12. Bowel Dysfunction Outcomes, Constipation, Anorectal Testing, Proctalgia Fugax, Peds, IBS, FI Flashcards
What are the two types of constipation?
1) Primary constipation with functional impairment of the colon and anorectal structures. 2) Secondary constipation related to organic or structural disease, systemic disease, or medications.
What defines severe constipation?
Severe constipation is defined as 1 bowel movement (BM) per week.
Who is most affected by constipation?
Those in nursing homes, women more than men, post-operative hip fracture patients, those with joint hypermobility, neurologic conditions, children, pregnant women, and young female athletes.
What are other factors contributing to constipation?
Lower social, economic, and education levels; high body mass index; reduced mobility; low consumption of fruits, vegetables, and fiber; living in densely populated communities; family history of constipation; anxiety; stressful life events; and depression.
What criteria must be present for a diagnosis of functional constipation?
The diagnosis must include the presence of 2 of the following criteria during at least 25% of defecations: straining to defecate, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction or blockage, digital maneuvers to defecate, and 3 BMs per week.
What are the three groups of primary constipation?
1) Normal transit constipation (NTC). 2) Slow transit constipation (STC). 3) Defecation disorders (DD).
What is the normal defecatory frequency?
Normal defecatory frequency ranges from 3 times per day to 3 times per week.
What is the recommended fiber intake for women aged 19-70?
21 to 25 g for women aged 19-70 who are not pregnant and not lactating.
What characterizes slow transit constipation (STC)?
STC is characterized by infrequent urges to defecate, abdominal pain, and distension, leading to hard stool and difficulty with evacuation.
What is the initial medical management for constipation?
The first stop is to see a primary care physician (PCP) who usually recommends laxatives or fiber.
What is the Rome III criteria used for?
The Rome III criteria are used for diagnosing functional gastrointestinal disorders, including constipation.
how is this differnt from bristol?
What does the Bristol Stool Form Scale assess?
The Bristol Stool Form Scale assesses stool consistency and correlates moderately with colonic transit time.
what are neuromuscular and Behavioral Management Recommendation to address behaviors associated with constipation?
neuromuscular impairments of sensory and motor coordination.
Examples
Standing or hovering over the toilet
failure to respond to the urge to defecate (too busy) or choosing to wait (until in the privacy of the home)
Excess straining
What are red flags to assess in constipation?
Bright red blood in the stool indicates lower gastrointestinal tract pathology, while black tarry stools may indicate bleeding from the upper gastrointestinal tract.
What do black nontarry stools indicate?
side effect of ingestion of medicines or supplements
(iron and bismuth salts, in particular)
ingestion of certain foods
(black licorice or beets).
What is the purpose of balloon expulsion testing?
Balloon expulsion testing identifies abnormal defecation patterns by having the patient expel an artificial stool.
anomanometry
measures pressure activity in the anorectum
provides information on rectoanal reflexes, rectal sensation (hypersensitivity or hyposensitivity), rectal compliance, ability to generate adequate intra-abdominal force to expel stool along with contraction versus relaxation of the EAS and PR-LA
Measurements of bowel transit are:
radiopaque marker test, radioisotopes and scintigraphy, and wireless motility capsule
What is the role of exercise in managing constipation?
Low-intensity exercise may increase or have no effect on gastric emptying, while high-intensity exercise may delay gastric emptying.
Why should coordination between abdominal wall muscle activation and PR-LA and EAS relaxation be performed for constipation concersn
promote coordination between abdominal wall muscle activation and PR-LA and EAS relaxation for stool expulsion. Verbal training alone or verbal training supplemented by instrumented biofeedback is equally effective in promoting motor learning.
What can biofeedback training used for in constipation management?
Biofeedback training is recommended for short- and long-term management of dyssynergic defecation.
* LA syndrome (sometimes seen with DD) Level 2 B evidence for Biofeedback
What is Slow Transit Constipation (STC)?
Characterized by infrequent urges to defecate, abdominal pain, and distension
STC involves slow movement in the colon leading to excessive fluid reabsorption and hard stool.
What leads to hard stool and difficulty with evacuation in STC?
Excessive amount of fluid is reabsorbed from the lumen of the colon
This is a result of slow colonic transit.
What is impaired in Slow Transit Constipation?
Function of the colonic pacemaker cells of Cajal
These cells are crucial for normal colonic motility.
What is condition is associated with persistent rectal distension in STC?
Disordered defecation
This can exacerbate the symptoms of STC.
How well do people with STC respond to fiber intake?
Do not respond well to fiber intake of 30 g per day
Increased fiber is typically recommended for other types of constipation.
What is another name for Defecation Disorders (DD)?
Outlet obstruction
This term highlights the blockage in the defecation process.
What are common symptoms of Defecation Disorders?
Straining, longer toileting time, manual assistance to complete rectal emptying
Manual assistance may include splinting or anal digitation.
What muscles are involved in uncoordinated or non-relaxing external anal sphincter?
External anal sphincter (EAS) and puborectalis muscle of the levator ani muscle (PR-LA)
Dysfunction in these muscles can lead to difficulty in defecation.
What type of training is recommended for managing dyssynergic defecation?
Biofeedback training
It is given a level 1, grade A recommendation for short- and long-term management.
What can cause rectal hyposensitivity?
Afferent nerve dysfunction or excessive rectal wall distension
Cause of DD can be rectal hyposensitivity due to either afferent nerve dysfunction or excessive rectal wall distension, thus requiring larger stool volumes to trigger defecation; and insufficient rectoabdominal coordination to evacuate stool
Poor detection of stool entering the rectum, balloon catheter retraining is indicated to enhance rectal sensory awareness
This condition requires larger stool volumes to trigger defecation.
What does insufficient rectoabdominal coordination affect?
Evacuation of stool
This can contribute to difficulties in defecation.
What can poor detection of stool entering the rectum lead to?
Indication for balloon catheter retraining
This retraining enhances rectal sensory awareness.
What learned patterns may contribute to Defecation Disorders?
Repeatedly deferring defecation due to fear, pain, urgency
This behavior can lead to rectal distension or retropulsion of stool.
What characterizes normal colonic transit?
Normal colonic stool movement with perceived difficult defecation or hard stools
This condition overlaps with constipation-dominant irritable bowel syndrome.
What is the best response for individuals with normal colonic transit?
Increased fiber and osmotic laxatives
These treatments help alleviate symptoms related to hard stools.
What is the MID for the Modified Manchester health Questionnaire (MMHQ)?
3
What is the MID for the long and short version Colorectal anal distress inventory (CRADI)?
11 for long version and 5 for short version
What is the MID for the long and short version Colorectal anal impact questionnaire (CRAIQ)?
CRAIQ - 18 for long version and 8 for short version
What is the MID for the FISI?
4
Constipation based off the rome IV criterial for adult functional constipation is:
- 6+ months of sx and sx present during the last 3 months
Sx include 2+ of the following: - Straining during more than ¼ of BMs
- Lumpy or hard stools more than ¼ of the time
- Sensation of incomplete evacuation more than ¼ of the time
- Sensation of anorectal obstruction/blockage more than ¼ of the time
- Manual maneuvers to facilitate more than ¼ of the time
- Fewer than 3 spontaneous bowel movements per week
- Loose stools rarely present without the use of laxatives
- Insufficient criteria present for IBS
What are common symptoms of slow transit constipation?
- Reduction in urge to defecate
- Abdominal pain
- Abdominal distension
These symptoms may indicate a reduction or loss of postprandial motor activity.
What is functional defecation?
Motor coordination between anal sphincter, levator ani, and abdominal wall muscles
Impairments in this coordination can lead to constipation.
What are some causes of functional defecation disorders?
- Musculoskeletal impairments
- Neurologic impairments
- Anismus
- Abdominopelvic muscle incoordination
- Reduced anorectal sensation
Anismus (high anal resting pressure), abdominopelvic muscle incoordination (dyssynergia), POP, reduced anorectal sensation, sensation of anal blockage or incomplete emptying
These factors can lead to difficulties in bowel movements.
What are early interventions for constipation management?
- Laxatives
- Dietary recommendations to increase fiber
These interventions may fail to improve constipation in about 50% of patients.
What does PT for functional constipation include?
- NMR with biofeedback
- Dietary and fluid recommendations
- Proper toileting techniques
- Abdominal massage
- Management of musculoskeletal impairments
This is aimed at retraining coordination and improving bowel health.
What is the grade and recommendation for EMG biofeedback training for functional constipation?
Grade B strong recommendation
Recommended for those aged 18+ with functional constipation.
What can be used to help functional constipation?
rectal balloon catheter biofeedback training
anorectal manometry biofeedback training (A)
EMG biofeedback training (B)
Manual therapy - abdominal massage - (A)
Manual therapy - other - (B)
Electrical stimulation - ( D )
It is filled with water or air and performed in side-lying.
What is the grade and recommendation for anorectal manometry biofeedback training?
Grade A strong recommendation
Involves both an internal balloon catheter and external surface electrodes.
What type of manual therapy is recommended for functional constipation?
Abdominal massage
Grade A strong recommendation for short-term effects.
What are some other manual therapy techniques recommended for functional constipation?
- Perineal self acupressure
- Reflexology
- Connective tissue mobilizations
- Joint mobilizations
- Visceral mobilizations
These techniques have a grade B moderate recommendation.
What is the grade for electrical stimulation recommendations for functional constipation?
Grade D weak recommendation
Includes intra-anal, transcutaneous, and cranial stimulation.
True or False: Functional constipation can occur in both males and females.
True
Recommendations apply to both genders.
What is the definition of Fecal Incontinence (FI)?
Recurrent and uncontrolled passage of fecal material for at least 3 months
This includes fecal staining of underwear.
Is flatus incontinence included in the definition of Fecal Incontinence?
No
Difficult to define when isolated passage of flatus is abnormal.
At what age is FI considered abnormal?
Once toilet training has been achieved, generally by 4 years
This indicates that FI should not occur after this age.
What are common causes of Fecal Incontinence?
- Anal sphincter weakness:traumatic, obstetric, surgical
- Neuropathy: pudendal) or generalized (DM)
- Pelvic floor disorders: rectal prolapse, descending perineum syndrome
- Disorders affecting rectal capacity and/or sensation:radiation proctitis, crohns disease, ulcerative colitis; anorectal surgery, rectal hypo/hypersensitivity,
- CNS disorders:dementia, stroke, brain tumors, MS, spinal cord lesions
- Psychiatric diseases and behavioral disorders
- Bowel disturbances: IBS, post cholecystectomy, diarrhea, constipation with fecal retention with overflow
- Non traumatic: scleroderma, idiopathic internal sphincter degeneration
What psychological problems may co-exist with Fecal Incontinence?
- Anxiety
- Depression
- Poor self-esteem
- Sexual challenges
These issues can exacerbate the impact of FI on quality of life.
What is the relationship between symptom severity and quality of life in patients with FI?
Significant correlation exists
More severe symptoms can lead to a lower quality of life.
What are some outcome measures for assessing Fecal Incontinence?
- Rockwood Fecal Incontinence QoL Scale
- Modified Manchester Health Questionnaire
- Fecal Incontinence and Constipation Assessment QoL
- Pelvic Organ Prolapse/Incontinence Sexual Questionnaire - IUGA
These tools help measure the impact of FI on patients’ lives.
What are independent risk factors for Fecal Incontinence?
- Diarrhea
- Cholecystectomy
- Current smokers
- Rectocele
- SUI
- BMI
- Obesity
- EAS atrophy
Each of these factors increases the likelihood of experiencing FI.
What factors are associated with an increased risk of Fecal Incontinence?
- Advanced age
- Increased disease burden
- Obstetric injury; intrument use and higher degree of tear
- Decreased physical activity
These factors can contribute to the development of FI.
What is the most frequently identified abnormality in FI, especially in older women?
Anal sphincter weakness
This is characterized by reduced resting and squeeze pressure.
What can internal anal sphincter defects lead to?
- Impaired sampling response
- Decreased resting pressure
These defects may be associated with structural disturbances or thinning.
What can reduced rectal sensation lead to in FI patients?
Stool enters anal canal and leaks before EAS contracts
This contributes to the incontinence experienced.
What are the effects of rectal hyper and hypo sensitivity in conditions like IBS?
Hyposensitivity can also contribute to fecal retention by decreasing frequency and intensity of urge- retention reduces sensation
Rectal hypersensitivity - IBS- may be associated with reduced rectal compliance
This can complicate the management of FI.
How does rectal capacity change in FI
Rectal capacity reduced in FI
sphinter pressure alone does not indicate continence vs incontince
how does the sampling reflex change in FI
Sampling occurs less frequently in incontinent patients- maybe depriving them of sensory information
what reflex may be abscent in FI
absent anocutaneous reflex in response to gentle stroking of the perianal region suggests nerve impairment
What is the typical definition of success in therapeutic trials for FI?
50% reduction in the number of episodes of FI or days per week
A patient’s perspective on success may differ.
What does an absent anocutaneous reflex suggest?
Nerve impairment
This reflex can be tested by gentle stroking of the perianal region.
What is the positive predictive value of a meticulous DRE for identifying low resting and squeeze pressures?
- 67% for low resting pressure
- 81% for low squeeze pressure
This indicates the effectiveness of DRE in diagnosing FI.
What is a recommended initial treatment for fecal incontinence?
Reduce laxatives or medications that can cause loose stools
Dietary trials may also be beneficial.
Which type of fiber has been shown to improve fecal incontinence?
Psyllium
Other types like gum arabic or carboxymethylcellulose did not show improvement.
What medication can improve stool consistency and increase internal sphincter tone?
Loperamide (2-4mg 30 minutes before meals)
What are the anticholinergic side effects seen with diphenoxylate combined with atropine?
Dry mouth, constipation, urinary retention, blurred vision
What FDA-approved treatments exist for fecal incontinence?
- Sacral nerve stimulation
- Anal submucosal injection of dextranomer in stabilized hyaluronic acid (NASHA Dx)
What characterizes unspecified anorectal pain?
Pain lasting more than 30 minutes with no tenderness of puborectalis
What is proctalgia fugax?
Sudden, severe pain in the rectal area, fleeting from seconds to minutes
What may precipitate attacks of proctalgia fugax?
Stressful life events or anxiety
What is the treatment approach for proctalgia fugax?
Reassurance and explanation
What symptoms characterize levator ani syndrome?
- Tenderness to puborectalis
- Pain lasting more than 30 minutes
- Vague, dull ache or pressure sensation high in the rectum
What is a common physical examination finding in levator ani syndrome?
Spasm of levator ani muscles and tenderness on palpation. more often on the left than right side, or of the pelvic floor or vagina.
use sigmoidoscopy, ultrasonography and pelvic imaging to exclude alternative diseases
What treatments are available for levator ani syndrome?
- Electrogalvanic stimulation
- Biofeedback training
- Muscle relaxants
- Digital massage of the levator ani muscles
- Sitz baths
What defines functional defecation disorders?
≥2 symptoms of chronic constipation or IBS with constipation, and ≥2 features of impaired evacuation
What are the characteristics of functional defecation disorders?
- Paradoxical contraction of pelvic floor muscles
- Inadequate relaxation of pelvic floor muscles
- Inadequate propulsive forces during defecation
what is function defication disorders? What are other terms for it?
- ≥2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with ≥2 features of impaired evacuation via manometry or abnormal balloon expulsion test
- Excessive straining, incomplete evacuation, digital facilitation of BM
- Dyssynergic defecation
- Inadequate defecatory propulsion
What is the focus of patient education for functional defecation disorders?
Patients often inadvertently squeeze or fail to relax their anus when straining
treatment for fxn defication disorder
Patient education: Explain to patients that they inadvertently squeeze or fail to relax their anus when they are straining.
Enhance push effort: Teach the patients to effectively push, when straining, by appropriately increasing the intra-abdominal pressure; use feedback from rectal sensor regarding abdominal and diaphragmatic push effort to expel stool.
Train to relax pelvic floor muscles: Teach patients to relax their pelvic floor muscles when straining. This skill can be taught by providing visual feedback regarding anal canal pressure or EMG activity (Figure 2).
Practice simulated defecation: Educate patient to practice defecation and expulsion of a lubricated, inflated balloon while the therapist assists by gently pulling on the catheter.
What does anorectal manometry assess?
- Resting anal pressure
- Squeeze pressure
- Internal anal sphincter inhibitory reflex
- Threshold volume of rectal distention
- Intra-abdominal pressure during attempted defecation
- Rectal compliance
What is the first choice imaging technique for identifying sphincter thinning or defect?
Anal endosonography
What does defecography confirm?
Structural alteration of the pelvic floor
What advantage does MRI have in assessing anal sphincter anatomy?
Visualizes anatomy and global pelvic floor movement in real time without radiation exposure
What can MRI indicate about the anal canal?
EAS atrophy and patulous anal canal, which may suggest denervation or damage to anal cushions
What is the first line treatment for Dyssynergic Defecation?
Biofeedback therapy
Biofeedback therapy is more effective than laxatives and has no side effects.
What is Anismus?
Paradoxical anal contraction during attempted defecation
Also referred to as PF dyssynergia, obstructive defecation, and other terms.
What percentage of patients with Dyssynergic Defecation have impaired rectal sensation?
50-60%
This suggests that the spasm or inability to relax the external anal sphincter is not solely responsible.
What diagnostic test is needed to exclude Hirschsprung’s disease?
Anorectal manometry
What is the normal physiological process that occurs during defecation?
Increased rectal pressure with simultaneous relaxation of the external anal sphincter
What are the four types of dyssynergia classified via anorectal manometry?
- Type I: Adequate propulsion force with paradoxical EAS pressure increase
- Type II: Inadequate propulsion force with paradoxical anal contraction
- Type III: Adequate propulsion force with inadequate relaxation of anal sphincter
- Type IV: Inadequate propulsion force with inadequate relaxation of anal sphincter
What does the Balloon Expulsion Test assess?
Time needed to expel a balloon filled with warm water placed in the rectum
What is the normal result for the Balloon Expulsion Test?
Balloon expelled within one minute. Balloon should be filled with 50 ml of warm water
What are the pros and cons of Magnetic Resonance Defecography?
- Pros: no radiation, excellent visualization of structures
- Cons: high cost, limited availability, difficulty detecting rectal intussusception
What is evaluated in a Colonic Transit Study?
Colonic transit time using various methods such as radiographs or wireless motility capsule
transit time is altered in Dyssynergic Defecation
What is the recommended first line treatment for patients with chronic constipation?
Evaluation and treatment for dyssynergia in order to improve transit time- this is easy hanging fruit
List the standard treatments for Dyssynergic Defecation.
- Standard treatment for constipation
- Biofeedback therapy
- Other measures (e.g., botulinum toxin injection, myectomy)
What dietary recommendations are suggested for managing constipation?
- Adequate fiber intake (25-35g daily)
- Fluid intake
- Regular exercise
What is the purpose of timed toilet training?
To establish a regular defecation pattern and avoid postponing the urge to defecate
What is the role of fiber in managing constipation?
- Accelerates colonic transit
- Bulks the stool
- Draws fluid into the lumen
What types of fiber are mentioned, and provide examples.
- Soluble fiber: psyllium husk
- Insoluble fiber: calcium polycarbophil, bran, methylcellulose
what are Methods to stimulate colon and other behaviors that can be used with Dyssynergic Defecation
Methods to stimulate colon: walking after meals, avoid postponing defecation (dont ignore/suppress the urge),
Timed toilet training: attempt BM 2x/daily - 30 min after meals; push at 50-70% of max effort of straining for no more than 5 min; avoid digital disimpaction
What pharmacologic agents can be used as adjunctive treatment with biofeedback?
- Intestinal secretagogues
- Serotonergic enterokinetic agents
What is the efficacy of biofeedback therapy for dyssynergic defecation?
70-80% for up to 2 years after treatment
How many sessions of biofeedback therapy are typically required?
4 to 6 sessions lasting 60 minutes each
What is the aim of the Rectoanal coordination protocol?
To synchronize abdominal push effort with relaxation of pelvic floor and anal canal
What is the goal of Rectal Sensory Training?
To improve thresholds for rectal sensory perception and awareness for stooling
What was shown to be superior in a recent RCT regarding rectal sensory training?
Barostat-assisted sensory training over syringe-assisted training
What are other methods of treatment for Dyssynergic Defecation?
- Myectomy
- Botulinum toxin injection
- Surgery
What is the purpose of the rectoanal coordination protocol?
To produce an adequate abdominal push effort synchronized with relaxation of the pelvic floor and anal canal
This is indicated by a rise in intrarectal pressure on the manometric tracing.
What posture should the patient maintain during attempted defecation?
Seated with legs apart and leaning forward
Correct posture is crucial for effective defecation.
What should the patient avoid during the attempted defecation?
Excessive pushing
Proper titration of abdominal push and anal sphincter relaxation is essential.
How much air is used to distend the balloon in the rectum for sensation?
60 cc of air
This provides the subject with a sensation of rectal fullness.
What is the simulated defecation maneuver?
Placing a 50 mL water-filled balloon in the rectum and attempting defecation on a commode
If the subject cannot expel the balloon, gentle traction is applied to assist.
What is the goal of rectal sensory training?
To improve thresholds for rectal sensory perception and promote better awareness for stooling
This training is essential for enhancing defecation awareness.
What is the first step in rectal sensory training?
Progressively inflate the balloon until the subject experiences an urge to defecate
The threshold volume is noted for future reference.
What happens during the second step of rectal sensory training?
The balloon volume is decreased in a stepwise manner by about 10%
The subject is encouraged to observe pressure changes and sensations.
What tools can be used for rectal sensory training?
Hand-held syringe attached to the manometry catheter with a rectal balloon or a barostat
Both methods are effective for sensory training.
Describe Rectoanal coordination and how to test it
Rectoanal coordination: purpose is to produce an adequate abdominal push effort (shown as a rise in intrarectal pressure on the manometric tracing) that is synchronized with relaxation of the pelvic floor and anal canal
Seated and correct for posture: keeping the legs apart as opposed to keeping them together, leaning forward
During the attempted defecation, the patient is instructed to titrate the degree of abdominal push and the anal sphincter relaxation effort and in particular not to push excessively,
Then the balloon in the rectum is distended with 60 cc of air to provide the subject with a sensation of rectal fullness
Describe anorectal sensation and how to test it
goal : improve the thresholds for rectal sensory perception and to promote better awareness for stooling.
* 1: is to progressively inflate the balloon until the subject experiences an urge to defecate. Then, this threshold volume is noted. The maneuver is repeated 2 or 3 times with this volume to educate the subject and to trigger appropriate rectal sensations
* 2. each subsequent inflation, the balloon volume is decreased in a stepwise manner by about 10%. During each distention, the subject is encouraged to observe the monitor and to note the pressure changes in the rectum and simultaneously pay close attention to the sensation they are experiencing in the rectum.
* Rectal sensory training can be performed with a hand-held syringe attached to the manometry catheter with a rectal balloon, or with a barostat. Barastat is better
Describe how to test Simulated defecation
: This maneuver is performed by placing a 50 mL water-filled balloon in the rectum, then sit on a commode and attempt defecation.75 If the subject is unable to expel the balloon, gentle traction is applied to the balloon to supplement the patient’s effort.
