Defecation Symptoms Research Articles

Does the presence of a true radiological rectocele increase the likelihood of symptoms of prolapse?

Posterior compartment prolapse is commonly due to a 'true' rectocele, i.e., a diverticulum of the rectal ampulla. This condition is associated with symptoms of obstructed defecation and may contribute to prolapse symptoms. We tested the hypothesis: 'A true rectocele is an independent predictor of symptoms of prolapse.' This was a retrospective cohort study of patients presenting to a urogynecology unit for symptoms of pelvic floor dysfunction between September 2011 and June 2016. Assessment included a structured interview, POP-Q examination and 4D TLUS. Ultrasound volume data were acquired on Valsalva. Offline measurements were performed by analysis of stored volume data sets at a later date, blinded to all clinical data. One hundred six patients were excluded because of incomplete data. Of the remainder, Bp was the most distal point on POP-Q in 348. Statistical analysis was performed on this cohort. Mean age was 60 (33-86) years and mean BMI 31 (18-55)kg/m². One hundred fifty-three patients (44%) presented with symptoms of prolapse; 272 were diagnosed with a true rectocele on TLUS. Bp on POP-Q and true rectocele on TLUS were both significantly associated with prolapse symptoms; however, on multivariate analysis the latter became nonsignificant (p = 0.059). Receiver-operating characteristic (ROC) analysis confirmed that the presence of a true rectocele on TLUS did not contribute significantly to symptoms of prolapse (AUC 0.66 for model with rectocele, AUC 0.65 without). The presence of a true rectocele on TLUS does not seem to contribute substantially to the manifestation of clinical symptoms of prolapse.

Novel Bionics Assessment of Anorectal Mechanosensory Physiology.

Biomechatronics (bionics) is an applied science that creates interdisciplinary bonds between biology and engineering. The lower gastrointestinal (GI) tract is difficult to study but has gained interest in recent decades from a bionics point of view. Ingestible capsules that record physiological variables during GI transit have been developed and used for detailed analysis of colon transit and motility. Recently, a simulated stool named Fecobionics was developed. It has the consistency and shape of normal stool. Fecobionics records a variety of parameters including pressures, bending, and shape changes. It has been used to study defecation patterns in large animals and humans, including patients with symptoms of obstructed defecation and fecal incontinence. Recently, it was applied in a canine colon model where it revealed patterns consistent with shallow waves originating from slow waves generated by the interstitial Cells of Cajal. Novel analysis such as the “rear-front” pressure diagram and quantification of defecation indices has been developed for Fecobionics. GI research has traditionally been based on experimental approaches. Mathematical modeling is a unique way to deal with the complexity. This paper describes the Fecobionics technology, related mechano-physiological modeling analyses, and outlines perspectives for future applications.

Statistical shape modeling of the pelvic floor to evaluate women with obstructed defecation symptoms

Obstructed defecation (OD) is common and may be related to compromised pelvic floor integrity. Magnetic resonance (MR) defecography and statistical shape modeling were used to define pelvic floor shape variations, hypothesizing that State (rest vs peak evacuation) and Group (control vs case) would significantly influence shape. 16 women underwent MR defecography (9 cases vs 7 controls). Midsagittal, 2D pelvic floors were segmented and aligned by corresponding points. Principal component scores were compared using a Two-Way Mixed MANOVA. Three modes described differences between State (p < 0.001) and Group (p = 0.023). The pelvic floor shape differed significantly between women with and without OD and during evacuation.

Apatinib for Treatment of Locally Advanced Rectal Angiosarcoma: A Case Report

Introduction: Primary colorectal angiosarcoma is a highly rare malignant tumor. There is no standard treatment method for this disease. No treatment of rectal angiosarcoma with apatinib has been reported so far. Case Presentation: In the current study, an 87-year-old male presented with the symptoms of frequent defecation for more than one month in Hangzhou, China, in 2018. The patient was initially diagnosed with a rectal stromal tumor. The patient underwent ultrasound-guided transrectal mass puncture in the next treatment. However, immunohistochemical examinations confirmed the initial diagnosis of rectal angiosarcoma. The patient had advanced age and rectal angiosarcoma with metastasis; he had no surgical indications, and we tried to use apatinib 250 mg/d treatment to control the progression of the lesion. Then, he received apatinib, a novel tyrosine kinase inhibitor of vascular endothelial growth factor receptor-2 (VEGFR-2). The patient has been stable to apatinib with a dose of 250 mg daily by now. Conclusions: Apatinib may play an important role in the treatment of unresectable angiosarcoma.

Validation of the low anterior resection syndrome score in finnish patients: preliminary results on quality of life in different lars severity groups.

Background and Aims:Low anterior resection syndrome is common after anterior resection for rectal cancer. Its severity can be tested with the low anterior resection syndrome score. We have translated the low anterior resection syndrome score to Finnish, and the aim of this study is to validate the translation.Materials and Methods:The translated Finnish low anterior resection syndrome score and European Organisation for Research and Treatment of Cancer quality-of-life questionnaire-C30 and QLQ-CR29 questionnaires were sent to 159 surviving patients operated with anterior resection for rectal adenocarcinoma between 2007 and 2014 in a tertiary referral center. Psychometric properties of the translation were evaluated in comparison to quality-of-life scales and in different risk factor groups.Results:In the study, 104 (65%) patients returned the questionnaires. Of these, 56 (54%) had major low anterior resection syndrome, 26 (25%) had minor low anterior resection syndrome, and 22 (21%) had no low anterior resection syndrome. Patients with major low anterior resection syndrome had a significantly lower quality of life and more defecatory symptoms as assessed with the European Organisation for Research and Treatment of Cancer questionnaires compared with those with no low anterior resection syndrome. Patients operated with total mesorectal excision had significantly higher low anterior resection syndrome scores compared with those operated with partial mesorectal excision (median/interquartile range 32/15 and 29/11, respectively, p = 0.037). The test–retest validity of the translation was good with an intraclass correlation coefficient of 0.77 (95% confidence interval 0.51–0.90).Conclusions:The Finnish low anterior resection syndrome score is a valid test in the assessment of postoperative bowel function and its impact on the quality of life. It can be implemented to use during regular follow-up visits of Finnish-speaking rectal cancer patients.

The Sub-Saharan Experience of Excisional Haemorrhoidectomy with Simultaneous Lateral Internal Sphincterotomy

Milligan-Morgan haemorrhoidectomy (MMH) is still regarded as the standard excisional haemorrhoid procedure. In our centre, prophylactic lateral internal sphincterotomy (LIS) has been routinely performed simultaneously with MMH due to increased incidence of concurrent chronic anal fissure (CAF). We aimed to review our practice, the safety and feasibility of routine MMH+LIS among patients with or without CAF. A prospective observational study was conducted to examine the outcome of MMH + LIS in Kassala, Sudan, from 2015 to 2018. The short-term outcomes of patients undergoing MMH+LIS were compared between patients with or without CAF. There were 252 patients included in the study, with the median age of 33 (ranged 13–80), and 146 (57.94%) were male patients. Of these, 205 patients (81.3%) had third-degree prolapsed haemorrhoids, and 47 patients (18.7%) had fourth-degree prolapsed haemorrhoids, with 73 (29%) patients had a concurrent chronic anal fissure. There were no significant difference (p > 0.05) between the comparing groups with regard to the complications occurred, which were post-operative bleeding (n = 4, 1.6%), anal stenosis (n = 5, 1.98%), faecal incontinence (n = 2, 0.79%), chronic anal pain (n = 5, 1.98%), chronic anal discharge (n = 3, 1.19%), pruritus ani (n = 4, 1.58%) and obstructed defaecation symptoms (n = 4, 1.58%). The overall complication rates were 16/252 (6.3%). Patients without pre-existing CAF were significantly associated with increased post-operative pain (p < 0.0001) after LIS. Prophylactic LIS, along with MMH, is a safe strategy with reasonable desired short-term outcomes and low complication rates. Patients with pre-existing CAF gain better pain control having had concurrent LIS which ultimately justify the procedure.

A 10-year retrospective cohort study to assess objective and subjective outcomes of combined stapled transanal rectal resection and urogynecological surgery for pelvic floor dysfunction.

To assess the subjective and objective outcomes of combined stapled transanal rectal resection (STARR) and urogynecological surgery to treat pelvic organ prolapse, with a 10-year follow-up. This was a retrospective cohort study analyzing prospectively collected data from 53 consecutive patients who underwent combined stapled transanal rectal resection and urogynecological surgery, from 1 January 2005 to 31 December 2007 at a tertiary referral Pelvic Floor Unit of an Italian hospital. Fifty-three patients with a median age of 60years (interquartile range (IQR) 67-52t), underwent STARR and concomitant urogynecological surgery. No serious postoperative complications were recorded, and 37/53 women (70%) were evaluated at the 10-year follow-up visit. The cure rate was optimal in 34 women (64.1%). Regarding persistent and/or recurrent symptoms, five sexually-active patients (9%) reported dyspareunia only; obstructed defecation symptoms recurred in ten women (19%); urinary incontinence occurred in eight patients (15%); four patients (11%) reported persistent perineal pain; and two patients (5%) experienced both the urge to defecate and voiding dysfunction. At the 10-year follow-up, 14/27 patients (52%) stated that they would undergo the same operation again, if necessary. Furthermore, the survey found that patients would recommend the combined surgery. The 10-year results of this study proved that combined rectal and urogynecological surgery is well tolerated, associated with low morbidity, and more effectively treats a distressing and debilitating condition vs separate surgeries for rectal and pelvic organ prolapse. We recommend complementing the relatively small scale of this study with randomized trials involving a sufficient number of patients, to provide more conclusive evidence on the cumulative long-term effects of combined surgery vs 2- or 3-stage surgery.

Laparoscopic sacrocolpopexy plus ventral rectopexy as combined treatment for multicompartment pelvic organ prolapse.

Pelvic organ prolapse (POP) is a dynamic disorder that affects the entire pelvic diaphragm. POP may often involve multiple organs. Abdominal sacrocolpopexy is considered the gold standard to treat female anterior and apical prolapse. Abdominal ventral mesh rectopexy has gained increasing acceptance as an effective treatment for rectal prolapse. The aim of the present study was to assess the safety, feasibility and 1-year outcomes of laparoscopic sacrocolpopexy plus ventral rectopexy as a combined treatment of multicompartment POP. All female patients at our institution with anterior and apical prolapse with symptoms of obstructed defecation were examined by an urogynecologist and a colorectal surgeon, and were judged suitable for the study. Patients with Pelvic Organ Prolapse Quantification (POP-Q) system stage III and IV and concomitant rectal prolapse were treated by laparoscopic sacrocolpopexy plus ventral rectopexy. After surgery, 1- and 12-month follow-up was performed and the data were retrospectively analyzed. Patients' symptoms were evaluated using the Female Sexual Distress Scale (FSDS), Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12), and Wexner-Agachan constipation score. A total of 98 patients underwent surgery. No intraoperative or postoperative morbidity occurred. At the time of follow-up, all women expressed great satisfaction with the surgical treatment: all the patients had at most POP-Q Stage 1 and 78.8% had a Patient Global Impression of Improvement (PGI-I) score < 3. Significant improvement of symptoms related to POP and to obstructed defecation syndrome, as shown by the FSDS, PISQ-12, and Wexner-Agachan constipation score, was observed in all patients at follow-up CONCLUSIONS: Laparoscopic sacrocolpopexy with ventral rectopexy is a feasible and safe procedure for the combined surgical management of anterior, apical, and posterior prolapse, and provides excellent objective and subjective outcomes.

The relationship between obstructed defecation and true rectocele in patients with pelvic organ prolapse

We aimed to investigate the prevalence of true rectocele and obstructed defecation (OD) in patients with pelvic organ prolapse (POP), to investigate the correlation between true rectocele and OD, and to understand the diagnostic value of translabial ultrasound (TLUS) in the diagnosis of true rectocele. The patients who scheduled for POP surgery were enrolled in this study. Patients who had previous reconstructive pelvic surgery or repair of rectocele were excluded. Birmingham Bowel and Urinary symptoms questionnaires and Longo’s obstructed defecation syndrome scoring system were used to assess the bowel symptoms of patients. TLUS was used to evaluate anatomical defects. P value <0.05 was considered statistically significant, and confidence intervals were set at 95%. 279 patients were included into this study. The prevalence rate of OD was 43%, and the average value of ODS score was 6.67. 17% patients presented straining at stool, 33% presented incomplete emptying, 13% presented digitations, and 12% required laxatives or enema. The prevalence rate of true rectocele was 23%. Defecation symptoms were significantly correlated with age, levator-ani hiatus, levator-ani muscle injury and true rectocele. Logistic regression showed that true rectocele and increased levator-ani hiatus were independent risk factors of OD. True rectocele was significantly correlated with straining at stool, digitation, incomplete emptying and requirement of laxatives or enema.In POP patients, the prevalence rate of true rectocele and OD was 23% and 43%, respectively. True rectocele was related to OD. TLUS was a valuable approach in anatomical evaluation of POP.

Commentary on “The role of conventional pelvic floor reconstructive surgeries in obstructed defecation symptoms change: CARE and OPTIMAL trials sub-analysis of 2-year follow-up data”

Commentary on “The role of conventional pelvic floor reconstructive surgeries in obstructed defecation symptoms change: CARE and OPTIMAL trials sub-analysis of 2-year follow-up data”

Mucopexy-Recto Anal Lifting (MuRAL) in managing obstructed defecation syndrome associated with prolapsed hemorrhoids and rectocele: preliminary results.

PurposeTreatment of rectocele associated with prolapsed hemorrhoids is a debated topic. Transanal stapling achieved good midterm results in patients with symptoms of obstructed defecation, nevertheless a number of severe complications have been reported. The aim of this study was to evaluate the safety and efficacy of a new endorectal manual technique in patients with obstructed defecation due to the combination of muco-hemorrhoidal prolapse and rectocele.MethodsPatients enrolled after preoperative obstructed defecation syndrome (ODS) score, defecography and anoscopy were submitted to the novel Mucopexy-Recto Anal Lifting (MuRAL) combined with a modified Block procedure, and followed up by independent observers with digital exploration 3 weeks postoperatively, and digital exploration plus anoscopy at 3, 6, and 12 months. Operative time, hospital stay, numerating rating scale (NRS), ODS, satisfaction scores, and recurrence rate were recorded.ResultsMean operative time was 35.7 minutes. Fifty-six patients completed 1-year follow-up: 7.1% had acute urinary retention, NRS score was < 3 from the third postoperative day, mean time of daily activity resumption was 12 days, none had persistent fecal urgency, 82% declared excellent/good satisfaction score, significant improvement of 6- and 12-month ODS score, no recurrence of rectocele, and 7.1% recurrence of prolapsed hemorrhoids were observed.ConclusionMuRAL associated with modified Block technique gave no severe complications and resulted in a safe and effective approach to symptomatic rectocele associated with muco-rectal prolapse. Further randomized studies, larger series, and longer follow-up are needed.

Management and re-thinking of low anterior resection syndrome based on present anal preservation strategy

Low anterior resection syndrome (LARS) is defined as a syndrome characterized by various abnormal defecation symptoms, including increased defecation times, urgency, frequent defecation, and fecal incontinence. LARS commonly develops after sphincter-preserving operation or reduction of protective ileostomy. The symptoms of LARS will alleviate gradually, and some patients may return to normal or basically normal. However, 60%-80% of the patients remains to suffer from LARS. Their daily life and psychosocial functionare seriously impaired. At present, the etiology of LARS is not well understood, but many factors are associated with LARS, such as tumor location, radiotherapy and surgical techniques and so on.

The role of conventional pelvic floor reconstructive surgeries in obstructed defecation symptoms change: CARE and OPTIMAL trials sub-analysis of 2-year follow-up data.

The current study was aimed at addressing two questions: first, is any conventional vaginal prolapse repair effective in curing obstructed defecation symptoms, and second, is there evidence to suggest that a sacrocolpopexy will increase the risk of worsening or new-onset obstructed defecation symptoms? This is a sub-analysis of two major clinical trials performed by the Pelvic Floor Disorders Network: the Colpopexy and Urinary Reduction Efforts (CARE) trial and the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial. Two-year follow-up data were included. Demographics, pelvic organ prolapse quantification examination, and symptoms were compared between first, two surgical arms in the OPTIMAL study and second, CARE and OPTIMAL datasets using Chi-squared test for categorical variables and Student's t test or Mann-Whitney U test for continuous variables. A total of 353 subjects form the OPTIMAL study and 279 subjects from the CARE study met the inclusion criteria. Regardless of trial, obstructed defecation symptoms were present in more than half of the patients at the initial visit before the surgical intervention, and interestingly, about one third of the patients were symptomatic at the 24-month follow-up in all surgical groups. The conventional vaginal prolapse surgeries, with or without posterior vaginal wall repair, improved obstructed defecation symptoms by 50%, but about 35% of patients were suffering from at least one of the aspects of obstructed defecation at the 24-month follow-up. It is also important to note that about a quarter of the patients experienced persisting or worsening of their obstructed defecation symptoms in the absence of anatomical failure.

Impact of TRREMS on symptoms of obstructed defecation due to rectocele: predictive factors and outcomes.

The aim of this study was to evaluate the impact of the transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS) on the treatment of obstructed defecation due to rectocele and to identify the predictive factors for unsuccessful results. Consecutive patients with obstructed defecation symptoms (ODS) associated with rectocele who had the TRREMS procedure were included. Each patient was assessed by echodefecography, manometry, and colonic transit time as well as the Cleveland Clinic constipation score (CCS) before therapy and at follow-up after 6months. Reduction in the CCS score was calculated as a ratio. Factors correlated with a decrease in the CCS were analyzed in a univariate analysis. A total of 81 patients were included. Nineteen patients had postoperative complications that were not severe: 7 (8.6%) had tenesmus, 6 (7.4%) stenosis (4 treated with digital dilatation and 2 with endoscopic stricturectomy), 4 (4.9%) residual mucosal prolapse treated with rubber band ligation, 1 (1.2%) early bleeding, and 1(1.2%) thrombosis. Seventy-nine (97.5%) patients had a significant clinical response with significant reduction of the CCS constipation score from median 13 (range 17-10) to 4 (range, 8-2) (p = 0.0001); only 2 patients (2.5%) had an unsatisfactory response, complaining of straining and vaginal digitation during the evacuatory effort. Patients with anismus previously treated with biofeedback had a lower reduction ratio of the CCS score compared with patients without anismus (61.2 ± 2.8% versus 70.9% ± 1.5, p = 0.0006). There were no significant differences in the reduction of the CCS according to age, parity, type of delivery, previous hysterectomy, post-menopausal status, rectal mucosal prolapse and/or associated rectal intussusception, grade of rectocele and presence of complications. The TRREMS procedure significantly improved evacuation disorders in this study. Appropriate selection of patients is key for the success of this approach. Anismus even if previously treated with biofeedback, was the main predictive factor of unsuccessful treatment.

Regions of the brain activated in bladder filling vs rectal distention in healthy adults: A meta-analysis of neuroimaging studies.

Adults with pelvic floor disorders commonly present with overlapping bladder and bowel symptoms; however, the relationship between urinary and defecatory dysfunction is not well understood. Our aim was to compare and determine if overlapping brain regions are activated during bladder filling and rectal distention in healthy adults. We conducted separate Pubmed searches for neuroimaging studies investigating the effects of rectal distention and bladder filling on brain activation in healthy subjects. Coordinates of activated regions were extracted with cluster-level threshold P < .05 and compared using the activation likelihood estimate approach. Results from the various studies were pooled and a contrast analysis was performed to identify any common areas of activation between bladder filling and rectal distension. We identified 96 foci of activation from 14 neuroimaging studies on bladder filling and 182 foci from 17 studies on rectal distension in healthy adults. Regions activated during bladder filling included right insula, right and left thalamus, and right periaqueductal grey. Regions activated during rectal distention included right and left insula, right and left thalamus, left postcentral gyrus, and right inferior parietal lobule. Contrast analysis revealed common activation of the right insula with both rectal distention and bladder filling. Bladder filling and rectal distention activate several separate areas of the brain involved in sensory processing in healthy adults. The common activation of the insula, the region responsible for interoception, in these two conditions may offer an explanation for the coexistence of bladder and defecatory symptoms in pelvic floor disorders.

Association of life habits and fermented milk intake with stool frequency, defecatory symptoms and intestinal microbiota in healthy Japanese adults.

Few studies have examined the effects of smoking habit, the frequency of alcohol drinking, exercise, and fermented milk consumption on defecatory symptoms and gut microbiota composition, and particularly their interactive effects. We examined the effect of these lifestyle factors on bowel movements and gut microbiota composition in 366 healthy Japanese adults by analysis of covariance. Smoking did not affect defecatory symptoms but was negatively correlated with total bacteria and Enterococcus counts. Drinking frequency was significantly positively correlated with a feeling of incomplete evacuation and counts of the Bacteroides fragilis group and Acidaminococcus groups. Exercise frequency tended to be negatively correlated with the Bristol Stool Form Scale score and was significantly negatively correlated with the counts of Enterobacteriaceae and positively correlated with the Prevotella counts in the faeces. The frequency of fermented milk consumption was not significant but tended to be positively correlated with stool frequency. The frequency of fermented milk consumption was significantly positively correlated with the counts of the Atopobium cluster, Eubacterium cylindroides group, Acidaminococcus group, Clostridium ramosum subgroup, and Lactobacillus in the faeces. The frequency of consumption of probiotic Lactobacillus casei-containing fermented milk was significantly positively correlated with stool frequency. The counts of probiotic Lactobacillus casei in the stool was positively correlated with the counts of Bifidobacterium and total Lactobacillus. These results suggest that smoking, alcohol drinking, exercise, and consumption of fermented milk, particularly containing probiotic L. casei, differently affect bowel movements and gut microbiota composition in healthy Japanese adults.

Impact of treatment for fecal incontinence on constipation symptoms

Defecatory symptoms, such as a sense of incomplete emptying and straining with bowel movements, are paradoxically present in women with fecal incontinence. Treatments for fecal incontinence, such as loperamide and biofeedback, can worsen or improve defecatory symptoms, respectively. The primary aim of this study was to compare changes in constipation symptoms in women undergoing treatment for fecal incontinence with education only, loperamide, anal muscle exercises with biofeedback or both loperamide and biofeedback. Our secondary aim was to compare changes in constipation symptoms among responders and nonresponders to fecal incontinence treatment. This was a planned secondary analysis of a randomized controlled trial comparing 2 first-line therapies for fecal incontinence in a 2× 2 factorial design. Women with at least monthly fecal incontinence and normal stool consistency were randomized to 4 groups: (1) oral placebo plus education only, (2) oral loperamide plus education only, (3) placebo plus anorectal manometry-assisted biofeedback, and (4) loperamide plus biofeedback. Defecatory symptoms were measured using the Patient Assessment of Constipation Symptoms questionnaire at baseline, 12 weeks, and 24 weeks. The Patient Assessment of Constipation Symptoms consists of 12 items that contribute to a global score and 3 subscales: stool characteristics/symptoms (hardness of stool, size of stool, straining, inability to pass stool), rectal symptoms (burning, pain, bleeding, incomplete bowel movement), and abdominal symptoms (discomfort, pain, bloating, cramps). Scores for each subscale as well as the global score range from 0 (no symptoms) to 4 (maximum score), with negative change scores representing improvement in defecatory symptoms. Responders to fecal incontinence treatment were defined as women with a minimally important clinical improvement of ≥5 points on the St Mark's (Vaizey) scale between baseline and 24 weeks. Intent-to-treat analysis was performed using a longitudinal mixed model, controlling for baseline scores, to estimate changes in Patient Assessment of Constipation Symptoms scores from baseline through 24 weeks. At 24 weeks, there were small changes in Patient Assessment of Constipation Symptoms global scores in all 4 groups: oral placebo plus education (-0.3; 95% confidence interval, -0.5 to -0.1), loperamide plus education (-0.1, 95% confidence interval, -0.3 to0.0), oral placebo plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2), and loperamide plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2). No differences were observed in change in Patient Assessment of Constipation Symptoms scores between women randomized to placebo plus education and those randomized to loperamide plus education (P= .17) or placebo plus biofeedback (P= .82). Change in Patient Assessment of Constipation Symptoms scores in women randomized to combination loperamide plus biofeedback therapy was not different from that of women randomized to treatment with loperamide or biofeedback alone. Responders had greater improvement in Patient Assessment of Constipation Symptoms scores than nonresponders (-0.4; 95% confidence interval, -0.5 to -0.3 vs -0.2; 95% confidence interval, -0.3 to -0.0, P < .01, mean difference, 0.2, 95% confidence interval, 0.1-0.4). Change in constipation symptoms following treatment of fecal incontinence in women are small and are not significantly different between groups. Loperamide treatment for fecal incontinence does not worsen constipation symptoms among women with normal consistency stool. Women with clinically significant improvement in fecal incontinence symptoms report greater improvement in constipation symptoms.

2113 Biofeedback Therapy With the Rao Protocol for Dyssynergic Defecation Is Effective Among Patients With Inflammatory Bowel Disease

INTRODUCTION: Dyssynergic defecation (DD) symptoms are common in patients with inflammatory bowel disease (IBD). Biofeedback (BFB) is a standard of care treatment for DD, however, few studies have evaluated its efficacy in IBD patients with DD. CASE DESCRIPTION/METHODS: This is a case series that looks at 5 patients with IBD who were enrolled in BFB for DD between 2015 to 2018 at a tertiary referral motility program. All patients had greater than two sessions, survey and high resolution anorectal manometry (HR-ARM) data were collected at baseline and during each DD BFB visit. The Rao protocol for BFB is a physician-led program that consists of an active phase with the number of sessions tailored to each patient’s progress, followed by refresher sessions. A solid state HR-ARM catheter is utilized with sensors in the rectum/pouch and anal canal. Stool retention simulation consists of inflation of a rectal balloon during manometry based BFB. A total of 5 patients were identified for this case series. The average age of the patients was 46 years. Of these 5 patients, 3 had Crohn’s disease and 2 had ulcerative colitis. After completion of BFB, IBD patients experienced a significant improvement in stool form (Bristol stool scale type 2 to 6, P = 0.01), rise in the defecation index (intrarectal/pouch pressure divided by intra-anal pressure during simulated defecation; 0.39 to 0.81, P = 0.04), and complete resolution of DD with a rectal balloon inflated to simulate stool present in the rectum/pouch on final BFB session (P &lt; 0.01). IBD patients did not report a significant improvement in global bowel satisfaction rating on a 10-point Likert scale (2.2 to 3.6, P = 0.22). DISCUSSION: Biofeedback with the Rao protocol in conjunction with use of HR-ARM catheters shows efficacy in the correction of dyssynergia pattern, leading to improvement in objective measures such as defecation index and stool form on diary in IBD patients. Subjective improvement in global bowel satisfaction rating was less than the non-IBD cohort. In conclusion, patients with IBD who are found to have DD should be given consideration for enrollment in a BFB program, which is a labor-intensive approach but has no adverse effects.

758 The Hidden Burden of Faecal Incontinence in Active and Quiescent Ulcerative Colitis: An Underestimated Problem?

INTRODUCTION: Despite advances in Ulcerative Colitis (UC) therapies, many patients suffer refractory defecatory symptoms in the absence of active inflammation. For this group, treatment is challenging, with a paucity of research and limited therapeutic options. In this prospective, ongoing study, we aim to determine the prevalence of faecal incontinence (FI) in patients with quiescent UC. METHODS: In a cross-sectional study, consecutive patients with UC attending Inflammatory Bowel Disease (IBD) clinics completed a series of validated questionnaires; including an IBD-specific FI questionnaire (ICIQ-IBD questionnaire), Hospital Anxiety and Depression Scale (HADS), the Rome IV diagnostic questionnaire, and the IBD-control questionnaire. Participants were requested to return a Faecal Calprotectin (FCP) within 2 weeks of completing questionnaires. Quiescent UC was defined as IBD-control 8 score ≥13 and IBD-control-VAS ≥85, and/or FCP levels ≤250 (where available, FCP data were used in preference to IBD-control to classify UC activity). Data were compared between active and quiescent groups using chi-square and non-parametric tests. RESULTS: Overall, n = 97 UC patients (n = 50 males, mean age 48 (range 18-82) participated. ICIQ-IBD data revealed that most patients experience FI (84/97 (87%) during 'relapses'. Interestingly, 58/97 (60%) reported FI when in 'remission', and this group had higher median HADS depression (P = 0.0002), poorer QoL scores (P &lt; 0.0001), and trend towards higher HADS anxiety (P = 0.09) scores, compared to those without FI. Disease activity data (IBD-control and/or FCP) were available for all patients, and based on these 61/97 (63%) had quiescent UC. The prevalence of FI based on ICIQ-IBD did not differ between those with active (22/36, 61%) and quiescent UC (36/61, 59%), P = NS. In those with FI on ICIQ-IBD, median IBD-FI symptom scores, IBD-FI QoL scores and HADS (anxiety: P = 0.47, depression: P = 0.18) id not differ between disease activity groups. However, within the quiescent group, patients that met the more stringent Rome IV criteria for FI (n = 13) had higher median IBD-FI symptom scores (P = 0.007) and HADS-depression scores (P = 0.05), a trend to worse IBD-FI QoL (P = 0.07), but similar HADS-anxiety (P = 0.68). CONCLUSION: This is one of the first studies to identify that FI affects most patients with UC, regardless of disease activity, with a detrimental impact on patients' psychological wellbeing and QoL. FI be screened for in IBD clinics. There is an urgent need for further research in this area.

Dynamic fluoroscopic defecography: updates on rationale, technique, and interpretation from the Society of Abdominal Radiology Pelvic Floor Disease Focus Panel.

Whether used as the primary diagnostic test or reserved as a problem-solving examination, fluoroscopic defecography (FD) remains an important tool in the workup and treatment of defecatory disorders. FD is a well-established, simple, and rapid examination that most closely resembles the actual process and position that a patient uses to enable defecation and provides both qualitative and quantitative information on the defecatory process. FD is indicated when re-creating the act of defecation is necessary, especially in patients with symptoms of obstructed defecation and where symptoms do not correlate with prior examinations such as MRI. Also, FD may help the patient understand the severity of their condition, better informing them of the structural and functional pathology, and aid in discussions with the surgeon regarding plans for treating their complex pelvic floor and defecatory problems. This review provides an up-to-date, comprehensive summary of FD and describes the indications for, techniques of, and common pathology encountered.