Rectal Balloon Expulsion Test Research Articles

Anal defecatory function in ulcerative colitis patients after total proctocolectomy and ileal pouch-anal anastomosis: a prospective cohort study.

Total proctocolectomy (TPC) followed by ileal pouch-anal anastomosis (IPAA) remains the only viable option whenever different treatment modalities fail in patients with ulcerative colitis (UC). Prospective cohort pre/post study examining the anal defecatory function and competence in UC patients undergoing TPC plus IPAA using high-resolution anorectal manometry (HR-ARM). Patients undergoing TPC and IPAA were enrolled in the study and subjected to HR-ARM prior to and 6 months after surgery. The anal resting, squeeze and push pressures were recorded, together with the rectal sensation and the rectal balloon expulsion test. The number of bowel movements, symptoms/signs related to fecal incontinence, as well as the IBDQ-32 quality of life questionnaires were documented during both HR-ARM visits. A total of 20 consecutive UC patients were recruited in our study. The mean (SD) number of bowel movements before the TPC plus IPAA was 10.1 (2.8), while the same number after the pouch surgery was 7.7 (3.1) [ P = 0.01]. Symptoms or signs of fecal incontinence were noted in one of our patients prior to the operation; however, none of our patients reported any such symptoms after the pouch surgery. The median (IQR) IBDQ-32 questionnaire scores before and after surgery were 121.5 (13.5) and 142.5 (16.0) respectively. At the same time, the anorectal function remained intact since both the anal resting and squeeze pressures were not significantly changed. UC patients subjected to TPC-IPAA exhibit improved bowel movements and a normal anal defecatory function and competence post-surgery.

An introduction to rectal balloon expulsion tests in a pelvic floor clinic

Biofeedback is a non-surgical treatment option for patients with pelvic floor symptoms, including faecal, flatus, urinary incontinence, obstructed defecation and evacuatory difficulties. A biofeedback therapist assesses the patient's pelvic floor muscle coordination and monitors their response to an inflated balloon acting as a simulated stool. Most patients attending the biofeedback clinic exhibit anorectal discoordination, which can be effectively corrected with rectal balloon expulsion exercise. Biofeedback therapy for pelvic floor dysynergic symptoms consists of biofeedback technique-guided pelvic floor relaxation, improving abdominal push effort, followed by simulated defecation and sensory training. This article discusses how to perform a rectal balloon expulsion test in a clinical setting by a trained therapist to improve clinical outcomes for pelvic floor dysfunction symptoms.

Comparison of anorectal manometry, rectal balloon expulsion test, and defecography for diagnosing defecatory disorders

Comparison of anorectal manometry, rectal balloon expulsion test, and defecography for diagnosing defecatory disorders

CME Exam 4: Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders

CME Exam 4: Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders

Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders

The utility of high-resolution anorectal manometry (HR-ARM) for diagnosing defecatory disorders (DDs) is unclear because healthy people may have features of dyssynergia. We aimed to identify objective diagnostic criteria for DD and to ascertain the utility of HR-ARM for diagnosing DD. Constipated patients were assessed with HR-ARM and rectal balloon expulsion time (BET), and a subset underwent defecography. Normal values were established by assessing 184 sex-matched healthy individuals. Logistic regression models evaluated the association of abnormal HR-ARM findings with prolonged BET and reduced rectal evacuation (determined by defecography). A total of 474 constipated individuals (420 women) underwent HR-ARM and BET, and 158 underwent defecography. BET was prolonged, suggesting a DD, for 152 patients (32%). Rectal evacuation was lower for patients with prolonged vs normal BET. A lower rectoanal gradient during evacuation, reduced anal squeeze increment, and reduced rectal sensation were independently associated with abnormal BETs; the rectoanal gradient was 36% sensitive and 85% specific for prolonged BET. A lower rectoanal gradient and prolonged BET were independently associated with reduced evacuation. Among constipated patients, the probability of reduced rectal evacuation was 14% when the gradient and BET were both normal, 45% when either was abnormal, and 75% when both variables were abnormal. HR-ARM, BET, and defecography findings were concordant for constipated patients, and reduced rectoanal gradient was the best HR-ARM predictor of prolonged BET or reduced rectal evacuation. Prolonged BET, reduced gradient, and reduced evacuation each independently supported a diagnosis of DD in constipated patients. We propose the terms probable DD for patients with an isolated abnormal gradient or BET and definite DD for patients with abnormal results from both tests.

Diagnostic Strategy and Tools for Identifying Defecatory Disorders.

This article reviews the indications, techniques, interpretation, strengths, and weaknesses of tests (anal manometry, anal surface electromyography, rectal balloon expulsion test, barium and MRI defecography, assessment of rectal compliance and sensation, and colonic transit) that are used diagnose defecatory disorders in constipated patients. The selection of tests and the sequence in which they are performed should be individualized to and interpreted in the context of the clinical features. Because anorectal functions are affected by age, results should be interpreted with reference to age- and sex-matched normal values for the same technique.

Review of the indications, methods, and clinical utility of anorectal manometry and the rectal balloon expulsion test.

Anorectal manometry (ARM) comprehensively assesses anorectal sensorimotor functions. This review examines the indications, techniques, interpretation, strengths, and weaknesses of high-resolution ARM (HR-ARM), 3-dimensional high-resolution anorectal manometry (3D-HR-ARM), and portable ARM, and other assessments (i.e., rectal sensation and rectal balloon expulsion test) that are performed alongside manometry. It is based on a literature search of articles related to ARM in adults. HR-ARM and 3D-HR-ARM are useful for diagnosing defecatory disorders (DD), to identify anorectal sensorimotor dysfunction and guide management in patients with fecal incontinence (FI), constipation, megacolon, and megarectum; and to screen for anorectal structural (e.g., rectal intussusception) abnormalities. The rectal balloon expulsion test is a useful, low-cost, radiation-free, outpatient assessment tool for impaired evacuation that is performed and interpreted in conjunction with ARM. The anorectal function tests should be interpreted with reference to age- and sex-matched normal values, clinical features, and results of other tests. A larger database of technique-specific normal values and newer paradigms of analyzing anorectal pressure profiles will increase the precision and diagnostic utility of HR-ARM for identifying abnormal mechanisms of defecation and continence.

Urinary Symptoms and Bladder Voiding Dysfunction Are Common in Young Men with Defecatory Disorders: A Retrospective Evaluation.

Lower urinary tract symptoms (LUTS) are frequently reported by constipated patients. Prospective studies investigating the association between defecatory disorders (DDs) and voiding dysfunction, predominantly in women, have reported conflicting results. This study investigated (1) the prevalence of LUTS in young men with DDs and (2) the association between objectively documented DDs and voiding dysfunction in constipated young men with LUTS. We reviewed the medical records, including validated questionnaires, of men aged 18-40 with confirmed DDs treated with pelvic floor physical therapy (PT) at our institution from May 2018 to November 2020. In a separate group of constipated young men with LUTS who underwent high-resolution anorectal manometry (HRM), rectal balloon expulsion test (BET), and uroflowmetry, we explored the relationship between DDs and voiding dysfunction. A total of 72 men were evaluated in the study. Among 43 men receiving PT for a proven DD, 82% reported ≥ 1 LUTS, most commonly frequent urination. Over half of these men experienced a reduction in LUTS severity after bowel-directed pelvic floor PT. Among 29 constipated men with LUTS who had undergone HRM/BET and uroflowmetry, 28% had concurrent defecatory and voiding dysfunction, 10% had DD alone, 14% had only voiding dysfunction, and 48% had neither. The presence of DD was associated with significantly increased odds of concurrent voiding dysfunction (odds ratio 9.3 [95% CI 1.7-52.7]). Most young men with DDs experience LUTS, which may respond to bowel-directed physical therapy. Patients with DD and urinary symptoms have increased odds of voiding dysfunction.

Effect of different body position on anorectal manometry for chronic constipation patients.

To analyze the different influence of body position on wireless high-resolution anorectal manometry parameters and in classification for chronic constipation patients. Fifty consecutive patients with chronic constipation and 20 healthy volunteers were included in this study, all of whom accepted the Rome IV constipation questionnaires, underwent rectal balloon expulsion test and wireless high-resolution anorectal manometry. The wireless high-resolution anorectal manometry was performed in the left lateral, seated, and squatting positions for every study subject. The Statistical Product and Service Solutions (SPSS) 21.0 software (IBM Corp., Armonk, NY, USA) was used for statistical analysis. The anal sphincter resting pressure, anal sphincter squeezing pressure, and rectal internal pressure during the evacuation in the seated position and squatting position were significantly higher than those in the left lateral position in both the volunteer group and patient group, without a significant difference between the seated position and squatting position. The initial perception threshold was higher in the patient group than in the volunteer group. The wireless high-resolution anorectal manometry in different positions combined with the rectal balloon expulsion test mainly affects the diagnosis of the subtype of inadequate defecatory propulsion. Compared with the left lateral position test, the wireless high-resolution anorectal manometry in the seated position and squatting positions is more consistent with the human physiological bowel condition, and the result of the test can be affected by the body position. The wireless high-resolution anorectal manometry can differentiate between subtypes during the diagnosis of inadequate defecatory propulsion.

Methods of Evaluation of Anorectal Causes of Obstructed Defecation.

Obstructed defecation is a complex disorder that results in impaired propagation of stool from the rectum. It is one of the major subtypes of functional constipation and can be secondary to either functional or anatomic etiologies. Patients with obstructed defecation typically present with symptoms of abdominal discomfort, a sensation of incomplete evacuation and rectal obstruction, passage of hard stools, the need for rectal or vaginal digitation, excessive straining, and reduced stool frequency. Evaluation of obstructed defecation is multimodal, starting with a thorough history and physical examination with focus on the abdominal, perineal, and rectal examination. Additional modalities to elicit the diagnosis of obstructed defecation include proctoscopy, colonic transit time studies, anorectal manometry, a rectal balloon expulsion test, defecography, electromyography, and ultrasound. The results from these studies should be taken in the context of each patient's clinical situation, as there is no single criterion standard for the diagnosis of obstructed defecation. Surgery is typically a last resort for these patients and the majority of patients will have good symptomatic management with diet and lifestyle changes. Patients who are found to have functional mechanisms behind their obstructed defecation also benefit from pelvic floor exercises and biofeedback therapy.

The incidence rate and characteristics of clinically diagnosed defecatory disorders in the community.

Defecatory disorders (DD) are defined by clinical and objective features of impaired rectal evacuation. The epidemiology of DD in the population is unknown, partly because many constipated patients do not undergo anorectal tests. Our objectives were to estimate the incidence rate and clinical features of DD in the community. We reviewed the medical records of all patients older than 16 years in Olmsted County, MN, who had constipation and underwent anorectal manometry from 1999 through 2008. Criteria for diagnosing DD were constipation for 6 months or longer and one of the following: (i) abnormal rectal balloon expulsion test; (ii) reduced or increased perineal descent; or (iii) two or more abnormal features with defecography or surface electromyography. Of 11 112 constipated patients, 516 had undergone anorectal tests; 245 of these (209 women, 36 men) had a DD. The mean (±SD) age at diagnosis was 44 years (±18) among women and 49 years (±19) among men. The overall age- and sex-adjusted incidence rate per 100 000 person-years was 19.3 (95% CI: 16.8-21.8). The age-adjusted incidence per 100 000 person-years was greater (p < 0.0001) in women (31.8, 95% CI: 27.4-36.1) than in men (6.6, 95% CI: 4.4-8.9). Prior to the diagnosis of DD, nearly 30% of patients had irritable bowel syndrome (IBS), 48% had a psychiatric diagnosis, 18% had a history of abuse, and 21% reported urinary and/or fecal incontinence. Among constipated patients, DD are fourfold more common in women than men and often associated with IBS and psychiatric diagnoses.

Practical Methods to Assess Chronic Constipation.

Defining the pathophysiology of chronic constipation is critical for planning management. After excluding organic diseases, physician should speculate whether the constipated patient has a defecatory disorder or not. Recently, American Gastroenterology Association suggested an updated algorithm in diagnosis of chronic constipation.1 The major change was anorectal manometry and a rectal balloon expulsion test as the initial step which should be considered even before conventional laxative trial especially in patients who are highly suspected as having a defecatory disorder. This change inevitably posed the measurement of colon transit time in the last step of the algorithm and assessment of colonic transit is not recommended as early study any more. What is the rationale of this change? The American Gastroenterology Association medical position statement provided two reasonable issues. First, because near half of patients with defecatory disorders show concomitant slow colonic transit, slow transit time cannot rule out the presence of defecatory disorders and omit anorectal studies. Defecatory disorders are treated with pelvic floor retraining behavioral therapy, namely biofeedback, even if slow colonic transit is concomitant. Second reason is that the administration of laxative is the main initial therapy regardless of colon transit if there is no evidence of defecatory disorders. Normal transit constipation and slow transit constipation are treated similarly. Then, what is the clinical impact of slow colonic transit? We select very exceptional case of refractory chronic constipation as a candidate of surgical treatment according to the colonic transit. Colectomy could be effective in medically refractory constipated patients with slow colonic transit if defecatory disorders are not concomitant. The overall satisfaction rate of surgery was about 86% in a systematic review involving 39 reports and 1423 patients.2 Confirming slow colonic transit and ruling out defecatory disorders are mandatory for the successful outcome. The present study by Park et al3 suggested that the gas volume scoring could be a practical method assessing colonic transit. Even though the authors cannot find a positive correlation of colon transit time and colon gas volume score, they demonstrated that the difference of gas volume existed between slow transit and normal transit, defined as 45 hours (mean value + 1 standard deviation). The difference of gas volume score was small, 5.66% vs 4.15%, and the sensitivity and specificity of the cut-off value to diagnose slow colon transit was disappointing. The failure of presenting valuable cut-off colon gas volume score to differentiate slow colon transit is a big drawback of this study, because there was only small mean difference of colon gas volume score between the groups and this small difference can be easily made by manual processing of gas volume scoring or by confusing small bowel gas as colon gas. Also the range of colon gas volume score largely overlaps each other. Therefore the present outcome has insufficient clinical impact to replace conventional method using radiopaque markers to assess colon transit time. But primary physicians can roughly discriminate slow transit constipation based on this tendency of colon gas on simple x-ray and colon transit. When primary physicians encounter a constipated patient with a relatively larger amount of colon gas on simple abdominal x-ray, they can suspect the patient may have slow colon transit. There are some practical methods to assess constipated patient and this include digital rectal exam and Bristol stool scale. We can consider additional anorectal tests in patients of abnormal digital rectal exam.4 Abnormal digital rectal exam by skillful examiner can practically suspect defecatory disorder. Also Bristol stool scale is a practical indicator of colon transit and this simple illustration can be useful in a clinical setting of discrepancy between the bowel frequency and stool hardness.5 Besides of this physical exam and simple illustration, simple abdominal radiography may give some additional information to primary physician.

Comparison of rectal balloon expulsion test in seated and left lateral positions

Defecatory disorders can be diagnosed by rectal balloon expulsion (BE) and anorectal manometry, which are traditionally evaluated in the seated and left lateral (LL) positions, respectively. The aims of this study were to compare BE in the LL and seated positions and to compare anorectal manometric parameters to BE performed in the seated and LL positions. 220 women [healthy (62), chronic constipation (158)] had anorectal high-resolution manometry and BE, summarized by time required (seated position, normal ≤60s) or external traction to facilitate expulsion (LL position, normal ≤100g). Balloon expulsion results in both positions were either concordant [normal (141) or abnormal (32)] or discordant [only LL abnormal (30), only seated abnormal (17)]. There was modest agreement [κ=0.44 (95% CI 0.30-0.57)] between seated and LL BE. Compared with subjects with normal BE in both positions, anal pressure during simulated evacuation (SE) was higher, and the rectoanal gradient (rectal-anal pressure) during SE was more negative in the other 3 categories (i.e., abnormal LL only, abnormal seated only, and both abnormal). High anal pressure during SE (OR=1.02, 95% CI 1.00-1.04) and high rectal sensory threshold for desire to defecate (OR=1.01, 95% CI 1.00-1.02) were associated with increased risk of abnormal BE in both positions, whereas high rectal pressure during SE (OR=0.96, 95% CI 0.93-0.98) was associated with lower risk. There is modest agreement between rectal BE in LL and seated positions. In addition to abnormal seated BE, which is considered indicative of pelvic floor dysfunction, high resolution manometry findings suggest that even some patients with abnormal BE in the LL position have pelvic floor dysfunction.

Correlation of Rectal Balloon Expulsion Test Between Seated and Supine Position

Purpose: Defecatory disorders are diagnosed by rectal balloon expulsion (BE) and anorectal manometry, which are traditionally evaluated in the seated and left lateral (LL) positions respectively. This may explain the observed limited correlation between rectoanal gradient (manometry) and balloon expulsion. Hence, our aims were to compare manometry with BE in the LL and seated positions. Methods: Sixty-two healthy women and 158 women with Rome II criteria for chronic constipation were included in the study. Balloon expulsion was assessed in seated (time needed to expel the balloon: normal - ≤60 s, abnormal - >60 s) and left lateral (additional traction weight needed to expel the balloon: normal - ≤100 g, abnormal - >100 g) positions. Based on BE, patients were classified into four groups: normal in both positions, abnormal in left lateral position only, abnormal in seated position only and abnormal in both positions. Anorectal pressures (rest, squeeze, and simulated evacuation (SE)) were measured by high resolution manometry (HRM). Demographic, manometry and clinical data was compared using chi-square and t-tests. Multivariable logistic regression was used to assess predictors of balloon expulsion in both positions. Results: BE performed in seated and left lateral positions was concordant in 173 subjects (normal in both positions - 141, abnormal in both positions - 32), and discordant in 47 subjects (abnormal only in left lateral position - 30, abnormal only in seated position - 17). There was modest agreement (κ=0.43 [95% CI 0.30-0.57]) between seated and left lateral BE. Age, BMI, anal resting and squeeze pressure, length of anal sphincter and squeeze duration were not significantly different among groups (Table). However, compared to subjects with normal BE in both positions, anal relaxation during simulated evacuation (SE) was lower, anal pressure during SE was higher, and the rectoanal gradient during SE was more negative in the 3 other categories; these variables were all associated (p ≤ 0.0004) with group status. High anal pressure during SE (OR1.02, 95% CI 1.00-1.04) and high rectal sensory threshold for desire to defecate (OR1.01, 95% CI 1.00-1.02) were associated with increased risk of abnormal BE in both positions, whereas high rectal pressure during SE (OR 0.96, 95% CI 0.93 - 0.98) was associated with lower risk.Table: [1720] Comparison of Symptoms and Anorectal Parameters among GroupsConclusion: This case-control study demonstrates modest agreement between rectal balloon expulsion in the left lateral and seated positions. In addition to abnormal seated BE, which is considered indicative of pelvic floor dysfunction, HRM findings suggest that even some patients with abnormal BE in the left lateral position have pelvic floor dysfunction.

Constipation of anorectal outlet obstruction: Pathophysiology, evaluation and management

Constipation is a subjective symptom of various pathological conditions. Incidence of constipation fluctuates from 2 to 30% in the general population. Approximately 50% of constipated patients referred to tertiary care centers have obstructed defecation constipation. Constipation of obstructed defecation may be due to mechanical causes or functional disorders of the anorectal region. Mechanical causes are related to morphological abnormalities of the anorectum (megarectum, rectal prolapse, rectocele, enterocele, neoplasms, stenosis). Functional disorders are associated with neurological disorders and dysfunction of the pelvic floor muscles or anorectal muscles (anismus, descending perineum syndrome, Hirschsprung's disease). However, this type of constipation should be differentiated by colonic slow transit constipation which, if coexists, should be managed to a second time. Assessment of patients with severe constipation includes a good history, physical examination and specialized investigations (colonic transit time, anorectal manometry, rectal balloon expulsion test, defecography, electromyography), which contribute to the diagnosis and the differential diagnosis of the cause of the obstructed defecation. Thereby, constipated patients can be given appropriate treatment for their problem, which may be conservative (bulk agents, high-fiber diet or laxatives), biofeedback training or surgery.

Update of Tests of Colon and Rectal Structure and Function

This review deals with the indications, methods, strengths, and limitations of anorectal testing in clinical practice. In chronic constipation, anal manometry and a rectal balloon expulsion test, occasionally supplemented by defecography, are useful to identify a functional defecatory disorder, because symptoms may respond to pelvic floor retraining. In patients with fecal incontinence, diagnostic testing complements the clinical assessment for evaluating the pathophysiology and guiding management. Manometry measures anal resting and squeeze pressures, which predominantly reflect internal and external anal sphincter function, respectively. Defecation may be indirectly assessed by measuring the recto-anal pressure gradient during straining and by the rectal balloon expulsion test. Endoanal ultrasound and magnetic resonance imaging (MRI) can identify anal sphincter structural pathology, which may be clinically occult, and/or amenable to surgical repair. Only MRI can identify external sphincter atrophy, whereas ultrasound is more sensitive for internal sphincter imaging. By characterizing rectal evacuation and puborectalis contraction, barium defecography may demonstrate an evacuation disorder, excessive perineal descent or a rectocele. Dynamic MRI can provide similar information and also image the bladder and genital organs without radiation exposure. Because the measurement of pudendal nerve latencies suffers from several limitations, anal sphincter electromyography is recommended when neurogenic sphincter weakness is suspected.

Phenotypic Variation in Functional Disorders of Defecation

Although obstructed defecation is generally attributed to pelvic floor dyssynergia, clinical observations suggest a wider spectrum of anorectal disturbances. Our aim was to characterize phenotypic variability in constipated patients by anorectal assessments. Anal pressures, rectal balloon expulsion, rectal sensation, and pelvic floor structure (by endoanal magnetic resonance imaging) and motion (by dynamic magnetic resonance imaging) were assessed in 52 constipated women and 41 age-matched asymptomatic women. Phenotypes were characterized in patients by principal components analysis of these measurements. Among patients, 16 had a hypertensive anal sphincter, 41 had an abnormal rectal balloon expulsion test, and 20 had abnormal rectal sensation. Forty-nine patients (94%) had abnormal pelvic floor motion during evacuation and/or squeeze. After correcting for age and body mass index, 3 principal components explained 71% of variance between patients. These factors were weighted most strongly by perineal descent during evacuation (factor 1), anorectal location at rest (factor 2), and anal resting pressure (factor 3). Factors 1 and 3 discriminated between controls and patients. Compared with patients with normal (n = 23) or reduced (n = 18) perineal descent, patients with increased (n = 11) descent were more likely (P < or = .01) to be obese, have an anal resting pressure >90 mm Hg, and have a normal rectal balloon expulsion test result. These observations demonstrate that functional defecation disorders comprise a heterogeneous entity that can be subcharacterized by perineal descent during defecation, perineal location at rest, and anal resting pressure. Further studies are needed to ascertain if the phenotypes reflect differences in the natural history of these disorders.

Functional obstructive defaecation

Objective: To study patients with obstructive defaecation to determine quantitatively its pathophysiology and homogeneity. Design: Twenty-two patients with obstructive defaecation were studied by isotope proctography and by conventional methods for quantitative analysis of the pathophysiological factors involved. Methods: Examination of the patients included ano-rectal manometry, the rectal balloon expulsion test, pelvic floor electromyography and isotope proctography. Eleven asymptomatic subjects were studied for comparison. Results: Pelvic floor electromyography revealed increased 'straining electromyographic activity' in all patients (P< 0.001). Patients with obstructive defaecation had impaired rectal sensation and were unable to perform a complete rectal evacuation (54% rectal evacuation) on isotope proctography. The defaecation time was prolonged and was associated with a reduced defaecation rate. Simultaneous recording of intrarectal pressures and external anal sphincter (EAS) electromyography during proctography revealed increased intrarectal pressure (P<0.0001) and EAS electromyographic voltage (P<0.01) during evacuation. The anorectal angles correlated with the pelvic floor movement and the anismus index. The anismus index in these patients correlated with the intrarectal pressure (P<0.02). No increase in the electromyographic voltage of the EAS was observed in any of the control subjects who successfully performed rectal balloon expulsion. Conclusion: Obstructive defaecation is a multifactórial condition involving derangements of rectal sensation and abnormal activity of the pelvic floor and anal sphincter musculature; its homogeneity is affected by the duration of the process.