Rectal Evacuation Research Articles

Emerging treatments in neurogastroenterology: a multidisciplinary working group consensus statement on opioid‐induced constipation

Opioids are effective for acute and chronic pain conditions, but their use is associated with often difficult-to-manage constipation and other gastrointestinal (GI) effects due to effects on peripheral μ-opioid receptors in the gut. The mechanism of opioid-induced constipation (OIC) differs from that of functional constipation (FC), and OIC may not respond as well to most first-line treatments for FC. The impact of OIC on quality of life (QoL) induces some patients to decrease or stop their opioid therapy to relieve or avoid constipation. At a roundtable meeting on OIC, a working group developed a consensus definition for OIC diagnosis across disciplines and reviewed current OIC treatments and the potential of treatments in development. By consensus, OIC is defined as follows: 'A change when initiating opioid therapy from baseline bowel habits that is characterized by any of the following: reduced bowel movement frequency, development or worsening of straining to pass bowel movements, a sense of incomplete rectal evacuation, or harder stool consistency'. The working group noted the prior validation of a patient response outcome and end point for clinical trials and recommended future efforts to create treatment guidelines and QoL measures specific for OIC. Details from the working group's discussion and consensus recommendations for patient care and research are presented in this article.

Mo2001 A Comparison of Rectal Evacuation Assessed by High Resolution Anal Manometry, Rectal Balloon Expulsion and Magnetic Resonance Proctography

compared to treatment without ERB(3). However, except for our report that IGRT+ERB reduces GI symptoms at 1 month(4), there is no randomized trial data comparing the effects of IGRT ± ERB on anorectal symptoms and function. Here we present patient evaluation at 1 year from the same prospective, randomized study. Methods: 22 patients, (73(51-84) years) with localized CaP treated by IGRT ± ERB (with, n=11) underwent the following evaluation: (i) GI symptoms (modified LENT-SOMA questionnaires), (ii) anorectal motor and sensory function (manometry with sleeve sensor and rectal balloon) and (iii) anal sphincteric morphology (endoanal ultrasound), before IGRT, at 1 month, and 1 year after its completion. One way ANOVA examined changes in GI symptom, anorectal functional and anal sphincteric morphology within each group. Two way repeated measures ANOVA with post hoc, and χ2 tests examined the differences between groups. p≤0.05 considered significant. Results: In the IGRT alone group, increased bowel frequency [9(5-18) vs 19(1442) bowel actions/week, p<0.001] and fecal incontinence scores [0(0-0) vs 3(0-10), p<0.05] at 1 year compared to baseline were associated with a reduction in increased intra-abdominal pressure [98±17 vs 77±13mmHg, p<0.05]. In contrast, no changes in symptom, functional nor morphological parameters within the IGRT+ERB group were observed. LENT-SOMA rectal bleeding scores were worse for IGRT alone compared to IGRT+ERB [1(0-2) vs 0(01), p<0.01] at 1 year. The prevalence of frequency and urgency of defecation, fecal incontinence and rectal bleeding at 1 year was also increased in the IGRT alone group and had a worse impact on QOL compared with the IGRT+ERB group (Table). There were no differences in any of the anorectal functional nor anal sphincteric morphologic parameters between the treatment groups.Conclusion: Increased bowel frequency and fecal incontinence scores in the IGRT alone group at 1 year were associated with evidence of anorectal dysmotility. The increased prevalence of GI symptoms was greater and had a worse impact on QOL in the IGRT alone group compared with the IGRT+ERB group. Further follow-up is needed to determine if these differences are sustained. Yeoh et al. Int J Radiat Oncol Biol Phys 2012;84(5):e593-e599, Smeenk et al. Radiother Oncol 2010;95;277-282, van Lin et al. Int J Radiat Oncol Biol Phys 2007;67:799-811, Botten et al. Gastroenterology 2013; Vol 144(5):S1pS-366

Autonomic dysreflexia during bowel evacuation procedures and bladder filling in subjects with spinal cord injury.

Randomized, controlled clinical trial. Bladder and bowel management may cause serious autonomic dysreflexia (AD) in subjects with high spinal cord injury (SCI). We aimed at investigating autonomic responses to digital rectal evacuation (DE), transanal irrigation (TAI) with 500 ml and filling cystometry (FC) in SCI. Aarhus University Hospital, Denmark. Eight subjects with SCI (AIS A) at or above T6 (high SCI) and a previous history of AD were compared with three subjects with SCI (AIS A) between T10 and L2 (low SCI). In randomized order, DE, TAI and FC were performed. AD was defined as an acute rise in systolic blood pressure (sBP) of ⩾30 mm Hg above baseline. Blood levels of norepinephrine and epinephrine were determined before and shortly after the procedures. During all three procedures, AD occurred in all patients with high SCI but not in those with low SCI. In high SCI subjects, DE increased median sBP from 127 (range: 86-154) to 188 (range: 140-206) mm Hg (P<0.02), TAI from 126 (range: 91-146) to 163 (range: 130-188) mm Hg (P<0.02) and FC from 125 (range: 106-149) to 200 (range: 179-220) mm Hg (P<0.01). The sBP increase was lower during TAI than during DE (P<0.05) or FC (P<0.02). In high SCI subjects, the blood levels of norepinephrine, but not those of epinephrine, increased significantly during all three stimuli (all P<0.05). Bowel and bladder management caused AD in high SCI. The response is less severe during TAI than during FC or DE.

Novel Association of Rectal Evacuation Disorder and Rumination Syndrome: Diagnosis, Co-morbidities and Treatment.

Patients with disorders of gastrointestinal function may undergo unnecessary treatment if misdiagnosed as motility disorders. To report on clinical features, medical, surgical and psychiatric co-morbidities, and prior treatments of a patient cohort diagnosed concurrently with non-psychogenic rumination syndrome and pelvic floor dysfunction (also termed rectal evacuation disorder). From a consecutive series (1994-2013) of 438 outpatients with rectal evacuation disorders in the practice of a single gastroenterologist at a tertiary care center, 57 adolescents or adults were diagnosed with concomitant rumination syndrome. All underwent formal psychological assessment or completed validated questionnaires. All 57 patients (95% female) fulfilled Rome III criteria for rumination syndrome; rectal evacuation disorder was confirmed by testing of anal sphincter pressures and rectal balloon evacuation. Prior to diagnosis, most patients underwent multiple medical and surgical treatments (gastrostomy, gastric fundoplication, other gastric surgery, ileostomy, colectomy) for their symptoms. Psychological co-morbidity was identified in 93% of patients. Patients were managed predominantly with psychological and behavioral approaches: diaphragmatic breathing for rumination and biofeedback retraining for pelvic floor dysfunction. Awareness of concomitant rectal evacuation disorder and rumination syndrome and prompt identification of psychological co-morbidity are keys to instituting behavioral and psychological methods to avoid unnecessary treatment.

Symptom distribution and anorectal physiology results in male patients with rectal intussusception and prolapse

BackgroundRectal intussusception and external rectal prolapse are uncommon proctographic findings in men reflecting the lack of studies investigating such patients. The aim of this study was to identify the demographic, clinical, and physiological characteristics of this population with a view to appreciate the mechanism of development of this condition. MethodsAll men, presenting with symptoms of constipation or fecal incontinence, who were diagnosed proctographically with recto-rectal intussusception (RRI)/recto-anal intussusception (RAI) or external rectal prolapse (ERP) between 1994 and 2007 at a tertiary academic colorectal unit were studied. Demographics, relevant comorbidities, distribution and symptom duration, and anorectal physiology results were analyzed retrospectively for each proctographic group and intergroup comparisons performed. ResultsTwo hundred five men (median age 50 y; range, 13–86) including 155 (75.6%) without any relevant comorbidities were studied. A significant proportion of patients in all proctographic groups reported rectal evacuatory difficulty ([RRI, 46.4%], [RAI, 39.4%], [ERP, 44.8%]; P = 0.38,analysis of variance). Patients also reported a combination of fecal incontinence symptoms (e.g., urge, passive, postdefecatory leakage) that did not differ across the proctographic groups. Anorectal physiological parameters were within normal range and were not found to be statistically different between the proctographic groups with the exception of anal resting pressure, which was lowest in ERP patients (62 cm H2O; range, 14–155) compared with patients with RRI (89 cm H2O; range, 16–250; P = 0.003) and RAI (92 cm H2O; range, 38–175; P = 0.006). ConclusionsMen with rectal intussusception and prolapse present with a combination of symptoms, predominantly defective rectal evacuation. Anorectal physiological assessment has failed to shed light into the mechanism of development of this condition and thus, the need for large observational studies incorporating integrated defecographic and manometric assessments of the evacuation process.

Prevalence of colonic motor or evacuation disorders in patients presenting with chronic nausea and vomiting evaluated by a single gastroenterologist in a tertiary referral practice

Nausea and vomiting are thought to result from upper gastrointestinal dysfunctions. Our clinical observations led to the hypothesis that colonic motor dysfunction is associated with nausea and vomiting. We reviewed electronic medical records (EMR) of 149 patients presenting with complaints of nausea and/or vomiting in a tertiary gastroenterology practice to investigate the association with disorders of colonic motor or evacuation disorders. We extracted demographics, gastric emptying (GE in 149) and colonic transit (CT in 138) of solids, ascending colon emptying half-time (AC t1/2 ), rectal evacuation by anorectal manometry (ARM) in 91 and balloon expulsion test (BE) in 55 patients. We estimated the proportions with delayed GE or CT, based on the 5th percentile of GE (in 319) and CT in 220 healthy volunteers using same method. Among 11 patients with nausea and/or vomiting with only GE measured, five had delayed and six normal GE. Among the 149 patients, 77 (52%) patients had evacuation disorders, confirmed by objective tests in 68 patients, and clinical examination in nine patients. In the 138 patients with both GE and CT measured, 106 (76%) had both normal GE and CT, 11 (8%) only delayed GE, 16 (11%) normal GE with delayed CT, and five (3%) delayed GE and CT. Among 21 patients (15%) with delayed CT, nine had slow AC t1/2 and 12 evacuation disorder. In patients with chronic nausea and/or vomiting in gastroenterology practice, evaluation of colonic motility and rectal evacuation should be considered, since about half the patients have abnormal functions that conceivably contribute to the presenting nausea and/or vomiting.

Relapsing faecal incontinence in the elderly: a no man’s land

Background Post-obstetric neuropathic faecal incontinence is a complex disorder of impaired motor function involving the sphincters and pelvic floor, often associated with impaired rectal evacuation and anorectal anaesthesia [1]. Direct trauma to the anal sphincter complex can give immediate problems or problems later in life. The initial therapy should be conservative. Patients with anatomic sphincter defect or with extensive sphincter damage, muscle loss or pudendal neuropathy are very likely to need surgery. Several surgical approaches have been proposed, but results still remain disappointing, although quality of life seems to be improved [2]; after the initial enthusiasm, the role of artificial bowel sphincter (ABS) has been scaled-down. These problems are even harder to face in elderly patients previously operated on with poor outcome for faecal incontinence.

PTU-126 Joint Hypermobility Syndrome, Rectal Hyposensitivity and Severe Constipation in young Nulliparous Females

IntroductionThe joint hypermobility syndrome (JHS) is a common non-inflammatory connective tissue disorder characterised by joint hyperflexibility and skin hyperelasticity. A validated 5 point hypermobility questionnaire screens for the presence or...

Mo2038 Nausea and/or Vomiting As the Presenting Symptoms in Patients With Colonic Dysmotility or Rectal Evacuation Disorder

Mo2038 Nausea and/or Vomiting As the Presenting Symptoms in Patients With Colonic Dysmotility or Rectal Evacuation Disorder

273 Efficacy of Sacral Nerve Stimulation for Treating Slow Transit Constipation: A Randomised, Double-Blind, Placebo-Controlled, 2 Phase Crossover Study

Sacral nerve stimulation (SNS) is a potential treatment for constipation refractory to standard therapies. Uncontrolled studies have shown promise, however, there have been no randomized controlled studies of its efficacy. Aim: In patients with slow transit constipation (STC), we evaluated the efficacy of suprasensory and subsensory SNS compared with sham, in a prospective, 18 week randomised, double-blind, placebo-controlled, 2 phase crossover study. The primary outcome measure was the proportion of patients who, on more than 2 days/ wk for at least 2/3 weeks, reported a bowel movement associated with a feeling of complete evacuation . (ANZ CT Registry; 00347680). Method: A caluclated 50 patients were needed to detect a 20% increase in response from sham(80% power 95% confidence). Following a 3 weeks of temporary peripheral nerve evaluation (PNE) all patients underwent a permanent implantation. Patients were then randomized into a double blind, cross-over study in which subsensory and suprasensory stimulation were compared to sham stimulation (Fig1). All patients kept daily stool dairies. Quality of life (QoL; SF36) was measured at the end of each treatment arm .Results: Of 59 patients with scintigraphically confirmed STC and no evidence of rectal evacuation disorder enrolled (4 male; 44 ± 15 yrs), 33% met the primary outcome measure during the PNE. 55 patients went on to permanent SNS implanted and were randomized into cross over study. The proportion of patients that satisfied primary outcome measure did not differ between suprasensory (30%) and sham (21%) stimulation nor between subsensory (25%) and sham (25%) stimulation. PNE did not provide an indicator of treatment success with only 8/16 PNE responders also responding suprasensory stimulation. In the SF36 only general health and and emotional well being improved during suprasensory stimulation (P=0.02). Conclusion: In patients with refractory STC, SNS did not improve the frequency of complete bowel movements over the 3-week active period, but did result in a modest improvement in general health. Secondary outcomes (pain, bloating, laxative-free days) and longer term responses of primary outcomes are awaited. (Supported by NMHRC Australia and Medtronic Australasia/USA). Cross-over design

Technical and Functional Results of the Artificial Bowel Sphincter for Treatment of Severe Fecal Incontinence

Fecal incontinence is a socially devastating problem that can be cured by the artificial bowel sphincter in selected cases. This study evaluates short- and long-term morbidity and functional results of the artificial bowel sphincter. This study is a retrospective evaluation of consecutive patients. This study was conducted at 2 academic colorectal units. Between May 2003 and July 2010, all consecutive patients who underwent artificial bowel sphincter implantation for severe fecal incontinence were included in the study. The artificial bowel sphincter was implanted through 2 incisions made in the perineum and suprapubic area. Patients were reviewed at months 1, 6, and 12, and then annually. Mortality, morbidity (early infection within the first 30 days after implant, and late thereafter), and reoperations including explantations were analyzed. Anal continence was evaluated by means of the Cleveland Clinic Florida score. Mean follow-up was 38 months (range, 12-98). Between May 2003 and July 2010, 21 consecutive patients with a mean age of 51 years (range, 23-71) underwent surgery. There was no mortality. All patients presented with at least 1 complication. Infection or cutaneous ulceration occurred in 76% of patients, perineal pain in 29%, and rectal evacuation disorders in 38%. The artificial bowel sphincter was definitely explanted from 17 patients (81%). The artificial sphincter was able to be activated in 17 patients (81%), and continence was satisfactory at 1 year in those who still had their sphincter in place (n = 12). There is a very high rate of morbidity and explantation after implantation of an artificial bowel sphincter for fecal incontinence. Four of 21 patients who still had an artificial sphincter in place had satisfactory continence at a mean follow-up of 38 months.

Randomised clinical trial: the effects of daikenchuto, TU‐100, on gastrointestinal and colonic transit, anorectal and bowel function in female patients with functional constipation

Daikenchuto, a Japanese herbal medicine used for post-operative ileus and constipation, dose dependently stimulates gastrointestinal (GI) motility and decreases rectal compliance and sensation. Effects of TU-100 (commercial form of daikenchuto) in adults with constipation are unknown. To compare the effects of oral TU-100, 2.5 g t.d.s. or 5 g t.d.s. and placebo t.d.s. on GI and colonic transit (CT), rectal compliance (RC) and sensation thresholds (RST), anal sphincter pressures (ASP) and bowel function in female patients with functional constipation (FC). We conducted a single-centre, randomised, parallel-group, double-blind, pharmacodynamic study; 45 female patients with FC without evidence of rectal evacuation disorder were assigned to 28 days' treatment with oral placebo or TU-100 (Tsumura USA, Princeton, NJ, USA). Demographic data and CT were measured at baseline and randomisation stratified by baseline CT (GC> or <1.9) and by BMI (<25 or ≥25 kg/m(2) ). At the end of treatment period, we measured GI and CT by scintigraphy, RST and RC by barostat, ASP by manometry, psychosensory sensations, bowel function by daily diary and quality of life (QOL). The study had power to detect effect sizes of 33% (CT), 40% (RC) and 46% (RST). Statistical analysis included BMI as covariate. TU-100 had no significant effects on GI or CT, RC, ASP, recto-anal pressure difference, or RST. The 5 g t.d.s./day dose was associated with lower RST for first sensation and gas (unadjusted P: 0.045 and 0.024 respectively). There were no treatment effects on psychosensory symptoms, stool frequency, stool consistency or QOL. Mechanisms underlying the observed clinical benefit of TU-100 remain unclear (ClinicalTrials.gov NCT01139216).

Colonic gas transit in patients with bloating: the effect of an electromechanical stimulator of the abdominal wall

The aim of our study was to evaluate gas retention, abdominal symptoms and changes in girth circumference in females with bloating using an active or sham abdominal wall mechanical stimulation. In 14 female patients, complaining of bloating (11 with irritable bowel syndrome and 3 with functional bloating according to the Rome III criteria) a gas mixture was continuously infused into the colon for 1 h (accommodation period). Abdominal perception and girth were measured. At the beginning of the 30-min period of free rectal gas evacuation (clearance period), an electromechanical device was positioned on the abdominal wall of all patients. The patients were randomly assigned to an active or a sham stimulation protocol group. Gas retention, perception and abdominal distension were measured at the end of the clearance period. All patients tolerated the volume (1,440 ml) of gas infused into the colon. Abdominal perception and girth measurements was similar in both groups during the accommodation period. At the end of the clearance, the perception score and the girth changes in the active and sham stimulation groups were similar (2.8 ± 2.0 vs. 1.4 ± 1.2, p = 0.2 and 4.9 ± 4.5 vs. 2.8 ± 2.3 mm, p = 0.3 active vs. sham, respectively). Furthermore, the mechanical stimulation of the abdominal wall did not significantly reduce gas retention (495 ± 101 ml vs. 566 ± 55, active vs. sham, p = 0.1). An external mechanical massage of the abdominal wall did not improve intestinal gas transit, abdominal perception and abdominal distension in our female patients complaining of functional bloating.

Normal Values for High-Resolution Anorectal Manometry in Healthy Women: Effects of Age and Significance of Rectoanal Gradient

High-resolution manometry (HRM) is used to measure anal pressures in clinical practice but normal values have not been available. Although rectal evacuation is assessed by the rectoanal gradient during simulated evacuation, there is substantial overlap between healthy people and defecatory disorders, and the effects of age are unknown. We evaluated the effects of age on anorectal pressures and rectal balloon expulsion in healthy women. Anorectal pressures (HRM), rectal sensation, and balloon expulsion time (BET) were evaluated in 62 asymptomatic women ranging in age from 21 to 80 years (median age 44 years) without risk factors for anorectal trauma. In total, 30 women were aged <50 years. Age is associated with lower (r=-0.47, P<0.01) anal resting (63 (5) (≥50 years), 88 (3) (<50 years), mean (s.e.m.)) but not squeeze pressures; higher rectal pressure and rectoanal gradient during simulated evacuation (r=0.3, P<0.05); and a shorter (r=-0.4, P<0.01) rectal BET (17 (9) s (≥50 years) vs. 31 (10) s (<50 years)). Only 5 women had a prolonged (>60 s) rectal BET but 52 had higher anal than rectal pressures (i.e., negative gradient) during simulated evacuation. The gradient was more negative in younger (-41 (6) mm Hg) than older (-12 (6) mm Hg) women and negatively (r=-0.51, P<0.0001) correlated with rectal BET but only explained 16% of the variation in rectal BET. These observations provide normal values for anorectal pressures by HRM. Increasing age is associated with lower anal resting pressure, a more positive rectoanal gradient during simulated evacuation, and a shorter BET in asymptomatic women. Although the rectoanal gradient is negatively correlated with rectal BET, this gradient is negative even in a majority of asymptomatic women, undermining the utility of a negative gradient for diagnosing defecatory disorders by HRM.

Barium proctography vs magnetic resonance proctography for pelvic floor disorders: a comparative study

Accurate and reliable imaging of pelvic floor dynamics is important for tailoring treatment in pelvic floor disorders; however, two imaging modalities are available. Barium proctography (BaP) is widely used, but involves a significant radiation dose. Magnetic resonance (MR) proctography allows visualization of all pelvic midline structures but patients are supine. This project investigates whether there are measurable differences between BaP and MR proctography. Patient preference for the tests was also investigated. Consecutive patients referred for BaP were invited to participate (National Research Ethics Service approved). Participants underwent BaP in Poole and MR proctography in Dorchester. Proctograms were reported by a consultant radiologist with pelvic floor subspecialization. A total of 71 patients were recruited. Both tests were carried out on 42 patients. Complete rectal emptying was observed in 29% (12/42) on BaP and in 2% (1/42) on MR proctography. Anismus was reported in 29% (12/42) on BaP and 43% (18/42) on MR proctography. MR proctography missed 31% (11/35) of rectal intussusception detected on BaP. In 10 of these cases no rectal evacuation was achieved during MR proctography. The measure of agreement between grade of rectal intussusception was fair (κ=0.260) although MR proctography tended to underestimate the grade. Rectoceles were extremely common but clinically relevant differences in size were evident. Patients reported that they found MR proctography less embarrassing but harder to empty their bowel. The results demonstrate that MR proctography under-reports pelvic floor abnormalities especially where there has been poor rectal evacuation.

Prise en charge initiale de l’incontinence anale

Initial management of fecal incontinence only requires medical treatment. Simple advices to regulate bowel movement (mucilages, rectal evacuation, loperamide). Transit disorders, and interestingly dyschesia, are frequently associated to fecal incontinence.In case of inefficacy, investigations are needed, guided by ethiopathology of incontinence wich can be suspected by medical interview and clinical exam.

Unusual site of graft erosion after abdominal sacrocervicopexy

Large fasciomuscular damage of the feminine pelvic floor resulting in pelvic organ prolapse constitutes a challenge for surgical reconstruction.Between 2005 and 2010, ten women aged 47-75 years were treated by abdominoperineal implantation of polypropylene mesh for modified sacral perineocolporectopexy and subsequently followed up. They were suffering from enterocele (9), genital prolapse (8), descending perineum (5), rectal prolapse (4), and rectocele (3). Five women were incontinent (mean Wexner 9) and six had incomplete rectal evacuation. Defecography revealed enterocele III (5) and II (4). Magnetic resonance (MR) diagnosed descending perineum in five patients (mean 3.8 cm).Permanent reconstruction of the pelvic floor and remission of organ prolapse was achieved at 12-months of follow-up in all except one patient. There were two small vaginal mesh erosions and one hematoma within the pelvic floor. Improvement at rectal emptying and anal incontinence (mean Wexner 4) were found.Modified sacral perineocolporectopexy is effective in the treatment of complex pelvic floor anatomical defects and organ prolapse. Improvements in rectal emptying, pelvic feeling of heaviness, and dyspareunia were achieved. The procedure was safe and characterized by good implant tolerance and a low rate of complications.

Constipation Is Also an Important Cause of Fecal Incontinence in Old People: Author's Reply

TO THE EDITOR: I would like to thank Dr. Lee for his thoughtful comments1 on the impact of constipation on fecal incontinence.2 The coexistence of fecal incontinence and constipation has been well characterized in children and the geriatric population. Fecal incontinence in children is secondary to 'overflow' which results from the presence of constipation.3 Also fecal incontinence occurs in a variety of organic disorders like congenital malformations, neurogenic problems like myelomeningocele, and other conditions affecting the anorectum, anal sphincters, or the spinal cord.4 However, there is limited data in non-geriatric adults. Fecal incontinence in adults is frequently associated with urge and diarrhea and is considered in chronic medical conditions, such as Parkinson's disease, or acquired through local pelvic floor dysfunction via trauma or surgery.5 Female predominance in fecal incontinence is regarded as the result of sphincter disruption secondary to obstetric injury. Under these conditions, fecal incontinence is easily presented if the patients have loose stool or diarrhea. The population based study for incidence of fecal incontinence showed that a higher prevalence of diarrhea and a higher probability of pelvic dysfunction might account for the higher prevalence of fecal incontinence at young women.6 In this study, urgency was a risk factor for development of fecal incontinence.6 In non-geriatric constipated adults, fecal incontinence is detected with similar proportion according to gender. In our study, there was no definitive gender difference in the prevalence of fecal incontinence and it is consistent with other population based study.6 Recent studies showed that a significant proportion of men with fecal incontinence had a history of perianal disease including hemorrhoids and surgical procedure.7 However, in some non-geriatric male patients with fecal incontinence, fecal impaction may also occur due to a combination of impaired rectal sensitivity (hyposensitivity), increased rectal compliance and increased rectal dimensions; these factors contribute to fecal retention by decreasing the frequency and intensity of the desire.8 Fecal seepage presents as the unintentional loss of small amount of stool, usually in the hours following defecation. Such seepage, clinically distinct from more major passive or urge-related fecal incontinence, occurs in patients with incomplete rectal evacuation, secondary to a dyssynergic pattern of defecation.9 However, our study did not show the strong association of constipation and fecal incontinence in young adult group, which is not clear whether it is the result of true negative association or type II error is. In geriatric and non-geriatric patients with fecal incontinence, both diarrhea and constipation may be the important risk factors for fecal incontinence. Fecal incontinence may be sub-classified by associated symptom patterns or underlying pathophysiology. Further meticulous investigation would improve understanding of risk factors coupled with diagnostic techniques and treatments, thereby improving outcomes in fecal incontinence.

Comment on Forsgren et al.: Anal incontinence and bowel dysfunction after sacrocolpopexy for vaginal vault prolapse

Dear Editor, We read with great interest the case-control study by Forsgren et al. in your journal [1]. The study aimed to determine the prevalence of bowel dysfunction after sacrocolpopexy. Abdominal sacrocolpopexy is considered the gold standard for pelvic organ prolapse repair. Forsgren et al. compared 78 women who underwent sacrocolpopexy with matched controls of 233 hysterectomized women without sacrocolpopexy, using a bowel function questionnaire and the Cleveland Clinic Incontinence Score. Sacrocolpopexy was associated with an increased prevalence of difficulty emptying the rectum, incomplete rectal evacuation, digitally assisted rectal emptying, and use of enemas. Constipation after sacral colpopexy was described by other authors as well; Virtanen et al. noted that 26 % of the patients had de novo constipation after abdominal sacropexy [2]. Forsgren et al. stated in their discussion that the constipation after sacrocolpopexy may be explained by a change of the anorectal angulation at defecation. With this letter we would like to propose that the constipation can be explained by injury of the autonomic nerves in the presacral space during sacrocolpopexy. Recent findings by our group [3] have emphasized that the risk of injury to the autonomic nerves in the presacral space is high. At the level of the promontory or just below, the superior hypogastric plexus branches into the hypogastric nerves (Fig. 1a, b). At this level preservation of the pelvic autonomic nerves is often difficult, because these nerves are not distinctly visible in the surgical field due to their delicate structure. Our results emphasize that topographic knowledge of the neural anatomy of the presacral

Semi‐automated vectorial analysis of anorectal motion by magnetic resonance defecography in healthy subjects and fecal incontinence

Inter-observer variability limits the reproducibility of pelvic floor motion measured by magnetic resonance imaging (MRI). Our aim was to develop a semi-automated program measuring pelvic floor motion in a reproducible and refined manner. Pelvic floor anatomy and motion during voluntary contraction (squeeze) and rectal evacuation were assessed by MRI in 64 women with fecal incontinence (FI) and 64 age-matched controls. A radiologist measured anorectal angles and anorectal junction motion. A semi-automated program did the same and also dissected anorectal motion into perpendicular vectors representing the puborectalis and other pelvic floor muscles, assessed the pubococcygeal angle, and evaluated pelvic rotation. Manual and semi-automated measurements of anorectal junction motion (r = 0.70; P < 0.0001) during squeeze and evacuation were correlated, as were anorectal angles at rest, squeeze, and evacuation; angle change during squeeze or evacuation was less so. Semi-automated measurements of anorectal and pelvic bony motion were also reproducible within subjects. During squeeze, puborectalis injury was associated (P ≤ 0.01) with smaller puborectalis but not pelvic floor motion vectors, reflecting impaired puborectalis function. The pubococcygeal angle, reflecting posterior pelvic floor motion, was smaller during squeeze and larger during evacuation. However, pubococcygeal angles and pelvic rotation during squeeze and evacuation did not differ significantly between FI and controls. This semi-automated program provides a reproducible, efficient, and refined analysis of pelvic floor motion by MRI. Puborectalis injury is independently associated with impaired motion of puborectalis, not other pelvic floor muscles in controls and women with FI.