Dyssynergic Defecation Research Articles

Comparing Diagnostic Tests in Dyssynergic Defecation-Constipation

Introduction: Idiopathic chronic constipation is a common medical problem, with an average reported prevalence of 15% in North America. The prevalence of constipation is higher in women. Normal transit constipation, colonic inertia, and dyssynergic defecation (DD) are subtypes of idiopathic chronic constipation. There is limited agreement among tests to diagnose dyssynergic defecation. Dyssynergic defecatory symptoms, failure to expel a 60-mL balloon during a balloon expulsion test, and anal sphincter dyssynergic pattern on manometry testing are frequently used for diagnosing pelvic floor dyssynergia. The aim of this study is to compare the result of different studies in predicting DD. Methods: From January 2013 to May 2014, 143 consecutive constipated patients referred for pelvic floor testing were included in the study and the results of their work-ups were collected. Detailed questionnaires regarding patients’ defecatory symptoms, pertinent medical and surgical history, medication use, and digital rectal exam by gastroenterologists with motility expertise were collected prior to anorectal high-resolution manometry testing. Results: Our study includes 143 patients with constipation who were referred by their primary physician or gastroenterologist to our tertiary care center for pelvic floor testing. The mean age of the patients was 50 years with the majority of the patients being female (87%). Mean resting pressures were 62±6 mm Hg, mean squeeze pressures 143±13 mm Hg, and maximum tolerated volume was 201±63 mL; 111 patients (78%) had symptoms on questionnaire suggestive of DD. While 80 patients (56%) had an expert-performed digital rectal exam suggestive of DD, high-resolution manometry diagnosed dyssynergic pattern in 83 patients (58%). Expert-performed digital rectal exam is 87% sensitive and 85% specific for diagnosing DD versus dyssynergia documented by high-resolution manometry as the gold standard. Balloon expulsion test was abnormal (more than 2 minutes) in 57 subjects (40%). Among 32 patients with DD on manometry test who had normal balloon expulsion test (<2 min), 14 (43%) patients had resting anal pressure less than 45 mm Hg. Conclusion: Defecation is a complex process, influenced by stool consistency and pelvic floor neuromuscular sensation and function. While, there is no single criterion in diagnosing dyssynergic defecation (DD), the ability to expel a 60-mL balloon does not exclude the presence of pelvic floor dyssynergia. Therefore, a careful interpretation of the test results is important in making the correct diagnosis.

Pelvic Floor Dyssynergia Causing Constipation in a Patient With Prader-Willi Syndrome

Introduction: Prader-Willi syndrome (PWS) is a multisystemic genetic disease present in 1/15,000-30,000 newborns. Constipation is very common in these patients as compared to the general population (40% vs 11%). The etiology of constipation in PWS may be multifactorial including a low fiber/high fat diet, rectal evacuation dysfunction due to decreased rectal sensation, reduced muscle tone, dyssynergic defecation (DD), or slow transit constipation. Data on the cause of constipation in PWS is limited and lacks use of objective testing such as anorectal manometry. Case Report: A patient with PWS was referred to a tertiary motility clinic for further evaluation of constipation. Patient was a 16-year-old female with PWS presenting with rectal pain and constipation for 2 years duration. Prior to that she was having 1 bowel movement (BM) daily. She notes having 1 soft BM every 5 days with a feeling of incomplete evacuation. Prior medications include polyethylene glycol, lubiprostone, milk of magnesia, and mineral oil leading to mild relief. She also uses bisacodyl as needed, magnesium citrate, and enemas weekly in order to have a BM. She notes passive fecal incontinence and has had to do manual disimpaction to aid with having a BM. Prior gastrographin enema mentioned a redundant sigmoid colon. Abdominal examination is unremarkable. On DRE she has a normal anocutaneous reflex with normal sphincter tone but an abnormal relaxation of puborectalis muscle. Both celiac serology and thyroid testing was normal. Anorectal manometry findings: Decreased resting pressure (52 mmHg), normal squeeze pressure (120 mmHg), normal RAIR and balloon expulsion. Rectal sensation testing was normal except for finding of rectal hypersensitivity (maximal tolerable volume of 160 ml only). An abnormal relaxation of the puborectalis and external sphincter muscles on push maneuvers was found suggesting DD. Patient was found to have DD with rectal hypersensitivity for which she was referred for biofeedback therapy. Constipation causing painful defecation and encopresis are highly prevalent in patients with PWS. In this case the symptoms are more likely to be caused by DD although wireless motility capsule was performed to rule out slow transit constipation. Discussion: DD may be a common finding in patients with PWS who commonly have other behavioral disorders associated with dyssynergia. Larger case series could help elucidate the role of diagnostic testing and biofeedback therapy in patients with PWS. We advocate performance of anorectal manometry to identify neuromuscular dysfunction in patients with PWS with subsequent biofeedback therapy depending on the degree of behavioral issues if dyssynergia is identified to minimize overuse of laxatives. Disclosure - Dr. Corral: no financial relationships. Dr. Kataria - no financial relationships. RN Vickers - no financial relationships. Dr. Koutouby - no financial relationships. Dr. Moshiree - Speaker’s Bureau: Gliven Imaging.

Predictive Value and Interexaminer Variability of Digital Rectal Examination for Dyssynergic Defecation in Constipated Patients Undergoing Anorectal Manometry

Introduction: Determine the efficacy of digital rectal examination (DRE) to identify patients with dyssynergic defecation (DD) by anorectal manometry (ARM) and balloon expulsion test (BET). Methods: We performed a prospective cohort study in adults with chronic constipation (CC) referred for ARM and BET from 5/11 to 5/14. All patients (pts) met the Rome III criteria for functional constipation. Each pt underwent a DRE by an experienced gastroenterologist and ARM/BET by 1 skilled technician. Data from DRE and ARM were collected using a standardized form using prespecified normal and abnormal criteria. During DRE, examiners assessed for sphincter relaxation or paradoxical contraction during simulated defecation. DRE results were compared to ARM (sphincter relaxation or contraction during simulated defecation) and BET (abnormal defined as the inability to pass a 50 ml water filled rectal balloon in <60 seconds). Positive predictive values (PPV = TP/TP+FP), negative predictive values (NPV=TN/TN+FN) and 95% confidence intervals were calculated for the overall group and each GI provider. Results: 209 (188 [90%] females, 86% Caucasian, Mean age = 48, and Mean BMI = 27.4) adults with CC who underwent DRE and ARM/BET were included in the analysis. Overall, 33% of patients who underwent ARM had a paradoxical sphincter contraction and 67% had a normal sphincter relaxation during simulated defecation. 28.9% had an abnormal BET. Compared to ARM, DRE correctly identified paradoxical sphincter contraction during simulated defecation in 34% of patients. Using ARM as a gold standard, DRE accurately detected normal anal sphincter relaxation during simulated defecation in 67% of patients. Predictive values for DRE using BET as a gold standard were similar. (Table 1). When data was stratified by the 3 providers, no significant differences were found in their ability to detect paradoxical sphincter contraction or normal sphincter relaxation during simulated defecation.Table 1Conclusion: These results suggest that the greatest benefit of DRE is derived from a normal examination. Because clinicians had difficulty accurately identifying paradoxical sphincter contraction during simulated defecation, patients with an abnormal DRE should be referred for anorectal manometry to assess for dyssynergic defecation. These results were generalizable amongst multiple providers at our institution. Disclosure - William D. Chey - Consultant: Astra-Zeneca, Forest, Ironwood, Perrigo, Prometheus, Nestle, Sucampo, Takeda, Furiex, SK, Ferring, Entera, Research Grant: Ironwood, Prometheus, Nestle, Perrigo. Jason Baker - no conflicts to disclose. Stacy Menees - no conflicts to disclose. Shanti Eswaran - no conflicts to disclose. Monthira Maneerattanaporn - no conflicts to disclose. Richard Saad - no conflicts to disclose.

Effect of Race, Gender and Body Position on the Prevalence and Type of Dyssynergic Defecation

Effect of Race, Gender and Body Position on the Prevalence and Type of Dyssynergic Defecation

Constipation in adults: diagnosis and management.

Symptoms of constipation occur at all ages, with the greatest prevalence in individuals older than 60years of age. It is estimated that 35 million individuals suffer from constipation in the USA, but only a small number will ever be diagnosed. Patients identify constipation symptoms differently than physicians. Whereas a patient may define their constipation by symptoms of bloating, distension, feeling of incomplete evacuation, abdominal discomfort, hard stools, and excessive straining, physicians often interpret prolonged timing between movements as the most essential criteria. An evaluation of constipation begins with a focused history of a person's bowel habit, medications, diet, physical activity, and an anorectal examination. In the absence of alarm signs, diagnostic testing for constipation is not routinely recommended in the initial evaluation. First-line management includes lifestyle changes of increased physical activity, high-fiber diets, adequate fluid intake, and bowel management techniques such as a straight back sitting position, using known triggers to stimulate bowel contractions, and a foot stool to elevate knees above bottom during toileting. When refractory to initial management, patients should have anorectal manometry to assess outlet function; additional testing may be required. Biofeedback is an effective treatment option for dyssynergic defecation. A range of traditional and new pharmacologic therapies are available to remedy constipation, from stool softeners to agents that increase intestinal transit. Managing the primary and secondary causes of constipation, incorporating effective bowel management techniques, along with the judicious use of laxatives can reduce constipation symptoms and improve quality of life.

Dyssynergic defecation may play an important role in postoperative Hirschsprung's disease patients with severe persistent constipation: Analysis of a case series

BackgroundAfter surgery for Hirschsprung's disease (HD) the majority of patients have satisfactory clinical outcomes. Nevertheless, a substantial number of patients remain who suffer from severe persistent constipation. Current consensus attributes these complaints to the hallmarks of HD. In non-HD patients a cause for severe constipation is dyssynergic defecation. MethodsRetrospectively, we reviewed the medical records of ten postoperative HD patients with severe persistent constipation who had undergone extensive anorectal function tests to diagnose the reason for the constipation. We analyzed the results of these tests. ResultsDuring the last three years, ten postoperative HD patients with severe persistent constipation were given extensive anorectal function tests. All ten patients were diagnosed with dyssynergic defecation. The ages at the time of diagnosis ranged from 7 to 19years with a median age of 12years. Signs of an enlarged rectum were seen in all ten patients, with a maximum measured value of 845mL. ConclusionsPatients with HD may also suffer from dyssynergic defecation. It is important to consider this possibility when dealing with severe persistent constipation in postoperative HD patients. Viable options for treating dyssynergic defecation are available that could prevent irreversible long-term complications.

Mo2008 Anorectal Manometry in Dyssynergic Defecation: Comparative Analysis of High-Resolution Pressure Topography and Waveform Manometry

quality (5/8 (63%) nulliparous vs. 3/13 (23%) parous) having recordings of excellent quality. Conclusions Electrical stimulation of the anal canal at motor threshold and recording of AEPs from channel Cz'-Fz is a reliable and reproducible method for examination of anal sensory function. Recordings of excellent quality are recorded from most healthy volunteers. Inability to record AEPs in patients with FI may suggest underlying injury to central sensory pathways.

Su1258 Benefit of Pelvic Floor Physical Therapy With Biofeedback in Pediatric Patients With Dyssynergic Defecation

Su1258 Benefit of Pelvic Floor Physical Therapy With Biofeedback in Pediatric Patients With Dyssynergic Defecation

Mo1999 Manometry Is Not Reliable in Diagnosing Dyssynergic Defecation

Mo1999 Manometry Is Not Reliable in Diagnosing Dyssynergic Defecation

885 Treatment Tasks of Biofeedback Therapy Protocol for Dyssynergic Defecation Based on Individual Physiologic Problem of Defecation: Their Prevalence and Association With Successful Treatment

885 Treatment Tasks of Biofeedback Therapy Protocol for Dyssynergic Defecation Based on Individual Physiologic Problem of Defecation: Their Prevalence and Association With Successful Treatment

Biofeedback for treatment of chronic idiopathic constipation in adults

Biofeedback for treatment of chronic idiopathic constipation in adults

What’s New in the Toolbox for Constipation and Fecal Incontinence?

Constipation and fecal incontinence (FI) are common complaints predominantly affecting the elderly and women. They are associated with significant morbidity and high healthcare costs. The causes are often multi-factorial and overlapping. With the advent of new technologies, we have a better understanding of their underlying pathophysiology which may involve disruption at any levels along the gut–brain–microbiota axis. Initial approach to management should always be the exclusion of secondary causes. Mild symptoms can be approached with conservative measures that may include dietary modifications, exercise, and medications. New prokinetics (e.g., prucalopride) and secretagogues (e.g., lubiprostone and linaclotide) are effective and safe in constipation. Biofeedback is the treatment of choice for dyssynergic defecation. Refractory constipation may respond to neuromodulation therapy with colectomy as the last resort especially for slow-transit constipation of neuropathic origin. Likewise, in refractory FI, less invasive approach can be tried first before progressing to more invasive surgical approach. Injectable bulking agents, sacral nerve stimulation, and SECCA procedure have modest efficacy but safe and less invasive. Surgery has equivocal efficacy but there are promising new techniques including dynamic graciloplasty, artificial bowel sphincter, and magnetic anal sphincter. Despite being challenging, there are no short of alternatives in our toolbox for the management of constipation and FI.

A Comparison of Standard Anorectal Manometry and High Resolution Manometry Patterns in Dyssynergic Patients

Aim: To compare dyssynergic sub type patterns between SARM and HRM. Methods: Patients with dyssynergic defecation diagnosed by ARM that had maintained the same stool patterns and frequency were re-evaluated with HRM while on waiting list for biofeedback training. Anorectal resting and squeezing pressure on the bed and commode were analyzed and compared between the two modalities. Paired t-test was used to compare the pressures and sensations. Results: 25 dyssynergic patients diagnosed with SARM (F=21, age 41±12.9) underwent HRM. Twenty four patients had dyssynergia on HRM (96%). Twelve (48%) had similar patterns on≥one position, and five (20%) had similar patterns in both positions. When comparing between HRM and SARM, the maximum resting pressure (70 vs 55.6 mmHg p<0.01), anal straining on bed (73 vs 46.4 mHg, p<0.01), rectal straining on commode (107.4 vs 71.8 mmHg, p<0.01) and anal straining pressures on commode (76.3 vs 48.9 mmHg, p<0.01) significantly deferred between the exams respectively. Conclusion: HRM pressures tend to be higher than SARM. Although there is high consensus regarding diagnosis of dyssynergia, there is low correlation regarding pattern types. New diagnostic pressure criteria should be adopted in centers converting to HRM.

Bear‐Down Maneuver Is a Useful Adjunct in the Evaluation of Children With Chronic Constipation

Chronic constipation is a common problem in pediatrics and often the result of obstructed defecation. The aim of this study was to determine the use of the bear-down maneuver (BDM) in the evaluation of children with chronic constipation and to establish optimal conditions for its performance. This retrospective study compares BDM with balloon expulsion testing (BET) during anorectal manometry in 38 children with chronic constipation. BDM was performed with 0-, 20-, 40-, and 60-mL balloon inflation. BET, performed with a 60-mL balloon, was considered normal if the balloon was expelled within 1 minute. Rectal pressure during BDM was 48% higher in patients able to expel the balloon during BET compared with those who could not (P < 0.05). Anal canal pressure was 46% lower in patients able to expel the balloon (P < 0.05). A rectoanal pressure differential greater than zero during BDM was 90% predictive that the subject would be able to expel the balloon. The optimal balloon inflation volume was 60 mL. BDM using an inflated balloon provides valuable mechanistic information in the evaluation of children with dyssynergic defecation. We found that patients often had either an insufficient rectal pressure during bear-down or an abnormally high anal canal pressure. This information may be useful in planning further treatment for these children.

High Resolution and High Definition Anorectal Manometry and Pressure Topography: Diagnostic Advance or a New Kid on the Block?

The recent development of closely spaced circumferential solid state transducers has paved the way for novel technology that includes high resolution anorectal manometry and topography (HRAM) and 3-D high definition anorectal manometry (HDAM). These techniques are increasingly being used for the assessment of anorectal neuromuscular function. However, whether they constitute a diagnostic advantage or a mere refinement of an old technology is unknown. Unlike the traditional manometry that utilized 3 or 6 unidirectional sensors, the closely spaced circumferential arrangement facilitates superior spatiotemporal mapping of pressures at rest and during various dynamic maneuvers. HDAM can provide knowledge of the three muscles that govern the anal continence namely, the puborectalis, and the internal and external anal sphincters, and can show how they mediate the rectoanal inhibitory reflex and sensorimotor responses and the spatiotemporal orientation of these muscles. Also, anal sphincter defects can be mapped and readily detected using 3-D technology. Similarly, HRAM has facilitated confirmation and development of phenotypes of dyssynergic defecation. Recently, normative data have also been reported with HRAM and HDAM, together with the influence of age, gender, and test instructions. The greater yield of anatomical and functional information may supersede the limitations of costs, fragility, and shorter life-span associated with these new techniques. Thus, HDAM and HRAM are not just new gadgets but constitute a significant and novel diagnostic advance. However, more prospective studies are needed to better define anorectal disorders with these techniques and to confirm their superiority.

Technique of Functional and Motility Test: How to Perform Biofeedback for Constipation and Fecal Incontinence

Biofeedback therapy is an instrument-based learning process centered on operant conditioning. The goal of biofeedback therapy in defecatory disorders is to strengthen the pelvic floor muscles, retrain rectal sensation and coordinate pelvic floor muscles during evacuation. Biofeedback therapy, in a broader sense, includes education, counseling, and diaphragmatic muscle training as well as exercise, sensory, and coordination training. For dyssynergic defecation, biofeedback therapy is a well-known and useful treatment option that had response rates of approximately 70-80% in randomized controlled trials. Biofeedback therapy for dyssynergic defecation consists of improving the abdominal push effort together with biofeedback technique-guided pelvic floor relaxation followed by simulated defecation and/or sensory training. For fecal incontinence, the results of a randomized controlled trial, which had a response rate of 76%, indicated that biofeedback therapy is useful in selected patients who fail to respond to conservative treatment and that training to enhance rectal discrimination of sensation may be helpful in reducing fecal incontinence. The focus of biofeedback therapy for fecal incontinence is on exercising external sphincter contractions under instant feedback, either alone or synchronously with rectal distension and/or sensory training. Biofeedback therapy is a safe treatment that may produce durable improvement beyond the active treatment period; however, a well-designed study to establish a standard protocol for biofeedback therapy is needed. This review discusses the technique of biofeedback therapy to achieve the goal and clinical outcomes for constipation and fecal incontinence.

Psychosocial Factors and Rectal Hyposensitivity

TO THE EDITOR: We read with interest the review article by Burgell and Scott1 regarding rectal hyposensitivity (RH). RH is clinically defined as elevated sensory thresholds to simple rectal balloon distension with a hand-held syringes. More exact diagnotic method is a computer-controlled barostat.1 Barostat testing of rectal sensation has been reported to be reproducible.2 RH has been reported in 18% to 68% of patients with functional constipation, and significantly related to functional anorectal obstruction, although RH is an etiology for or a consequence of functional anorectal obstruction.3 However it is noted that the diagnostic method most commonly used in assessment of sensory function is not barostat testing but simple balloon test. Recently, Lee et al4 reported that RH and functional anorectal outlet obstruction are common entities but appear not to be significantly associated. Contrary to previous knowledge, RH was not significantly related to functional factors including dyssynergic defecation, rectocele and rectal intussusception in the study using gold standard method (barostat). We also would like to show the previous our barostat study regarding to the relationships between the RH and clinical, functional and psychosocial factors. In 49 patients with functional constipation based on Rome II criteria, we performed symptom questionnaires, Symptom Checklist 90-Revision (SCL-90-R), rectal sensitivity test using barostat, colon transit time, anaorectal manometry, balloon expulsion test and defecography. Twelve patients (24%) showed RH. There were no significant differences in age, gender, stool form using Bristol scale, colon transit time, abnormal balloon expulstion test, ratio of slow transit constipation and ratio of pelvic floor dyssynergia. There is a tendency to increase in depression score in RH group than rectal normosensitive (N) group (54.1 ± 10.7 vs. 48.2 ± 10.2, P = 0.094). Global severity index was significantly increased in RH group than N group (33.4 ± 1.7 vs. 32.2 ± 1.0, P < 0.05) (Figure). The positive symptom distress index also had a tendency to increase in RH group than N group (54.3 ± 13.0 vs. 48.2 ± 12.5, P = 0.066). Further study is needed to elucidate the relationship between rectal hyposensitivity and psychosocial factors. Figure Asscoiation with psychosocial factors. There is a significant difference in the mean value for global scale index between rectal hyposensitivity and normosensitive group. GSI, global scale index; PSDI, positive symptom distress index; PST, positive symptom ...

Biofeedback therapy in constipated, female patients and caused by radical hysterectomy or vaginal delivery

AbstractBackground and AimChronic constipation is frequently seen in women who have undergone hysterectomy or delivery. However, reports regarding anorectal physiologic features in those patients are rare. Patients with constipation associated with either radical hysterectomy or vaginal delivery were analyzed in order to clarify the anorectal physiologic features and the effectiveness of biofeedback therapy.MethodsOf the constipated patients, a hysterectomy group (n = 40), delivery group (n = 41), and a control group (n = 89), who had no history of either surgery or delivery before developing functional constipation were included. Their anorectal physiological tests and the effectiveness of biofeedback therapy were investigated.ResultsThe volume of desire to defecate was greater in the hysterectomy group than in the control group (86.5 ± 55.0 mL vs 62.9 ± 33.7 mL; P = 0.03), and more than 240 mL of maximal volume of toleration was more frequently noted in the hysterectomy group (32.5%) than in the delivery group (14.6%) and control group (13.5%) (P = 0.02).The failure of balloon expulsion was more frequently noted in the delivery group (44.0%) than in the hysterectomy group (15.0%) and control group (25.0%) (P = 0.01). The defecation satisfaction score was significantly increased after biofeedback therapy in the hysterectomy group (2.0 ± 2.7 vs 7.8 ± 1.5, P &lt; 0.001), the delivery group (1.6 ± 2.1 vs 6.7 ± 2.0, P &lt; 0.001), and the control group (2.5 ± 2.7 vs 6.9 ± 2.1, P &lt; 0.001).ConclusionsRectal hyposensitivity could have been the characteristic mechanism in the hysterectomy group, whereas dyssynergic defecation could have been the cause in the delivery group. Biofeedback therapy was effective for both groups.

Mo2045 Overlap of IBS With Normal Transit Constipation but Not Dyssynergic Defecation

Mo2045 Overlap of IBS With Normal Transit Constipation but Not Dyssynergic Defecation

Sa2038 Dyssynergic Defecation Can Be Diagnosed by Questionnaire and Physical Examination

Sa2038 Dyssynergic Defecation Can Be Diagnosed by Questionnaire and Physical Examination