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PubMed1993

Straining at stool and laxative taking in an English population.

A population-based sample of 834 men (ages 40-69 years) and 1058 women (25-29 years) was investigated with respect to straining to defecate, stool form, bowel habit, and use of laxatives, by means of a questionnaire and a three-stool record form. Straining was common but, contrary to standard teaching, far from universal. It was unrelated to age but was commoner in women than men. Many people underestimated how often they strained. Overall, 32% of defecations in women and 22% of defecations in men were associated with straining to start and 15% and 9%, respectively, with straining to finish. Straining was to some extent related to stool type: the lumpier a stool, the more often it elicited straining. However, it seems likely that straining in some people is just a habit. Use of laxatives was found to be less prevalent than in the past, and most people with evidence of constipation did not use them. Use of laxatives increased with age, and some older people used them inappropriately. The most popular laxatives were based on phenolphthalein, senna, or magnesium.

Adult↗
PubMed1991

Anorectal dysfunction in patients with urologic disturbance due to multiple sclerosis.

Anorectal function was evaluated in 11 patients with voiding dysfunction due to multiple sclerosis. In six patients with constipation, three also had symptoms of obstructed defecation and one patient was incontinent due to stercoral diarrhea. One patient was only fecal incontinent and one patient had obstructed defecation as the only symptom. Three patients had no anorectal symptoms. Anal manometry in the women compared with a control group revealed significant lower anal resting and squeeze pressures, although no significant difference of rectal sensation to distention with air was found. Pudendal nerve terminal latencies were obtained in seven patients and were all normal. In four patients latency could not be demonstrated due to poor contraction of the sphincter on stimulation of the pudendal nerve. Two of these patients were incontinent and two had both constipation and obstructed defecation. It is concluded that patients with voiding symptoms due to multiple sclerosis often reveal anorectal symptoms or motility disorders. Although anal sphincter function is reduced, fecal incontinence is not prevalent in this group. The reason for this lies probably in the fact that many of the patients are constipated, thus securing fecal continence.

Adult↗
PubMed1991

Functional comparison between double and triple ileal loop pouches.

Ileal pouch function in 35 patients operated upon by the same surgeon were compared. Seventeen of the patients had a double loop (J) ileal pouch-anal anastomosis (IPAA) and 18 a triple loop (S) pouch. The patients were examined a mean of 27.9 months and 5.1 months, respectively, after ileostomy closure. Ten of the S-pouch patients were evaluated more than 6 months (S greater than 6 months), mean 9.1 after ileostomy closure. There were no differences in the mean maximum resting pressures or maximum squeeze pressures between the groups. The incidence of daytime and nocturnal leakage was lower in the S-pouch group, 22 and 29 percent, than in the J group 29, and 53 percent. Though the mean maximum tolerated volume (MTV) of the S-pouch group was greater than the J group, the difference was not statistically significant. The difference in the mean compliance between the J- and S-pouch groups and the J and S greater than 6 months group was statistically significant (P less than 0.01) and (P less than 0.008). All the patients could evacuate spontaneously. The difference in the 24-hour frequency of defecation between the S greater than 6 months and J group was significant (P less than 0.05), but not between the S and J groups. The median frequency of nocturnal defecation between the S greater than 6 months and J pouch groups was significant (P less than 0.005), but not between the S and J groups. The triple loop S-pouches were more compliant than the J-pouches and had a better functional result as shown by a lower incidence of nocturnal leakage, and a lower frequency of defecation during the day and night.

Adenomatous Polyposis Coli↗
PubMed1997

Anismus: fact or fiction?

PURPOSE: Although anismus has been considered to be the principal cause of anorectal outlet obstruction, it is doubtful whether contraction of the puborectalis muscle during straining is paradoxical. The present study was conducted to answer this question. METHODS: During the first part of the study, we retrospectively reviewed 121 patients with constipation and/or obstructed defecation (male:female, 10/111; median age, 51 years). All of these patients underwent electromyography (EMG) of the pelvic floor and the balloon expulsion test (BET) in the left lateral position. Evacuation proctography was performed in all of these patients in the sitting position. Both the posterior anorectal angle and the central anorectal angle were measured. EMG and BET were also performed in ten controls (male:female, 4/6; median age, 47). In 147 patients with fecal incontinence (male:female, 24/123; median age, 58) only EMG activity was recorded. Criteria for anismus during straining were increase or insufficient (<20 percent) decrease of EMG activity, failure to expel an air-filled balloon on BET, and decrease or insufficient (<5 percent) increase of anorectal angle on evacuation proctography. Between June 1994 and March 1995, we conducted a second prospective study in a consecutive series of 49 patients with constipation and/or obstructed defecation and 28 patients with fecal incontinence. Both groups were compared with 19 control subjects. In this study, all three tests were performed. EMG and BET were performed both in the left lateral position and in the sitting position. RESULTS: The retrospective study was undertaken by comparing the constipated patients with the incontinent patients and the controls, and the anismus detected by EMG was found in, respectively, 60, 46, and 60 percent. Failure to expel the air-filled balloon was observed in 80 constipated patients (66 percent) and in 9 control subjects (90 percent). Based on posterior anorectal angle and central anorectal angle measurements, anismus was diagnosed in, respectively, 21 and 35 percent of constipated patients. In the prospective study, none of the tests showed significant differences regarding the prevalence of anismus between the two subgroups of patients and the control subjects. The prevalence of anismus only differed between constipated and incontinent patients when the diagnosis was based on BET in the sitting position (67 vs. 32 percent; P < 0.005). Our study shows that contraction of the puborectalis muscle during straining is not exclusively found in patients with constipation and/or obstructed defecation. The three tests most commonly used for the diagnosis of anismus showed an extremely poor agreement. CONCLUSION: Based on these findings, we doubt the clinical significance of anismus.

Adult↗
PubMed1990

Videoproctographic assessment after restorative proctocolectomy.

Videoproctography was performed in 40 patients after restorative proctocolectomy to evaluate pouch emptying, anopouch angle, and pelvic floor movement in relationship to functional outcome. Results were compared between the two different pouch designs tested and a control group of 26 patients who had an intact rectum. There was no difference in emptying between the two pouch designs or compared with the control subjects. Emptying did not influence either the frequency of defecation or patient soiling rate. The presence of an anal stricture was associated with poor emptying in each case in the pouch group. Anorectal angle was no different between the different pouch designs or compared with the control group at rest, during pelvic floor contraction, or attempted defecation. A similar finding was obtained with anorectal angle position and movement during pelvic floor contraction and attempted defecation in both pouch design groups and when compared with normal rectum. This study shows that the only factor that is consistently associated with poor pouch emptying is the presence of an anal stricture.

Adult↗
PubMed1992

Outpatient protocol for biofeedback therapy of pelvic floor outlet obstruction.

Pelvic floor outlet obstruction is a rare cause of severe constipation. Anal myectomy, subtotal colectomy, and medical therapy have limited success. The purpose of this study was to develop a short outpatient treatment using biofeedback techniques. Nine patients with severe constipation and straining resulting from pelvic floor outlet obstruction underwent complete investigation of the pelvic floor musculature and anal sphincter mechanism. Patients were unable to expel a 60-cc rectal balloon and had nonrelaxing puborectalis on defecography. The treatment protocol utilized anal surface electromyography to document improper straining and retrain pelvic floor muscles to relax during defecation. Sensory retraining with a rectal balloon, behavioral relaxation techniques, and defecation of simulated stool using a 120-cc Metamucil (Procter & Gamble, Cincinnati, OH) slurry in the rectum allowed re-establishment of normal defecation in all nine patients. Repeat training was required in three patients during follow-up. Treatment of pelvic floor outlet obstruction with outpatient retraining techniques is possible.

Adult↗
PubMed1997

Colorectal function in patients with spinal cord lesions.

PURPOSE: This study was designed to describe the frequency and severity of colorectal problems among patients with spinal cord lesions and to determine whether these problems are associated with age, gender, time since the lesion, and level and severity of the lesion. PATIENTS AND METHODS: A detailed questionnaire describing colorectal and bladder function was sent to all 589 members of The Danish Paraplegic Association; 424 responded (72 percent). RESULTS: Only 19 percent felt a normal desire to defecate, whereas the remaining patients felt no desire to defecate (38 percent) or a combination of abdominal discomfort (37 percent) and headache, physical uneasiness, and perspiration (25 percent). Digital stimulation of the anal canal before defecation or digital evacuation of the rectum was used regularly by 65 percent of patients. Fecal incontinence was experienced by 75 percent of patients; however, most patients only had a few episodes of fecal incontinence each month (15 percent) or each year (56 percent). Overall, 39 percent of patients reported that colorectal dysfunction caused some or major restrictions on social activities or on their quality of life, and 30 percent regarded colorectal complaints to be worse than both bladder and sexual dysfunction. The severity of most symptoms was significantly correlated with the severity of the lesion, and the self-reported impact on social activities or quality of life was significantly more severe among women than men. CONCLUSION: Colorectal dysfunction is very common among spinal cord-injured patients, often causing restriction on social activities and quality of life. Therefore, these problems deserve more attention in the treatment of spinal cord-injured patients.

Adolescent↗
PubMed1997

Functional results after restorative proctocolectomy complicated by pouchitis.

UNLABELLED: This study aimed to examine the incidence and cumulative risk of pouchitis after restorative proctocolectomy for ulcerative colitis and to evaluate the clinical and functional results in patients with pouchitis. METHODS: A total of 291 patients had proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis between January 1985 and January 1996. During follow-up, 65 patients had one or more episodes of pouchitis based on clinical, histologic, and endoscopic criteria. Functional results and patient satisfaction in these patients were compared with those of 65 matched control patients who had experienced no episodes of pouchitis. RESULTS: Pouchitis developed in 65 patients (22 percent), giving rise to a cumulative frequency of 28 percent at 11 years after the operation. Only 13 patients (4.5 percent) had chronic pouchitis that required long-lasting treatment. A permanent ileostomy had to be constructed in one patient (0.3 percent) because of pouchitis. During the last year (1995), 60 percent of patients with pouchitis had medication, most often metronidazole and/or corticosteroids. Defecation frequency per 24 hours was 6.7 for all patients with pouchitis, 8.2 for those with chronic pouchitis (P < 0.05), and 6.3 for patients without pouchitis. Nighttime defecation occurred in 44 (80 percent) patients with pouchitis, compared with 37 (67 percent) of those without pouchitis (P > 0.05). Frequencies of soiling or flatus incontinence did not differ between the two groups. During the last year, 43 (80 percent) of the pouchitis patients, who answered the questionnaire, were working all the year or were on sick-leave less than one month. CONCLUSIONS: Episodic pouchitis is easily treated and causes minimum functional consequences, whereas chronic pouchitis increases defecation frequency and needs prolonged medication. Pouchitis seems not to be a major threat to preventing the use of restorative proctocolectomy in ulcerative colitis, but still the small group of chronic pouchitis patients remains a problem.

Adolescent↗
PubMed2001

Colectomy for slow-transit constipation: preoperative functional evaluation is important but not a guarantee for a successful outcome.

PURPOSE: This study was designed to assess the results of preoperative functional evaluation of patients with severe slow-transit constipation in relation to functional outcome. METHODS: Four hundred thirty-nine patients with chronic intractable constipation were evaluated by marker studies. Twenty-one patients underwent colectomy and ileorectal anastomosis for slow-transit constipation. Mean colorectal transit time was 156 hours (normal, <45 hours). Small-bowel transit time was normal in ten patients and delayed in five patients. Six were nonresponders. Morbidity was 33 percent. Small-bowel obstruction occurred in six patients; relaparotomy was done in four patients. Follow-up varied from 14 to 153 (mean, 62) months. RESULTS: After three months, defecation frequency was increased in all. Mean stool frequency improved from one bowel movement per 5.9 days to 2.8 times per day. Sixteen patients felt improved after surgery. Seventeen continued to experience abdominal pain, and 13 still used laxatives and enemas. Satisfaction rate was 76 percent (16 patients). After one year, defecation frequency was back at the preoperative level in five patients. An ileostomy was created in two more patients because of incontinence and persistent diarrhea. Eleven patients (52 percent) still felt improved. A relation between small-bowel function and functional results could not be demonstrated. CONCLUSIONS: Preoperative evaluation is important but not a guarantee for, successful outcome. Colectomy remains an ultimate option for patients with disabling slow-transit constipation, but patients should be informed that, despite an increased defecation frequency, abdominal symptoms might persist. Any promiscuous use of colectomy to treat constipation should be discouraged.

Anastomosis, Surgical↗
PubMed1992

Internal rectal intussusception: results of surgical repair.

Twenty-four patients with obstructed defecation due to rectal intussusception diagnosed by defecography were treated with rectopexy either by the Wells technique (9 patients) or by Orr's operation (15 patients). After follow-up from one to eight years, defecography demonstrated disappearance of the intussusception in 22 patients. None of the patients were completely relieved of their symptoms. Nine (41 percent; 95 percent confidence limits: 21-64) were improved and 13 were unchanged (59 percent; 95 percent confidence limits: 36-79), with no difference between the two procedures. One patient with solitary rectal ulcer was improved, and the ulcer disappeared. Four patients with moderate preoperative incontinence became continent postoperatively, but obstructed defecation was only improved in two of these patients. It is concluded that rectal intussusception is probably a secondary phenomenon in patients with obstructed defecation and that a conservative attitude toward surgery should be adopted.

Adult↗
PubMed1992

Quality of life after total proctocolectomy and ileal J-pouch-anal anastomosis.

We investigated the daily life and opinions of patients after total proctocolectomy and ileal J-pouch-anal anastomosis. Eighty patients answered a questionnaire, completed Cattell's anxiety scale, and recorded bowel function for one month. Both colitis and polyposis patients defecated five times daily, had 1.6 episodes of nocturnal motions weekly, and soiled twice weekly. However, colitis patients were more satisfied with their bowel function and surgical outcome than were polyposis patients. This difference had a close relationship to the personality factors of ego strength and frustration. All patients with either disease who defecated less than three times daily, had no nocturnal motions, and had no soiling showed normal ego strength and frustration and were completely satisfied with their bowel status and operation. In contrast, patients defecating more than seven times daily or more than once per week nocturnally and soiling more than four times weekly had high frustration and were dissatisfied. Thus, satisfaction with surgery correlated not only with the objective outcome but also with personality and lifestyle.

Adenomatous Polyposis Coli↗
PubMed1987

Is paradoxical contraction of puborectalis muscle of functional importance?

Paradoxical contraction of the puborectalis muscle during simulated defecation straining (anismus) has been cited as a cause of constipation. The functional specificity of this phenomenon was evaluated in 79 patients, 50 with constipation, 21 with idiopathic perineal pain, and eight with solitary rectal ulcer syndrome. Electromyogram evidence of paradoxical puborectalis contraction was observed in 38 (76 percent), ten (48 percent), and four (50 percent) of these patients, respectively. All patients with solitary rectal ulcer syndrome had difficulty defecating; defecation was normal in all patients with perineal pain. These observations suggest that paradoxical contraction of the puborectalis muscle is not a specific finding, and that it is not the sole cause of constipation in patients with anismus.

Adolescent↗
PubMed1988

Balloon sphincterography. Clinical findings after 200 patients.

There are two muscular mechanisms of fecal continence. The anal sphincter squeezes the anal canal, thus lengthening it and increasing its resistance. The puborectalis kinks the distal rectum, preventing the transmission of intra-abdominal pressures into the anal canal. Balloon sphincterography simultaneously records the shape of the anal canal and distal rectum and measures the strength of the puborectalis and anal sphincter muscles. This allows the physician to evaluate the function of these important muscles in patients with symptomatic defecation disorders such as constipation, incontinence, and rectal prolapse. A cylindrical balloon is connected by a hose to a fluid reservoir filled with liquid barium. The deflated balloon is placed into the anal canal and inflated by raising the fluid reservoir in increments. Fluoroscopy visualizes the balloon's shape and video records the results. Quantitative sphincterogram measurements in patients with defecation disorders include (the three measurements in each category refer respectively to incontinent patients [N = 87], prolapse patients without incontinence [N = 26], and constipated patients [N = 65]); anorectal angle (degrees + S.D.): 114 + 28, 103 + 18, 95 + 19; anal canal length (mm + S.D.): 33 + 11, 38 + 10, 39 + 10; squeeze pressure (cm H2O + S.D.): 68 + 23, 80 + 16, 91 + 22, and opening pressure (cm H2O + S.D.): 52 + 25, 67 + 22, 81 + 24. The method is useful in identifying specific defects, such as paradoxic puborectalis contractions, that can cause constipation, and injuries to the sphincters that can cause incontinence. In over 280 patients with a wide variety of defecation disorders, sphincterography has yielded information not available by standard manometric techniques. It augments the findings of defecography.

Anal Canal↗
PubMed2006

Visceral hypersensitivity following cold water intake in subjects with irritable bowel syndrome.

BACKGROUND: Visceral hypersensitivity has been shown to be present in irritable bowel syndrome (IBS). This study sought to investigate rectal sensitivity and abdominal symptoms in IBS patients before and after 220 ml cold water intake. METHODS: A total of 60 IBS patients and 18 healthy controls participated in this study. Both the perception thresholds and defecation thresholds to rectal balloon distension were measured. Then, all subjects were asked to drink 220 ml 37 degrees C warm water or 4 degrees C cold water, and these steps were repeated 20 min later. Symptoms including abdominal pain/discomfort, bloating, and diarrhea were recorded during the study. RESULTS: Compared with the controls, the thresholds of initial sensation to rectal balloon distention in IBS patients were significantly lower while the defecation thresholds were higher in constipation-predominant IBS patients. After drinking cold water, the perception thresholds in IBS patients and the defecation thresholds in diarrhea-predominant IBS patients were further decreased. However, warm water intake did not change the perception thresholds significantly in either IBS patients or controls. A negative linear correlation was found between the symptoms and the visceral perception thresholds in diarrhea-predominant IBS patients who showed significant symptoms after cold water intake. CONCLUSION: The results indicated that cold water intake leads to lowered visceral perception thresholds in IBS patients that were inversely relevant to the abdominal symptoms in symptomatic diarrhea-predominant IBS patients. The alteration of rectal sensitivity and abdominal symptoms following cold water stimulation provided further objective evidence for visceral hypersensitivity in IBS patients.

Adult↗
PubMed2004

Colonic surgery with accelerated rehabilitation or conventional care.

BACKGROUND: For patients undergoing colonic surgery, the postoperative hospital stay is usually 6 to 10 days, and the morbidity rate is 15 to 20 percent. Fast-track rehabilitation programs have reduced the hospital stay to 2 to 3 days. The aim of this study was to evaluate the postoperative outcome after colonic resection with conventional care compared with fast-track multimodal rehabilitation. METHODS: One hundred thirty consecutive patients receiving conventional care (group 1) in one hospital were compared with 130 consecutive patients receiving multimodal, fast-track rehabilitation (group 2) in another hospital. Outcomes were time to first defecation after surgery, postoperative hospital stay, and morbidity during the first postoperative month. RESULTS: Median age was 74 years (group 1) and 72 years (group 2). American Society of Anesthesiologists (ASA) score was significantly higher in group 2 ( P < 0.05). Defecation occurred on day 4.5 in group 1 and day 2 in group 2 ( P < 0.05). Median hospital stay was 8 days in group 1 and 2 days in group 2 ( P < 0.05). The use of a nasogastric tube was longer in group 1 ( P < 0.05). The overall complication rate (35 patients) was lower in group 2 ( P < 0.05), especially cardiopulmonary complications (5 patients; P < 0.01). Readmission was necessary in 12 percent of cases for group 1 and 20 percent in group 2 ( P > 0.05). CONCLUSIONS: Time to first defecation, hospital stay, and morbidity may be reduced after colonic resection with fast-track multimodal rehabilitation.

Adult↗
PubMed2003

Scintigraphic assessment of retrograde colonic washout in fecal incontinence and constipation.

PURPOSE: This study aimed to evaluate the colorectal luminal transport obtained by retrograde colonic washout with a new scintigraphic technique. METHODS: Nineteen patients (5 with spinal cord lesion, 6 with idiopathic fecal incontinence, and 8 with idiopathic constipation) treated with retrograde colonic washout took indium-111-labeled polystyrene pellets to label the bowel contents. Technetium-99m-diethylene-triamine-pentaacetic acid was mixed with the irrigation fluid to assess its extent within the colorectum. Scintigraphy was performed before and after a standardized washout procedure. The colorectum was divided into four segments: the cecum and ascending colon, the transverse colon, the descending colon, and the rectosigmoid. Assuming ordered evacuation of the colorectum, the contribution of each colonic segment to the total evacuation was expressed in percent of the original segmental counts. The contributions of each segment were summed to reach a total defecation score (range, 0-400), and directional segmental transports were estimated. RESULTS: The defecation score in patients with idiopathic constipation (median, 59; range, 21-130) differed significantly (P < 0.05) from the scores in those with spinal cord lesions (median, 204; range, 108-323) and idiopathic fecal incontinence (median, 188; range, 155-234). Thus, patients with spinal cord lesion or idiopathic fecal incontinence were able to empty most of the rectosigmoid and most of the descending colon, but those with idiopathic constipation could only empty 59 percent of the rectosigmoid. The irrigation fluid on average reached a point just beyond the right colic flexure that correlated with the defecation score (r(2) = 0.58, P < 0.001). CONCLUSION: The effect of retrograde colonic washout was significantly better in spinal cord lesion and idiopathic fecal incontinence than in idiopathic constipation, and its effect correlated with the extent to which the irrigation fluid had entered the colorectum.

Adolescent↗
PubMed2005

Improvement of wound healing after hemorrhoidectomy: a double-blind, randomized study of botulinum toxin injection.

PURPOSE: Hemorrhoidectomy is usually associated with significant pain during the postoperative period. The spasm of the internal sphincter seems to play an important role in the origin of pain. This study was designed to evaluate the effectiveness of intrasphincter injection of botulinum toxin after hemorrhoidectomy in reducing the maximum resting pressure of the anal canal, accelerating wound healing, and decreasing postoperative pain when resting and during defecation. METHODS: Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 30 days afterward in all patients undergoing Milligan-Morgan hemorrhoidectomy. One group received an injection of 0.4 ml of saline into the internal anal sphincter, the other group were injected with 0.4 ml of solution containing 20 units of botulinum toxin. RESULTS: After five days from hemorrhoidectomy, maximum resting pressure decreased in the group injected with botulinum toxin and increased in the placebo group. The time of healing and postoperative pain when resting and during defecation significantly decreased in the group treated with an injection of botulinum toxin. CONCLUSIONS: Botulinum toxin injection into internal anal sphincter after hemorrhoidectomy is effective in reducing maximum resting pressure, time of healing, and postoperative pain both on resting and during defecation in absence of complications or side effects.

Adult↗
PubMed2006

Botulinum toxin vs. topical glyceryl trinitrate ointment for pain control in patients undergoing hemorrhoidectomy: a randomized trial.

PURPOSE: The maximum resting pressure in the anal canal is greatly raised after hemorrhoidectomy. This increase is likely to be the cause of postoperative pain, which is still the most troublesome early problem after hemorrhoidectomy. This study was designed to compare, after hemorrhoidectomy, the effects of intrasphincter injection of botulinum toxin vs. application of glyceryl trinitrate ointment in improving wound healing and reducing postoperative pain at rest or during defecation. METHODS: Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 40 days after hemorrhoidectomy. One group received one injection containing 20 IU of botulinum toxin, whereas the other an application of 300 mg of 0.2 percent glyceryl trinitrate ointment three times daily for 30 days. RESULTS: Five days after hemorrhoidectomy, maximum resting pressure was significantly reduced compared with baseline values in both groups (85 +/- 15 vs. 68 +/- 11 mmHg for the group treated with botulinum toxin, 87 +/- 11 vs. 78 +/- 11 mmHg for the group treated with glyceryl trinitrate ointment). Overall analysis of postoperative pain at rest showed a significant reduction in the botulinum toxin group vs. glyceryl trinitrate group, whereas pain during defecation and time of healing were similar. Adverse effects, such as headaches, were observed only in the glyceryl trinitrate group. Forty days after hemorrhoidectomy in the glyceryl trinitrate group, maximum resting pressure values were similar to preoperative ones, whereas the values were still reduced in the botulinum toxin group. CONCLUSIONS: A single intrasphincter injection of botulinum toxin was more effective and safer than repeated applications of glyceryl trinitrate in reducing early postoperative pain at rest but not during defecation.

Adult↗