not detected in skin pretreated with microneedles, which suggests that microneedle-treated skin may not be especially susceptible to infection. In conclusion, this study demonstrates local transdermal delivery of PE to the anal sphincter muscle using microneedles, which may provide a novel treatment for fecal incontinence.

Impact of Sleep Dysfunction on Anorectal Motility in Healthy Humans

Background/AimsSleep dysfunction is associated with altered gastrointestinal function and subsequently exacerbations of gastrointestinal problems. We aimed to investigate whether sleep dysfunction would influence anorectal motility as determined by anorectal manometry. The effect of anxiety on anorectal motility was also determined.MethodsA total of 24 healthy volunteers underwent anorectal manometry. The anorectal parameters included resting and squeeze sphincter pressure, sensory thresholds in response to balloon distension, sphincter length, rectal compliance, and rectoanal inhibitory reflex. Sleep dysfunction was subjectively assessed by using Pittsburgh Sleep Quality Index (PSQI). Anxiety was assessed by the application of the State-Trait Anxiety Inventory questionnaire.ResultsThere were sixteen subjects without sleep dysfunction (7 women; mean age, 22 years) and eight subjects with sleep dysfunction (2 women; mean age, 22 years). There was no group difference in the volume threshold for rectoanal inhibitory reflux, rectal compliance or sphincter length (P = NS). Anal sphincter pressure did not differ between the groups (P = NS). The rectal sensitivity for different levels of stimulation did not differ between the groups (P = NS). Sleep quality as determined by PSQI correlated with rectal compliance (r = 0.66, P = 0.007). Although there was no differences in any manometric parameters between subjects with and without anxiety, the anxiety score correlated with rectal compliance (r = 0.57, P = 0.003).ConclusionsDespite a positive association between rectal compliance and the level of subjective sleep or anxiety, sleep dysfunction did not apparently affect most of anorectal function in healthy subjects, nor did anxiety.

Predictors of outcome of anorectal biofeedback therapy in patients with constipation

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. 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. 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. 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. 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.

Functional and Morphologic Outcome After Stapled Transanal Rectal Resection for Obstructed Defecation Syndrome

Stapled transanal rectal resection is a novel surgery for obstructed defecation syndrome. Few data on the functional and morphologic outcome after the surgery have been reported. This study aimed to evaluate the functional and morphologic outcome after stapled transanal rectal resection. This is a prospective study of consecutive patients undergoing transanal rectal resection. The study was conducted at a tertiary referral hospital, Beijing, China, from May 2007 to May 2009. Eighty-six consecutive female patients with obstructed defecation syndrome were carefully selected. All patients underwent stapled transanal rectal resection. The main outcome measures were patients' symptoms, obstructed defecation syndrome score, Wexner incontinence score, anorectal manometry and defecography before and 1 year after surgery. The occurrence of all symptoms were significantly reduced after the procedure (P < .0001). Obstructed defecation syndrome score was decreased from 18.17 ± 4.68 preoperatively to 7.36 ± 3.52 postoperatively (P < .0001) with the Wexner incontinence score unchanged. Maximum tolerable rectal volume was significantly decreased (236.08 ± 50.00 vs 205.25 ± 29.60, P < .0001) after surgery with anal sphincter pressures unchanged. Postoperative defecography was performed in 64 patients. Rectocele disappeared in 40 of 62 patients. The depth of rectocele was reduced from 35.40 ± 4.58 mm preoperatively to 19.77 ± 9.19 mm postoperatively (P < .0001). Incomplete evacuation disappeared in 41 of 51 patients. Intussusception was completely corrected in 39 of 56 patients. The reduction of obstructed defection syndrome score was greater in patients with both rectocele and intussusception corrected than others (12.75 ± 2.24 vs 9.17 ± 3.47; P < .0001). This study was limited owing to the lack of a control group and the medium-term results. Stapled transanal rectal resection is an effective procedure for obstructed defecation syndrome. The functional outcome is good with the preservation of sphincter function and continence postoperatively. The morphologic outcome confirmed its efficacy in correcting rectocele and intussusception, and correlated well with clinical improvement.

Anal Fissure

Anal fissure is one of the most common anorectal problems. Anal fissure is largely associated with high anal sphincter pressures and most treatment options are based on reducing anal pressures. Conservative management, using increased fiber and warm baths, results in healing of approximately half of all anal fissures. In fissures that fail conservative care, various pharmacologic and surgical options offer satisfactory cure rates. Lateral internal sphincterotomy remains the gold standard for definitive management of anal fissure. This review outlines the key points in the presentation, pathophysiology, and management of anal fissure.

Anorectal functions after perineal and retropubic radical prostatectomy - a prospective clinical and anal manometric assessment

IntroductionThe aim of this study is to evaluate the anorectal functions of prostate cancer patients who have undergone radical perineal prostatectomy (RPP) or radical retropubic prostatectomy (RRP) surgery.Material and methodsThirty-seven patients with an indication for radical prostatectomy were included after informed consent. Anorectal manometry was performed before and one month after the surgery in 22 RPP and 15 RRP patients in our clinic. Clinical assessment was evaluated by anorectal functions with anal incontinence scoring (AIS) (Fernandez; no incontinence = 0; maximal incontinence = 12). Patients with a history of anorectal surgery were excluded from the study. The following data were recorded: external anal sphincteric pressure (EASP), internal anal sphincteric pressure (IASP), minimum ano-rectal reflex volume (MARRV) and minimum rectal sensory volume (MRSV).ResultsIn the RPP and RRP groups, the mean age was 66 (56-75) and 64.3 (52-73) years, respectively. In the RPP group, EASP and IASP values showed a significant decrease after the surgery. In the RRP group, EASP and IASP were also decreased after the surgery, but without statistical significance. No significant change was seen in MARRV and MRSV of either group. When the scores of AIS were analysed, no significant clinical difference between pre- or post-operative scores was seen in RPP and RRP groups.ConclusionsPerineal or retropubic surgery may injure pelvic floor muscles and/or supplying nerves, which likely causes anorectal dysfunction. Although there is a significant decrease in early postoperative EASP and IASP after RPP, it has no clinical significance according to AIS.

Usefulness of manometry to select patients with anal fissure for controlled anal dilatation

To evaluate the use of anorectal manometry to select patients for controlled anal dilatation. A prospective study was performed using anorectal manometry on all patients with chronic anal fissure who did not have a good response to conservative treatment. Those with increased anal resting pressure were treated with controlled anal dilatation using a two valved anuscope. A second anorectal manometry was indicated after controlled anal dilatation. 19 patients without anorectal pathology (Healthy Control Group) and 57 patients with chronic anal fissure were included in this study. Controlled anal dilatation was performed on 27 patients, maximum resting pressure 122 ± 19 mmHg. In the controlled anal dilatation group the healing rate was 92.5%, mean maximum resting pressure post-controlled anal dilatation was 91 ± 30 mmHg. We found one case of transitory anal incontinence (3.7%). None of the patients had anal incontinence at 18 months of the follow-up. In the remaining 30 patients non selected for controlled anal dilatation (chronic anal fissure control group), a proportion of 53.3% recurrences were registered after conservative treatment. Anal healing of chronic anal fissure and a significant decrease in maximum resting pressure recorded by manometry confirms the success of this procedure. The manometric evaluation of the maximum resting pressure is useful in the selection of chronic anal fissure patients for controlled anal dilatation. The efficacy of dilatation to treat chronic anal fissure in patients with raised anal sphincter pressure was high and complications were rare.

Colonic Transit Correlates with Frequency of Bowel Movements but Not Stool Form in Patients with Constipation

Purpose: Constipation is a prevalent disorder characterized by infrequent bowel movements, hard stools, straining with bowel movements, and/or a sensation of incomplete evacuation. Stool frequency and stool form are often used by clinicians as indicators of colonic transit in constipated patients. The aim of this study was to evaluate the relationship of stool form and frequency with colonic transit in constipated patients. Methods: Patients who underwent whole gut scintigraphy followed by anal manometry for constipation were studied prospectively from January 2008 until May 2010. Each patient completed a questionnaire addressing their number of bowel movements per week and the Bristol stool form scale (BSFS). Whole gut transit scintigraphy measured gastric emptying, small bowel transit, and colonic transit via measurement of a geometric center at 24, 48, and 72 hours. Anal manometry assessed basal anal sphincter pressure (BASP), internal anal sphincter (IAS) relaxation, and balloon expulsion time. Spearman analysis was used to analyze correlations between BSFS, frequency of bowel movements, colonic transit, BASP, IAS relaxation, and balloon expulsion time. Results: A total of 171 patients, 25 males and 146 females, with a mean age of 43.4 years were evaluated. The number of bowel movements correlated with colonic transit at 24 hours (r=0.261, p=0.003), 48 hours (r=0.336, p=0.0001), and 72 hours (r=0.425, p<0.0001). Although a correlation was seen between frequency of bowel movements and BSFS (r=0.435, p<0.001), there was no correlation between BSFS and colonic transit at 24 hours (r=0.070, p=0.422), 48 hours (r=0.131, p=0.139) or 72 hours (r=0.132, p=0.136). Balloon expulsion time, BASP, and IAS relaxation did not correlate with frequency of bowel movements (r=-0.091 [p=0.284], r=0.078 [p=0.334], r=-0.061 [p=0.451]), BSFS (r=0.069 [p=0.438], r=0.201 [p=0.017], r=-0.103 [p=0.220], or colonic transit at 24 hours (r=0.137 [p=0.102], r=0.126 [p=0.115], r=-0.067 [p=0.404]), 48 hours (r=0.103 [p=0.226], r=0.124 [p=0.122], r=-0.058 [p=0.469]) or 72 hours (r=-0.009 [p=0.918], r=0.162 [p=0.044], r=-0.017 [p=0.836]). Conclusion: Frequency of bowel movements correlates with colonic transit in patients with chronic constipation. Interestingly, in this study, stool form did not correlate with colonic transit. Balloon expulsion time, BASP, and IAS relaxtion also had no correlation with frequency or form of bowel movements as well as colonic transit. Thus for the clinician, decreased number of bowel movements, rather than stool form, is associated with slow colonic transit.

Neurophysiologic Investigation of Anal Function following Double Stapling Anastomosis

Background and Aim: Manual dilatation of the anal sphincter and transanal introduction of the circular stapling device are required for intraluminal stapling anastomosis. This procedure has been regarded as one of the causes of postoperative evacuatory disorder in low anterior resection. However, there has been no evidence of this matter. Therefore, we conducted this study to clarify the impact of the procedure of stapling anastomosis on postoperative anal function. Methods: Twenty-five cases with sigmoid colon cancer underwent potentially curative sigmoid colectomy with stapling anastomosis (ST group) and 20 cases with hand-sewn anastomosis (non-ST group). The patients were questioned regarding the daily frequency of bowel movement, the presence of urgency and soiling, and Wexner’s incontinence score. Anorectal manomatry and pudendal nerve terminal motor latency were also evaluated. The patients’ questionnaire and physiologic examinations were prospectively obtained before, and 1 and 6 months after the operation. Results: Postoperative bowel habit was graded as satisfied in 92% (23/25 patients) in the ST group and 90% (18/20 patients) in the non-ST group. There was no significant difference between the 2 groups in terms of presence of fecal incontinence, discrimination of gas and stool, and daily frequency of bowel movement. In anal manometry, there was no significant difference between the 2 groups regarding the resting and squeezing anal canal sphincter pressures at 1 and 6 months postoperatively. Pudendal nerve terminal motor latency showed their latency from 2.0 to 2.5 ms throughout the periods, and there was no difference between the 2 groups before, and 1 and 6 months after the operation. Conclusion: Stapling anastomosis does not affect anal function in the early postoperative period.

Incision and drainage of perianal abscess with or without treatment of anal fistula

The perianal abscess is a common surgical problem. A third of perianal abscesses may manifest a fistula-in-ano which increases the risk of abscess recurrence requiring repeat surgical drainage. Treating the fistula at the same time as incision and drainage of the abscess may reduce the likelihood of recurrent abscess and the need for repeat surgery. However, this could affect sphincter function in some patients who may not have later developed a fistula-in-ano. We aimed to review the available randomised controlled trial evidence comparing incision and drainage of perianal abscess with or without fistula treatment. Randomised trials were identified from MEDLINE, EMBASE, the Cochrane Library, and reference lists of published papers and reviews. Trials comparing outcome after fistula surgery with drainage of perianal abscess compared with drainage alone were included in the review. The primary outcomes were recurrent or persistent abscess/fistula which may require repeat surgery and short-term and long-term incontinence. Secondary outcomes were duration of hospitalisation, duration of wound healing, postoperative pain, quality of life scores. For dichotomous variables, relative risks and their confidence intervals were calculated. We identified six trials, involving 479 subjects, comparing incision and drainage of perianal abscess alone versus incision and drainage with fistula treatment. Metaanalysis showed a significant reduction in recurrence, persistent abscess/fistula or repeat surgery in favour of fistula surgery at the time of abscess incision and drainage (RR=0.13, 95% Confidence Interval of RR = 0.07-0.24). Transient manometric reduction in anal sphincter pressures, without clinical incontinence, may occur after treatment of low fistulae with abscess drainage. Incontinence at one year following drainage with fistula surgery was not statistically significant (pooled RR 3.06, 95% Confidence Interval 0.7-13.45) with heterogeneity demonstrable between the trials (Chi(2) =5.39,df=3, p=0.14, I(2) =44.4%). The published evidence shows fistula surgery with abscess drainage significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery. There was no statistically significant evidence of incontinence following fistula surgery with abscess drainage. This intervention may be recommended in carefully selected patients.

Is Abnormality in the Conventional Anorectal Manometry Really Abnormal?

A 54-year-old woman, with chronic abdominal discomfort and difficulty in defecation, was admitted to the hospital. There were no abnormal findings on abdominal X-ray and colonic transit time remained within the normal values. The result by colonoscopic examination was normal. Bulk-forming laxatives were prescribed for a month, but symptomatic improvement was not found at all. Then, a defecography and the high resolution anorectal manometry (HR-ARM) of ManoScan TM system (Sierra Scientific Instruments, Los Angeles, CA, USA) were performed to differentiate functional anorectal disorders. Defecogram did not show significant findings. HR-ARM finding in left lateral decubitus position revealed the inappropriate increase of rectal pressure and no decrease in anal sphincter pressure (Fig. 1A). These findings were consistent with pelvic floor dyssynergia. However, when HR-ARM was performed with the patient in the sitting position, the increase of rectal pressure could be found in coordination with relaxation of the anal sphincter pressure (Fig. 1B). These results were consistent with the previous report obtained in the lying position; one-third showed dyssynergia and one-half could not expel artificial stool. However, when sitting with distended rectum, most patients showed a normal defecation pattern and ability to expel stool.1 Figure 1 Colored pressure topography plots of anorectal pressure during simulated defecation in left lateral decubitus position (A) and sitting position (B). High resolution anorectal manometry (HR-ARM) finding in left lateral decubitus position revealed inappropriate ... During the conventional water perfusion manometry, patients are expected to be in their lateral decubitus position, which interferes with an optimal abdominal contraction and anal relaxation during simulated defecation. However, in case of HR-ARM, patients can take sitting position in commode, which is more physiological since patients can feel more comfortable and they can generate enough movement of rectum for defecation and adequate anal relaxation.2 In conclusion, defecation is best evaluated in the sitting position of patient by using HR-ARM.

T1353 Fecal Incontinence in Males: Anal Sphincter Pressure is Not the Answer

T1353 Fecal Incontinence in Males: Anal Sphincter Pressure is Not the Answer

T1348 Predictors of Outcome of Biofeedback Therapy in Patients With Constipation

Background: Ano-rectal biofeedback therapy (BFT) is a safe and effective treatment in patients with constipation. Given the high prevalence of constipation, there is a need to prioritise patients. Therefore, the aim of this study was to further explore factors which predict success or failure of BFT. Several previous studies have examined this in part, with the only consistent finding being that the patient's willingness to participate predicts success of therapy. Methods: 102 consecutive patients (mean age 48±2 yrs, 88 females) with constipation referred for anorectal BFT were evaluated. All patients completed the Rome questionnaire, a validated constipation questionnaire, and 10 cm visual analogue scales for willingness to participate in BFT, satisfaction with bowel habit and impact on quality of life. All patients underwent comprehensive anorectal manometry and balloon expulsion test. Patients were enrolled in a 6 weekly-visit BFT program. Independent predictors were identified using a bootstrapped backward elimination procedure based on linear regression with change in bowel satisfaction as the outcome. Only predictors selected in ≥50% of bootstrap samples were considered. Results: 96 patients completed the full course of BFT. Stool consistency (p=0.009), willingness to participate (p<0.001), balloon expulsion time (p=0.02) and resting anal sphincter pressure (p=0.04) were positively correlated with an improvement in bowel satisfaction scores. On the other hand, more laxative use (p=0.049) and a greater satisfaction with bowel habit at baseline (p<0.001) correlated with no improvement in bowel satisfaction scores. The outcome of BFTwas not influenced by age, duration of symptoms or compliance with therapy. Multiple linear regression indicated that stool consistency (p=0.02) and willingness to participate (p= 0.003) independently predicted an improvement in bowel satisfaction scores after BFT, and total constipation score (p=0.006) and baseline satisfaction with bowel habit (p<0.001) independently predicted worsening in bowel satisfaction scores after BFT. The model including these 4 variables explained 52% of the variance in treatment outcome. Conclusion: In agreement with previous studies, success of BFT is predicted by a greater willingness to participate. New findings are that (1) harder stools predict a successful outcome, while more prolonged balloon expulsion and anal sphincter hypertonia at baseline are associated with greater bowel satisfaction after BFT; and (2) the presence of more severe constipation predicts failure of BFT. This information should be taken into account when prioritising patients for BFT.

Differences in ano‐neorectal physiology of ileoanal and coloanal reconstructions for restorative proctectomy

Restorative proctectomy with straight coloanal anastomosis (CAA) and restorative proctocolectomy with ilealpouch-anal anastomosis (IPAA) are options for maintaining bowel integrity after rectal resection. The aim of this study was to compare clinical function and anorectal physiology in patients treated with CAA and IPAA. Three-dimensional vector-manometry and neorectal volumetry were performed in straight CAA [53 patients (34 male)] and IPAA [61 patients (39 male)] for ulcerative colitis. Function was assessed using a 14 day incontinence diary. Function was similar in both groups, but neorectal compliance and threshold volumes for sensation, urge and maximum tolerated volume (MTV) were significantly higher after IPAA than after CAA. Mean pressure, vector volume and sphincter symmetry at rest were significant determinants of continence in both groups but squeeze pressure did not correlate significantly with function in either group. Threshold volume, MTV, and compliance were significantly correlated with frequency of defecation in patients with IPAA but not with CAA. A strong consistent resting anal sphincter pressure is one determinant of continence after both IPAA and CAA. Squeeze pressures do not influence the functional result. In IPAA but not CAA, the neorectum has a reservoir function which correlates with the postoperative frequency of defaecation.

Multiple Rectal Polyps in a Young Woman with Constipation

A 27-year-old Asian-American woman presented for evaluation of long-standing constipation. Her first severe episode of constipation occurred at age 7 and resolved with colonic lavage. Colonoscopy at that time was normal. She then experienced complete resolution of her symptoms from ages 7 to 17, when she started again experiencing defecatory difficulties with infrequent and hard stools, difficulties with evacuation, and a sensation of incomplete rectal emptying. On presentation in July 2009, she was dependent on two Senna pills per day; without them, she would not have a bowel movement for up to 1 week. She also reported episodes of rectal bleeding or blood in toilet paper, and abdominal bloating and pain that were relieved with bowel evacuation, as well as continuous and severe straining at evacuation with a feeling of incomplete evacuation. She did not, however, use finger manipulations to facilitate defecation. Her past medical and surgical history was negative and she was using no other medications except for oral contraceptives and multivitamins. She was single, worked as a program manager, lived with her boyfriend, and exercised 3–4 times/week. She did not smoke cigarettes, and drank wine socially. She was vaccinated against human papillomavirus (HPV). Family history was significant for her mother having lung cancer and her father with diabetes mellitus; she had one healthy sister. Upon further review of systems, she reported 8 lbs of weight gain, general fatigue, headaches, and mild anxiety. Her physical examination was normal except for small external hemorrhoids. Complete blood count, comprehensive chemistry panel, and thyroid function tests were all normal. On initial assessment of her constipation, a lactulose breath test was negative. A colon transit study using Sitzmarks was normal. An anorectal motility and compliance study showed a normal anal sphincter length of 5 cm, a normal internal anal sphincter pressure of 72 mmHg, and a slightly decreased external anal sphincter pressure of 91 mmHg. Rectal sensation was impaired since she barely sensed a rectal balloon filled with 50 cc of water. The anorectal inhibitory reflex was present and elicited with 30 cc of balloon distention, thereby excluding Hirschsprung’s disease. Rectal compliance was normal, but she was unable to expel an empty rectal balloon, which was suggestive of pelvic floor dysfunction. Colonoscopy revealed multiple inflammatory polyps in the rectal vault extending circumferentially to the anorectal junction. Biopsies of the polyps were performed and were associated with significant oozing that required control with application of hemostatic clips (Fig. 1). Pathologic examination of the polyp biopsies revealed six separate fragments of rectal mucosa. Five of these fragments showed polypoid hyperplastic mucosa with areas of ulceration, consistent with rectal prolapse. One of these fragments showed an area of moderate squamous epithelial dysplasia (AIN 2). No evidence of an invasive lesion was identified (Fig. 2). Despite her previous vaccination history, HPV immunohistochemistry was positive. She was then treated with polyethylene glycol twice daily for the next 3 months with some improvement of her G. Triadafilopoulos (&) Division of Gastroenterology and Hepatology, Stanford University Medical Center, Alway Building, Room M 211, 300 Pasteur Drive, MC: 5187, Stanford, CA 94305-5187, USA e-mail: vagt@stanford.edu