Normal Defecation Research Articles

Gracilis muscle transposition for anal incontinence in children: Long-term follow-up

We report a series of 7 patients, aged 6.5 to 19 years (mean, 12.9), who have been treated for uncontrollable fecal incontinence since 1976: 5 had imperforate anus and multiple subsequent operative procedures, 1 had a low myelomeningocele with bisphincteric incontinence, and 1 had a traumatic destruction of the sphincter apparatus. A modified Pickrell procedure was performed, with the gracilis muscle transposed subcutaneously, without constructing a pulley through the median raphe as originally described. All patients were evaluated by anorectal manometry preoperatively and postoperatively. They were followed-up for a period of 0.5 to 12.5 years (mean, 4.4). All patients were continent at follow-up, with a normal defecation pattern and no enemas required. None of the patients had evidence of fibrosis of the muscle or anal canal, and tension in the transposed muscle was maintained. Voluntary contractions remain efficient in all cases. Age was thought to be an important factor: personal motivation and compliance with physiotherapy, essential for a good outcome, is unlikely to be present in the younger child. We conclude that the gracilis sling procedure is an excellent long-term alternative for total fecal incontinence when time and other therapeutic measures have failed.

Behavioral modification of colonic function

We challenged the two hypotheses: first, that defecation can be suppressed for an extended time, and second, if so, that this has an effect on upper colonic motility. Thus we studied 12 male volunteers with conditions of identical nutrition and patterns of physical activity over a two-week period, where one week with normal defecation and one week with voluntary prolonged suppression of defecation followed each other in randomized order. Frequencies of defecation, stool weights, total and segmental colonic transit times (using radiopaque markers) were compared. Frequency of defecations and stool weights were lower during suppressed defecation [8.9 +/- 0.66 vs 3.7 +/- 0.41 (mean +/- SE) bowel movements per week, P = 0.003, and 1.30 +/- 0.09 vs 0.98 +/- 0.13 kg/week, P = 0.01]. Total transit times were increased from 28.8 +/- 4.4 to 53.1 +/- 4.3 hr, P = 0.004. Segmental transit times were increased in the rectosigmoid (from 8.83 +/- 3.6 to 32.1 +/- 5.6 hr, P = 0.04) and right hemicolon (from 14.5 +/- 0.9 hr to 19.7 +/- 1.5 hr, P = 0.02) by suppression of defecation. We conclude that defecation habits may induce changes in colonic function such as those seen in constipation and that functional anorectal outlet obstruction may, probably by reflex mediation, affect the right colon.

Modulation of abnormal defecation dynamics by biofeedback treatment in chronically constipated children with encopresis

To determine whether outcome in chronically constipated and encopretic children with abnormal defecation dynamics could be improved with biofeedback training, we randomly assigned patients, 5 to 16 years of age, to receive conventional treatment alone (n = 19) or conventional plus biofeedback treatment (n = 22) and evaluated physiologic outcome at 7 months and clinical outcome at 7 and 12 months. Eighty-six percent of patients learned normal defecation dynamics with up to six biofeedback sessions. At 7 months, 13% of conventionally treated and 77% of biofeedback-treated patients had normal defecation dynamics (p less than 0.01); one conventionally treated (5%) and 12 biofeedback-treated patients (55%) had recovered (p less than 0.01). Learning normal defecation dynamics was correlated with clinical recovery (p less than 0.01). At 7 months, 11% of patients with normal defecation dynamics after biofeedback treatment had abnormal defecation dynamics, and 71% of the biofeedback-treated patients with normal defecation dynamics recovered. At 12 months, 16% of conventionally treated and 50% of biofeedback-treated patients had recovered (p less than 0.05). Balloon defecation did not improve significantly in those who learned normal defecation dynamics. Therefore the ability to defecate balloons is apparently not dependent on the normal function of the external and sphincter and pelvic floor muscles alone. Biofeedback treatment is complementary to a good conventional therapeutic regimen in patients with abnormal defecation dynamics.

Defecometry. A new method for determining the parameters of rectal evacuation.

The parameters of defecation, i.e., maximum rectal pressure increase during straining, duration of effective evacuation, and the work performed to evacuate a simulated stool, can be quantified by defecometry, a new method to evaluate the defecation act. Simultaneous anal pressure records demonstrate the nature of the sphincter activity during simulated defecation. The test was performed on 19 patients with constipation and on 14 controls. Five patients could not evacuate the simulated stool, while five others could, but more laboriously than the remaining nine patients whose defecation was comparable with the controls. Laborious defecation is characterized by longer duration and more performed work during evacuation. Every patient with difficult or ineffective evacuation had sphincter contraction during defecation, whereas this phenomenon was not observed in patients with normal defecation. Defecometry permits more adequate identification and characterization of the outlet-obstruction-type constipated patients than the simple balloon expulsion test and the analysis of sphincter activity during straining with empty rectum in lateral decubitus. Early diagnosis and treatment of patients with outlet obstruction is important to avoid late neuromuscular damage to the pelvic floor.

Pelvic Floor Physiology

Pelvic floor physiology is poorly understood. The funnel shape of the pelvic floor and anal canal is uniquely developed to provide discriminatory continence of gas, liquid, and solid. Proximally, the pelvic floor consists of the pubococcygeus and iliococcygeus muscles. Distally, the anal canal is surrounded by the internal and external sphincter muscles. The anorectal ring is situated between the proximal pelvic floor and the distal anal canal. It is the site of the puborectalis muscle, which is anatomically, neurologically, and functionally merged with the deep portion of the external sphincter muscle. It is at this site that unique forces act to create both a flutter valve and the anorectal angle with the flap valve. Extrinsic pressures at this level reinforce both the flap valve and the flutter valve. Intrinsic pressures are generated by all of the surrounding muscles to produce a high-pressure zone. These factors are critical, but many other factors, such as rectal capacity, compliance, colonic transit, motility, and sensory mechanisms, also interact in a complex way to provide normal continence and defecation. Not surprisingly, no single test allows a complete assessment of the interactions of all these factors. Nevertheless, analysis of components thought to be important in pelvic floor physiology has contributed significantly to the understanding of normal as well as abnormal physiology. Although clinical evaluation continues to be the cornerstone of the diagnosis of pelvic floor disorders, anorectal physiological testing has contributed significantly to our understanding of the dynamics of the pelvic floor. With the refinement of existing techniques and the addition of new investigative tools, it is anticipated that knowledge of pelvic floor physiology will continue to grow.

Evaluation of Biofeedback in Childhood Encopresis

SummaryIn order to evaluate the efficacy of biofeed‐back for childhood encopresis, 50 children with enco‐presis were prospectively studied and randomized to receive biofeedback (B) or mineral oil therapy (M). Specificity of biofeedback was also evaluated by comparing outcomes of both regimens in children with normal (n = 32) and abnormal (n = 18) defecation patterns. Using a single blinded design, there were no significant differences in clinical outcomes between the 24 children receiving B and the 26 children receiving M at 3, 6, and 12

Assessment of the percentages of maximum static pressure in the anal canal for postoperative continence in patients with imperforate anus.

The maximum static pressure in the anal canal was measured using an open-tip manometric method with a continuous infusion system. The values obtained from 49 postoperative patients with imperforate anus were expressed as a percentage of those values obtained from 108 aged-matched controls. The value was observed to be 50 per cent or more in those patients with translevator type, showing normal defecation, 30-50 per cent in those with supralevator type, showing normal defecation or constipation, and 30 per cent or less in those with supralevator type, showing incontinence, and 30 per cent or less in those who had undergone surgery on the anal area at another hospital and required re-operation at our department, showing normal continence or incontinence.

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation: Reversion to normal defecation after combined excision operation and end colostomy for rectal cancer

Twenty-one patients with combined excision operation for rectal cancer were subjected to electromyographic study of the levator ani muscle, the puborectalis muscle, and the external anal sphincter. Myoelectric activity of the puborectalis and levator ani muscles was detected in 12 patients, 6 of whom had normal activity of both muscles. Of the remaining six patients, there was reduced activity of the levator ani muscle in four and of the puborectalis muscle in all six. These patients underwent training and electric stimulation of these muscles. To verify the myoelectric findings, 15 specimens removed at combined excision operation were examined grossly and microscopically for the muscles removed at operation. Eight specimens were found to be free of the levator and puborectalis muscles, which indicated that these muscles were not excised. The 12 patients with myoelectrically active levator and puborectalis muscles were operated on to restore defecation by way of the normal perineal route. The technique comprises freeing of the colostomy and mobilization of the entire left side of the colon. The perineal scar is then excised and the colonic end fixed to the perineal skin and thus is controlled by the levator and puborectalis muscles. Full fecal control was achieved in seven patients and incomplete control in five. It is concluded that excision of the levator ani muscle, the puborectalis muscle, and the external anal sphincter should not be considered a standard part of the radical operation for cancer of the lower or middle third of the rectum, and that a combined excision operation has no place in the treatment of rectal cancer.

Impairment of defecation in young women with severe constipation

Anorectal manometry, radiology, and tests of simulated defecation were carried out in 14 severely constipated young women and 29 age-matched controls. The resting anal sphincter pressures were reduced in the patients, but the squeeze pressures, rectoanal inhibitory reflex, and rectal pressures upon balloon distention were all normal. At rest, the anorectal angle was more obtuse in the constipated group, but there was no overall increase in perineal descent in constipated patients compared with controls. The presence of a balloon in the rectum and the onset of pain were perceived in constipated patients at volumes that were not significantly different from those in normal volunteers. Constipated patients, however, required higher rectal volumes to induce the desire to defecate and to stimulate regular rectal contractions. Constipated patients also found it more difficult to pass simulated stools from the rectum than the normal controls and, unlike most normal controls, failed to inhibit their external anal sphincter on attempted defecation. These findings suggest that young women with severe constipation have great difficulty initiating the coordinated set of events that constitute a normal defecation response.

The continent ileostomy (Kock's pouch) versus the restorative proctocolectomy (pelvic pouch).

AbstractThe Kock continent ileostomy and the ileoanal anastomosis with a pelvic ileal reservoir are each alternatives to conventional ileostomy in patients undergoing proctocolectomy for ulcerative colitis and polyposis coli. Problems associated with construction of the nipple valve have been the chief factor limiting the popularity of continent ileostomy, but these can be minimized by strict attention to technique. The cumulative revision rate for nipple valve dysfunction over a 7‐year period has been below 30%, and continence can usually be restored by reoperation. A successful pelvic reservoir procedure maintains both the normal defecation pathway and satisfactory continence, although rectal sensation is impaired; pelvic sepsis is the major postoperative risk (15–20%). Both types of operation are associated with nonspecific inflammation of the reservoir (“pouchitis”) in some 20% of patients. The pelvic pouch procedure is likely to become the chief method for preserving fecal continence after proctocolectomy, but the Kock pouch should be considered for inappropriate or unsuccessful cases.

Disturbances in the defecation mechanism with special reference to intussusception of the rectum (internal procidentia).

Anorectal disorders that disturb normal defecation are described, especially intussusception of the rectum (internal procidentia). A review of 190 patients, half of whom were treated operatively and the other half conservatively, is presented. Diagnostic procedures, symptoms, and indications for operations are evaluated. We believe that intussusception of the rectum is a relatively common cause of difficult emptying of the rectum and, when the correct diagnosis is established, operation presents a fair chance for improvement.

Relaxation biofeedback conditioning as treatment of a disturbed defecation reflex

The case history is presented of a patient with a disturbed defecation reflex by viral encephalopolyradiculoneuritis. The inability to defecate was thought to be due to hyper-reflexibility and, hence to increased spasm of the external anal sphincter. Normal defecation was eventually brought about by an operant learning technique, as described originally by Haskell and Rovner. The patient was conditioned to relax his external anal sphincter once he felt rectal fullness and the urge to defecate. Defecation was initiated by a Dulcolax suppository.

An Epidemiological Note On The Taeniasis In Korea

The present study was undertaken to evaluate the prevalence rate of Taenia spp. infection and distribution of taeniasis caused by T. solium among Koreans in several localities in Korea during the period from 1977 to 1980. A total of 1,946 stool specimens collected from students and inhabitants of Chungcheong Bug Do and Gyeongsang Nam Do were examined by cellophane thick smear method. Among them, 40 persons were detected as Taenia egg positive cases. The overall positive rate of Taenia spp. shows 2.1 %. The prevalence rate of male (2.3 %) is relatively higher than that of female (1.4 %). In order to observe the distribution of Taenia solium infection, the whole worms or a part of proglottids of Taenia spp. were collected from the stools of egg positive cases by normal defecation or anthelmintic treatment. For the species identification, expelled proglottids were examined microscopically by the number of branches of the uterus, presence of a vaginal sphincter or the accessory ovarian lobe etc. Among 199 egg detected cases in this study 59 (39.1 %) out of 151 cases in Seoul, 12(40.0 %) of 30 cases in Gyeongsang Nam Do and 2 (25.0 %) from 8 taeniasis cases in Cheju Do were infected with T. solium. But none of T. solium infection was found from 10 egg positive cases in Chungcheong Bug Do. As a whole, the composition of species shows 36.7 per cent of T. solium infection and 55.8 % of T. saginata infection, and in 7.5 per cent the species were not identified.

The Irritable Gut: Functional Disorders of the Alimentary Canal

Following an introductory description of the neural, muscular, and hormonal role in intestinal motility, the author discusses the importance of healthy bowel habits and the role of dietary fiber in normal defecation. He then briefly tries to relate the response of the gut to emotions and the importance of sigmoidoscopy in the evaluation of the bowel. The chapters are short, and the explanations are brief—perhaps a bit too brief for the student or generalist interested in basic principles that will permit him to build his understanding of this important segment of gastroenterology from them. For the gastroenterologist the material is rather oversimplified. Discussion of practical clinical aspects of constipation, functional diarrhea, gas, and dyspepsia is replete with numerous pointers that will render diagnosis and management of their problems much easier. In his discussion of laxatives, the author, recognizing and acknowledging the inadequacy and inaccuracy of the classification, nevertheless uses it

Coccidial infection withEimeria Tenellaand caecal defaecation in chicks

1. The periodicity of caecal defaecation was investigated in chicks infected with Eimeria tenella. The birds were illuminated for 12 h/d (07.00-19.00) and faeces were collected at 3-h intervals for up to 21 d. 2. In uninfected birds caecal faeces were never collected during the dark period. During the periods 07.00-10.00 h, 10.00-13.00 h, 13.00-16.00 h and 16.00-19.00 h, caecal defaecation occurred on approximately 44, 19, 55 and 91% of the total number of days respectively. 3. In infected birds production of haemorrhagic caecal faeces began from between 90 and 156 h after infection and continued during both light and dark periods for between 12 and 48 h. After this period, no caecal faeces were observed for between 39 and 120 h. Normal caecal defaecation resumed from between 198 and 264 h.

Anal tonometry in the neonatal period in mature and premature children.

Anal tonometry was performed during the first days of life in twelve premature and fourteen mature children without signs of gastrointestinal disease. A new tonometer with small dimensions was used. A pressure decrease of the internal anal sphincter after distension of the rectum could be demonstrated in all children examined and as early as two hours after birth. This was to be expected as the relaxation of the internal sphincter is part of the normal defecation reflex. Thus anal tonometry can be used in the early diagnosis of Hirschsprung's disease presumable already from the very first days of life.

A pattern analysis study of weanling diarrhoeal disease of infants.

Methods of pattern analysis based on statistical signal procedures have been applied to (512-day) records of daily defaecation rate obtained in an ensemble of weanling infants. Careful analysis of the records using several different methods has established the potential significance of the signal. A technique of coherent averaging has produced a stable consistent age-dependent baseline of average behaviour, referred to as an average profile. Extensions have been proposed for the application of statistical methods for the acquisition of standard patterns of diarrhoeal behaviour. Numerical low pass filtering the signal allows a dichotomization of cases, the significance of which is confirmed by differences of class average profiles. Removing the class average profile from the records shows that the majority of cases exhibit consistent individual signal patterns; standardized patterns of behaviour can also be discussed. It is tentatively concluded that objective specification of normal and abnormal defaecation behaviour could be based on spontaneous patterns identified in the records. Several methods have been suggested. Methods similar to those applied here would appear, on the evidence of this study, to be applicable to a variety of other longitudinal epidemiological studies.

Functional Importance of Extrinsic Parasympathetic Innervation to the Distal Colon and Rectum in Man

Abstract A patient with multiple sclerosis had a bladder incontinence due to hyperactivity of the detrusor muscle. She underwent resection of the nervi erigentes in an attempt to relieve this symptom. After the procedure, she immediately lost rectal sensation and the ability to defecate. Fluoroscopic examination of the colon after perfusion with diluted barium revealed motility of the right colon, but little progression of the substance towards the left colon. Transit time through the large intestine of 20 radio-opaque markers introduced by mouth was markedly slower in the patient than in 9 healthy control subjects. In particular, the distribution of the markers in the large intestine, as determined on daily plain films of the abdomen, revealed that, in the patient, the markers were retained longer in the right colon, appeared later, and were retained longer in the left colon, and none was excreted within 8 days. The distal colon and rectum were bypassed by a Soave type of procedure, anastomosing the right part of the transverse colon to the dentate line. At laparotomy, the left colon and left half of the transverse colon were strikingly dilated and did not show any sign of haustration. After the procedure, the transit time of radio-opaque markers returned to normal. Pathological examination revealed thickening of the muscularis mucosae in the specimen as compared with control colons resected for unobstructed carcinomas. In addition, there was neuronal loss, decrease in size of the remaining neurons, and marked focal Schwann cell hyperplasia. It is concluded that the nervi erigentes have ramifications to the left colon and left half of the transverse colon in man, and that this parasympathetic extrinsic innervation to the distal large intestine plays an important role in the maintenance of normal defecation.

Dissociation of open-field behavior and pituitary-adrenal function

Low overall activity, high defecation and high adrenocortical secretions in response to the open-field (OF) test (behavior in a novel arena) are presumed to indicate “emotionality.” Pituitary-adrenal secretions have been considered to be simply an additional indicant of emotional arousal or as a mediator of differences in OF behavior. During lactation in rats there is a reduction in corticosterone elevations following OF exposure; OF behavior, however, did not vary With this physiological change. In a second experiment, pituitary-adrenal activity was blocked with a median eminence implant of hydrocortisone. The OF behavior of these implanted rats did not differ from the no-implant controls; cholesterol-implanted controls had higher activity and corticosterone levels and normal defecation. OF activity was dramatically depressed in subjects who had received traumatic shock treatment previously, but pituitary-adrenal activity at the time of the OF test was unrelated to this depressed activity, and OF defecation was normal. We conclude that pituitary-adrenal secretions do not mediate differences in OF behavior and that since the complex of low overall activity, high defecation and high adrenocortical levels are frequently dissociated, these responses cannot serve to validate each other as measures of emotionality.

Clinical use of erythromycin suppository--history and clinical effects of the suppository

Suppositorium, a form of medication, has already been brought into use since old egyptyan andancient chinese era, chiefly for local use. But, practically, it was since 17th century thatsuppositorium became gradually one of usual forms of medication. In Japan, however, it is not so favourable type of drugs, as compared in the countries in Europe or America. But recently, it has become used more widely for systemic purpose to avoid some untoward gastric side effects due to drugs. Thus, I had an oppotunity to administer Erythrosin-suppositorium, newly made and delivered to us, to the patients thought to have bacterial infections. In all, 18 patients were treated as shown in Table 1. They were: 1 c.c.+otitis media, 1 chronic upper respiratory inflamation, 1 pyelitis, 1 bronchopneumonia, 1 alveolar pyorrhea, 4 scarlatina and 9 angina tonsillaris.All were well tolerated and cured except one with chronic upper respiratory inflamation. These results were thought to be same, as compared with hitherto known results of usual perioral Erythrosin tablet. Moreover, this Erythrosin-suppositorium was well tolerated without any gastric disorder in 2 patients in this series, who always complained of some gastric disorders after oral Erythrosin-tablet. There was no side-effect seen in this series. It was noticed that in some younger children, the relation between their normal defecation time and drug-administration time schould be taken in care, because their anal mucosa becomes a little irritated shortly after insertion of suppository. A new method for evaluation of drug with anti-streptococcal activity was described and shown in coloured figures.