Case-Based Review

Defecation Disorders: Diagnosis and Treatment

Journal of Clinical Outcomes Management. 2014 October;22(10)

References

1. Higgins PD, Johanson JF. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol 2004;99:750–9.

2. Rao SS, Mudipalli RS, Stessman M, Zimmerman B. Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus). Neurogastroenterol Motil 2004;16:580–96.

3. Rao SS, Tantiphlachiva K, Rao PS, et al. How useful is digital rectal examination in the assessment of patients with dyssynergia? Am J Gastroenterol 2007;S268:419.

4. Pepin C, Ladabuam U. The yield of lower endoscopy in patients with constipation: survey of a university hospital, public county hospital, and a Veterans Administration medical center. Gastrointest Endosc 2002;56:325–32.

5. Rao SS. Constipation: evaluation and treatment. Gastroenterol Clin North Am 2003;32:659–83.

6. Rao SS, Camilleri M, Hasler WL, et al. Evaluation of gastrointestinal transit in clinical practice: position paper of the American and European Neurogastroenterology and Motility Societies. Neurogastroenterol Motil; 2011; 23: 8-23.

7. Savoye-Collet C, Savoye G, Koning E, et al. Defecography in symptomatic older women living at home. Age Ageing 2003;32:347–50.

8. Bolog N, Weishaupt D. Dynamic MR imaging of outlet obstruction. Rom J Gastroenterol 2005;14:293–302.

9. Rao SS, Kavlock R, Rao S. Influence of body position and stool characteristics on defecation in humans. Am J Gastroenterol 2006;101:2790–6.

10. Karlbom U, Lundin E, Graf W, Pahlman L. Anorectal physiology in relation to clinical subgroups of patients with severe constipation. Colorectal Dis 2004;6:343–9.

11. Chiarioni G, Whitehead WE, Pezza V, et al. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology 2006;130:657–64.

12. Rao SS, Seaton K, Miller M, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol 2007;5:331–8.

13. Chiarioni G, Saladini L, Whitehead W. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology 2005;129:86–97.

14. Heymen S, Scarlett Y, Jones K, et al. Randomized controlled trial shows biofeedback to be superior to alternate treatments for patients with pelvic floor dyssynergia-type defecation [abstract]. Am J Gastroenterol 2005;100:S335.

15. Hallan RI, Williams NS, Melling J, et al. Treatment of anismus in intractable constipation with botulinum A toxin. Lancet 1988;2:714–7.

16. Boccasanta P, Venturi M, Stuto A, et al. Stapled transanal rectal resection for outlet obstruction: a prospective, multicenter trial. Dis Colon Rectum 2004;47:1285–97.

17. Sharara AI, Azar C, Amr SS, et al. Solitary rectal ulcer syndrome: endoscopic spectrum and review of the literature. Gastrointest Endosc 2005;62:755–62.

18. Tjandra JJ, Fazio VW, Church JM, et al. Clinical conundrum of solitary rectal ulcer. Dis Colon Rectum 1992;35:227–34.

19. Felt-Bersma RJ, Cuesta A. Rectal prolapse, rectal intussusception, rectocele, and solitary rectal ulcer syndrome. Gastroenterol Clin North Am 2001;30:199–222.

20. Vaizey CJ, van den Bogaerde JB, Emmanuel AV, et al. Solitary rectal ulcer syndrome. Br J Surg 1998;85:1617–23.

21. Rao SS, Ozturk R, De Ocampo S, Stessman M. Pathophysiology and role of biofeedback therapy in solitary rectal ulcer syndrome. Am J Gastroenterol 2006;101:613–8.

22. Kumar M, Puri AS, Srivastava R, Yachha SK. Solitary rectal ulcer syndrome in a child treated with local sulfasalazine. Indian Pediatr 1994;31:1553–5.

23. Zargar SA, Khuroo MS, Mahajan R. Sucralfate retention enemas in solitary rectal ulcer. Dis Colon Rectum 1991;34:455–7.

24. Bishop PR, Nowicki MJ. Nonsurgical therapy for solitary rectal ulcer syndrome. Curr Treat Options Gastroenterol 2002;5:215–23.

25. Ederle A, Bulighin G, Orlandin PG, Pilati S. Endoscopic application of human fibrin sealant in the treatment of solitary rectal ulcer syndrome [letter]. Endoscopy 1992;24:736–7.

26. Jarrett ME, Emmanuel AV, Vaizey CJ, Kamm MA. Behavioural therapy (biofeedback) for solitary rectal ulcer syndrome improves symptoms and mucosal blood flow. Gut 2004;53:368–70.

27. Tweedie DJ, Varma JS. Long-term outcome of laparoscopic mesh rectopexy for solitary rectal ulcer syndrome. Colorectal Dis 2005;7:151–5.

28. Rao SS. Diagnosis and management of fecal incontinence. American College of Gastroenterology Practice Parameters Committee. Am J Gastrenterol 2004;99:1585–604.

29. Rao SS, Patel RS. How useful are manometric tests of anorectal function in the management of defecation disorders? Am J Gastroenterol 1997;92:469–75.

30. Rao SS. Pathophysiology of adult fecal incontinence. Gastroenterology 2004;126(1 Suppl 1):S14–22.

31. Deutekom M, Dobben AC, Terra MP, et al. Clinical presentation of fecal incontinence and anorectal function: what is the relationship? Am J Gastroenterol 2007;102:351–61.

32. Wald A. Con: anorectal manometry and imaging are not necessary in patients with fecal incontinence. Am J Gastroenterol 2006;101:2681–3.

33. Bharucha AE. Pro: anorectal testing is useful in fecal incontinence. Am J Gastroenterol 2006;101:2679–81.

34. Tuteja AK, Rao SS. Review article: recent trends in diagnosis and treatment of faecal incontinence. Aliment Pharmacol Ther 2004;19:829–40.

35. Terra MP, Beets-Tan RG, van der Hulst VP, et al. MRI in evaluating atrophy of the external anal sphincter in patients with fecal incontinence. AJR Am J Roentgenol 2006;187:991–9.

36. Sun WM, Read NW, Verlinden M. Effects of loperamide oxide on gastrointestinal transit time and anorectal function in patients with chronic diarrhoea and faecal incontinence. Scan J Gastroenterol 1997;32:34–8.

37. Harford WV, Krejs GJ, Santa Ana CA, Fordtran JS. Acute effect of diphenoxylate with atropine (Lomotil) in patients with chronic diarrhea and fecal incontinence. Gastroenterol 1980;78:440–3.

38. Remes-Troche JM, Ozturk R, Philips C, et al. Cholesteryramine—a useful adjunct for the treatment of patients with fecal incontinence. Int J Colorectal Dis 2008;23:189–99.

39. Rao SS. The technical aspects of biofeedback therapy for defecation disorders. Gastroenterologist 1998;6:96–103.

40. Rao SS, Welcher KD, Happel J. Can biofeedback therapy improve anorectal function in fecal incontinence? Am J Gastroenterol 1966;91:2360–6.

41. Byrne CM, Solomon MJ, Young JM, et al. Biofeedback for fecal incontinence: short-term outcomes of 513 consecutive patients and predictors of successful treatment. Dis Colon Rectum 2007;50:417–27.

42. Norton C, Chelvanayagam S, Wilson-Barnett J, et al. Randomized controlled trial of biofeedback for fecal incontinence. Gastroenteroloy 2003;125:1320–9.

43. Heymen S, Whitehead W. EMG biofeedback vs. Kegel exercise for the treatment of fecal incontinence. Gastroenterology 2007;132:A–83.

44. Pager CK, Solomon MJ, Rex J, Roberts RA. Long-term outcomes of pelvic floor exercise and biofeedback treatment for patients with fecal incontinence. Dis Colon Rectum 2002;45:997–1003.

45. Ozturk R, Niazi S, Stessman M, Rao SS. Long-term and objective changes of anorectal function after biofeedback therapy for faecal incontinence. Aliment Pharmacol Ther 2004;20:667–74.

46. Byrne CM, Solomon MJ, Rex J, et al. Telephone vs. face-to-face biofeedback for fecal incontinence: comparison of two techniques in 239 patients. Dis Colon Rectum 2005;48:2281–8.

47. Zorcolo L, Covotta L, Bartolo DC. Outcome of anterior sphincter repair for obstetric injury: comparison of early and late results. Dis Colon Rectum 2005;48:524–31.

48. Madoff RD. Surgical treatment options for fecal incontinence. Gastroenterology 2004;126(1 Suppl 1)S48–54.

49. Thornton MJ, Kennedy ML, Lubowski DZ, King DW. Long-term follow-up of dynamic graciloplasty for faecal incontinence. Colorectal Dis 2004;6:470–6.

50. Leroi AM, Parc Y, Lehur PA, et al. Efficacy of sacral nerve stimulation for fecal incontinence: results of a multicenter double-blind crossover study. Ann Surg 2005;242:662–9.

51. Vaizey CJ, Kamm MA, Nicholls RJ. Double-blind crossover study of sacral nerve stimulation for fecal incontinence. Dis Colon Rectum 2000;43:298–302.

52. Graf W, Mellgren A, Matzel KE, et al. . Efficacy of dextranomer in stabilised hyaluronic acid for treatment of faecal incontinence: a randomised, sham-controlled trial. Lancet;2011;377:997–1003.

Rectal Examination

Physical examination in patients with constipation should include a detailed rectal examination. The perianal skin should be inspected closely for fissures, fistulae, and skin excoriation. The anocutaneous reflex should be checked along with resting and squeeze anal tone. A study by Rao et al[3] showed that rectal examination could identify 76% of patients with dyssynergia. The sensitivity and positive predictive value for diagnosing dyssynergia with digital rectal examination was 81% and 99%, respectively, making it a good screening test for dyssynergia [3].

When is colonoscopy indicated in the workup of constipation?
What imaging studies may be useful?

Colonoscopy

Colonoscopic evaluation is only indicated in patients with alarming features such as rectal bleeding, weight loss, unex-plained abdominal pain, palpable mass in the abdomen or rectum, persistent and unexplained anal/rectal pain, or anemia, as well as in patients over age 50 years [4].

Colonic Transit Study

Two imaging studies can be useful in the evaluation of a patient with constipation: colonic transit study and defeco-graphy. A colonic transit study provides useful information regarding the rate at which stool travels through the colon. This test is performed by administering one capsule (Sitzmarks, Konsyl Pharmaceuticals, Fort Worth, TX) containing radiopaque markers. A plain radiograph of the abdomen is obtained on day 6 (120 hr after ingestion of capsule). A transit study is considered abnormal if more than 20% of markers (> 5) are present on a plain radiograph of the abdomen. Approximately two-thirds of patients with dyssynergia have an abnormal colonic transit study, with retention of markers either in the rectosigmoid region or throughout the colon [5]. Wireless motility capsule is a newer test that is comprised of ingesting a capsule and wearing a recorder for up to 5 days. This test measures regional transit (ie, gastric emptying, colonic transit time, and whole gut transit time), is standardized and validated, and avoids use of radiation [6].

Defecography

Defecography is conducted by instilling a barium paste in the rectum and monitoring evacuation of the barium radiologically. It can reveal poor activation of the levator ani muscles, prolonged retention of the barium, inability to expel the barium, absence of a striping wave, rectal mucosal intussusception, rectocele, abnormal perineal descent, or rectal prolapse [5]. Although abnormalities are frequently found on defecography, they may not translate into clinical dysfunction. In one study, 77% of women with complaints of defecation disorders had abnormalities on defecography, but there was no relationship between the abnormalities and the patients’ symptoms [7]. Hence, defecography is not recommended unless there is clinical suspicion of prolapse or excessive descent. Endoanal and dynamic pelvic magnetic resonance imaging (MRI) can evaluate global pelvic floor anatomy in dynamic function [8]. Dynamic MRI in the seated position provides the most physiologic approach.

What testing is needed to make a diagnosis of dyssynergic defecation?

Both an abnormal balloon expulsion test and an abnormal pattern of defecation on anal rectal manometry are required to diagnose dyssynergic defecation [9]. Anorectal manometry provides information regarding rectal and anal pressures at rest and during maneuvers of simulated defecation as well as information on rectal sensation, rectoanal reflexes, and compliance [2,10]. There are 4 patterns of dyssynergia found on anorectal manometry: type 1, normal push effort with paradoxical contraction of the anal sphincter; type 2, poor push effort with paradoxical contraction of the anal sphincter; type 3, normal push effort with incomplete or absent relaxation of the anal sphincter; and type 4, poor push with incomplete anal relaxation. The balloon expulsion test should be included in the work-up of dyssynergia.