Introduction

Functional constipation represents a common disorder, burdened by a significant impact on the patient’s quality of life and a difficult clinical management, due to the absence of a known pathophysiological model. Considering that functional constipation predominantly affects females, many studies evaluated the role of sex hormones in development of this condition. However, the literature limits are represented by the lack of in vivo studies and by the heterogeneity of the clinical and experimental characteristics of the study groups. Persons with gender incongruence (Assigned Male at Birth, AMAB, and Assigned Female at Birth, AFAB) that are undergoing Gender Affirming Hormone Therapy (GAHT) represent an interesting model for the study of sex hormones action in vivo.

Aims & Methods

This study aims to investigate the effects of oestrogens and testosterone on stool frequency and consistency; abdominal symptoms (pain, bloating); symptoms related to constipation (pain during defecation and difficulty in evacuation), defecation urgency.
Twenty-two subjects undergoing GAHT have been evaluated before and after 24 weeks of hormonal therapy based on oestradiol valerate gel (AMAB persons) or testosterone (AFAB persons) (1). All subjects underwent clinical history, physical examination, and filled in the Patient Assessment of Constipation-Symptoms (PAC-SYM) questionnaire, which assesses the severity of symptoms related to constipation using a score (higher the score, higher the symptoms severity). The subjects compiled a two-week daily diary, reporting frequency of evacuations, stool consistency according to the Bristol Stool Form Scale (BSFS), presence of pain related to evacuation, defecation urgency and other abdominal GI symptoms. Blood samples were taken to assess the levels of β-estradiol and testosterone during therapy period. In AMAB, serum estradiol <200 pg/ml and testosterone <55 ng/dl were considered as therapy target levels. In AFAB, the target level of testosterone was 400-700 ng/dL (2). Statistical significance (p value <0.05) has been assessed using the chi-square test for categorical variables.

Results

A higher PAC-SYM score in all subscales was observed in AMAB persons. These subjects also reported more frequently stools type 1, 2 and 3 according to the BSFS. On the contrary, AFAB persons reported a decrease in all subscales of the PAC-SYM score and softer stool consistency. No significant association was observed between hormonal levels and variation of the PAC-SYM score (all subscales) or the stool consistency.

Conclusion

The results of this study suggest that sex hormones could play a role in the development of gastrointestinal functional symptoms. Therapy with oestrogens seems to cause the onset of constipation symptoms and the change of stools from normal to hard consistency suggests a possible slowdown of colonic transit. On the contrary, therapy with testosterone seems to relate with an improvement of constipation symptoms and stool consistency.

References

(1) Hembree WC, Cohen-Kettenis PT, GoorenL et al. (2017). “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline”, Journal of Clinical Endocrinology and Metabolism, 102:3869-3903
(2) Fisher, A D et al. “SIGIS-SIAMS-SIE position statement of gender affirming hormonal treatment in transgender and non-binary people.” Journal of endocrinological investigation vol. 45,3 (2022): 657-673. doi:10.1007/s40618-021-01694-2

Disclosure

Nothing to disclose.

Introduction

Constipation is a prevalent gastrointestinal disorder, commonly assessed using the Rome IV (R-IV) criteria for functional constipation. However, there is often a disconnect between a patient’s subjective perception of constipation and the clinical criteria used for diagnosis. Patients may either perceive constipation when they do not meet the diagnostic criteria or fail to recognize it despite fulfilling the criteria. This gap in understanding can lead to over- or under-diagnosis and inappropriate treatment.

Aims & Methods

This study aimed to investigate the association between patients' subjective perception of constipation and the fulfillment of Rome IV (R-IV) diagnostic criteria, addressing potential discrepancies that may impact clinical diagnosis and management. A cross-sectional study was conducted with 501 participants from the National Hospital Sri Lanka, who completed a self-reported questionnaire assessing bowel habits. Participants were categorized into four groups based on perceived constipation and R-IV fulfillment. Pearson’s chi-square test evaluated the association between these variables, while logistic regression analyzed predictors (gender, physical activity, water intake, stool consistency, and manual maneuvers) of constipation perception.

Results

Among the 501 participants (51.1% female), 36% reported perceiving constipation, whereas 25.5% met the R-IV criteria for functional constipation. A significant association was found between perceived constipation and R-IV criteria fulfillment (χ² = 12.77, p < 0.001). Notably, 23.6% of participants (Group 2) perceived constipation without fulfilling the criteria, while 13.0% (Group 3) met the criteria without perceiving constipation. Only 12.6% both perceived constipation (Group 1) and met the R-IV criteria, and 50.9% (Group 4) neither perceived constipation nor met the criteria. Manual defecation maneuvers were reported by 20.8% of participants, with digital evacuation (49%), bidet use (32.7%), and water enemas (31.7%) being the most common. The logistic regression model was statistically significant (χ²(5) = 60.222, p < 0.001), explaining 15.5% of the variance (Nagelkerke R²) and correctly classifying 70.7% of cases. Participants requiring manual maneuvers were 5.17 times more likely to report constipation (p < 0.001), while higher Bristol Stool Category scores were associated with a reduced likelihood of constipation perception (OR = 0.85, p = 0.009). Gender, physical activity, and water intake did not significantly influence the model.

Conclusion

This study highlights the significant association between perceived constipation and fulfillment of the Rome IV criteria. However, a substantial proportion of participants either perceive constipation without meeting the criteria or meet the criteria without recognizing the condition. These findings emphasize the limitations of relying solely on patient-reported symptoms, which may not always align with clinical diagnoses. A comprehensive approach that integrates objective diagnostic measures and patient perception could enhance diagnostic accuracy, reduce unnecessary interventions, and improve patient care in resource-limited settings like Sri Lanka.

References

Drossman, D. A., & Hasler, W. L. (2016). Rome IV—Functional GI Disorders: Disorders of Gut-Brain Interaction. Gastroenterology, 150(6), 1257–1261. https://doi.org/10.1053/j.gastro.2016.03.035

Introduction

Constipation is a common anorectal symptom that causes significant changes in the patients' quality of life. Anorectal manometry (ARM) and magnetic resonance (MR) defecography are important tools in diagnosing disorders associated with constipation, which are mainly structural and/or functional. Pelvic floor dyssynergia is diagnosed in the presence of alterations in 2 of the following: defecation kinetics in ARM, balloon expulsion test (BET) and/or MR defecography.

Aims & Methods

Compare the findings in ARM and MR defecography, in patients with constipation.
Retrospective cohort study including patients who fulfilled the Roma IV criteria for functional constipation, who were submitted to ARM and MR defecography. The London classification was used to describe the findings in ARM, establishing 3 groups of patients: Group 1 with those who had normal anorectal coordination and normal BET, Group 2 had altered anorectal coordination and altered BET, and Group 3 with those who had inconclusive findings: altered anorectal coordination and normal BET or normal anorectal coordination with abnormal BET. The structural alterations considered significant in MR defecography were those described as moderate to severe, which lead to defecation obstruction.

Results

A total of 51 patients were included, most were female (98.0%), with a mean age of 55 ± 12 years. Regarding the ARM findings, 16 patients were in Group 1 (31.4%), 11 in Group 2 (21.6%) and 24 in Group 3 (47.1%). Forty-three patients had alterations in MR defecography (84.3%), with 42 patients having at least one structural alteration and the most common being rectocele (72.5%) and descending perineum syndrome (66.7%). Pelvic floor dyssynergia was diagnosed by MR defecography in 9 patients (17.6%).
In the group of patients with normal anorectal coordination in ARM and normal BET (Group 1: n=16), 14 had significant structural alterations in MR defecography (87.5%) and 2 patients had no alterations (12.5%). In the group of patients with altered anorectal coordination in ARM and altered BET (Group 2: n=11), 8 also had structural alterations in MR defecography (72.7%). In the group of patients with inconclusive findings in ARM (Group 3: n= 24), 20 had structural alterations (83.3%) and 3 patients had pelvic floor dyssynergia diagnosed by MR defecography (12.5%), 2 of whom had both alterations (8.3%). In this group, 3 patients had no alterations in MR defecography (12.5%).
Patients with pelvic floor dyssynergia, with or without structural alterations, had a significantly lower rectoanal pressure differential than those with solely structural alterations (-25.0 ± 27.1 vs 5.7 ± 30.0 mmHg, p=0.004). There were no statistically significant differences in the values of anal pressure at rest and voluntary contraction pressure between patients with pelvic floor dyssynergia and those with solely structural alterations (p=0.350 and p=0.833), as well as in the values of residual anal pressure, intrarectal pressure and percentage of relaxation during defecation (p=0.267, p=0.257 and p=0.348).

Conclusion

Most patients had alterations in MR defecography, regardless of the ARM findings. Therefore, it is important to interpret the results of the ARM in conjunction with an imaging test capable of identifying structural alterations that may condition defecation in patients with functional constipation. In addition, those with pelvic floor dyssynergia, with or without associated structural alterations, had a lower rectoanal pressure differential than those with solely structural alterations.

Introduction

Inflammatory bowel disease (IBD) and endometriosis are immuno-mediated chronic inflammatory diseases observed in young women, sharing some of the clinical manifestations (i.e. abdominal pain). The possible association and the relationship between endometriosis and IBD is undefined.

Aims & Methods

In a multidisciplinary approach, we aimed to assess in patients with IBD and concomitant endometriosis, the clinical outcome in terms of abdominal pain and endometriosis-related symptoms at 6 and 12 months and characteristics of endometriosis. All female IBD pts in childbearing age referring symptoms compatible with endometriosis were enrolled and referred to dedicated gynecologists for transvaginal ultrasonography (TVS). Inclusion criteria: 1) female gender; 2) age ≥18 and ≤55 years; 3)well-defined diagnosis of IBD; 4) symptoms compatible with endometriosis; 6) consent. Exclusion criteria: 1) pregnancy; 2) menopause; 3) suspected pelvic malignancy at TVS. Characteristics of IBD, endometriosis and adenomyosis were classified according to standard criteria. Data were expressed as median [range]. The Student-t Test and χ2 test were used for comparisons.

Results

Endometriosis was diagnosed in 25 (71%) out of 35 IBD patients with compatible symptoms. These 25 IBD pts included 12 (48%) Crohn’s Disease (CD) and 13 (52%) Ulcerative Colitis (UC). CD and UC patients were comparable in terms of age (38 [28-47] vs 39 [25-53]; p=0.75). IBD characteristics included: IBD duration: 11.5 [1-35], CD 11 [1-25] vs UC 12 [1-35] years; p=0.8, CD localization: ileum 4 (33.3%), colon 1 (8.4%), ileum-colon 7 (58.3%), CD behavior: non-stricturing non-penetrating 6 (50%), stricturing in 3 (25%), penetrating in 3 (25%) pts, UC extent: proctitis 3 (23%), left-sided 5 (38.5%), pancolitis in 5 (38.5%) pts. Other IBD characteristics did not differ between CD and UC pts with endometriosis. In IBD patients with endometriosis, a comparable frequency of dysmenorrhea (9 [75%] vs 13 [100%] pts; p=0.47), dyschezia (5 [41.7%] vs 6 [46.1%] pts; p=0.85), dyspareunia (9 [75%] vs 10 [76.9%] pts; p=0.72), dysuria (0 [0%] vs 3 [23.1%] pts; p=0.24) was observed between CD and UC. At transvaginal ultrasonography, deep infiltrating endometriosis was observed in all thr 25 patients with IBD and endometriosis. Moreover, a high frequency of rectal endometriosis was detected in these 25 IBD pts (6 [24%]). Adenomyosis was observed in 19 (76%) IBD pts with endometriosis, with no differences between CD and UC (8 [66.6%] vs 11 [84.6%]; p=0.56).
Among the 25 IBD pts with endometriosis, 10 (40%) underwent dienogest or estroprogestinic treatment. At 6 months, gynecological follow up was available in 9 pts, of whom 7 were on dienogest or estroprogestinic treatment. Among these 7 pts, 4 reported no endometriosis-related symptoms and 5 no abdominal pain. At 12 months, gynecological clinical follow-up currently includes 6 pts (25%), all on progestinic treatment. Of these, only 2 pts reported abdominal pain while 3 pts reported recurrence of endometriosis-related symptoms.

Conclusion

In the tested population, endometriosis was present in half of IBD pts with compatible symptoms, particularly DIE, with a high rate of rectal endometriosis. After endometriosis treatment, a lower proportion of patients referred abdominal pain. Endometriosis, often mimicking IBD, should be searched and treated in IBD young patients in order to avoid ineffective treatments.