Introduction

Functional Defecation Disorders (FDD) are a frequent cause of refractory functional constipation (FC). The diagnosis of FDD requires anorectal manometry (ARM) and a balloon expulsion test (BET), which are not easily available outside referral centers. FDD often do not respond to conventional treatments, while they respond to biofeedback.

Aims & Methods

The aim of our study was to evaluate if pain reported by patients during defecation or elicited during digital rectal examination (DRE) predicted a FDD diagnosis in a cohort of refractory FC patients.

Two-hundred and thirty-eight FC (Rome III Criteria) patients failing a 30-day conservative treatment trial (increased fiber and fluids, tailored laxatives) were enrolled in the study. The presence of weekly anorectal pain during defecation and the elicited pain/tenderness consequent to a stretching of the levator ani muscle during DRE (DRE-pain) had been evaluated before and after the macrogol trial. Possible causes of organic anorectal pain were excluded.
All patients underwent:

• ARM+BET;
• barium defecography, if ARM and BET were discordant;
• second DRE with evaluation of DRE-pain.

OR and accuracy were calculated for both pain during defecation and DRE-pain in predicting a Rome III FDD.

Results

One hundred and twenty patients (50.42%) showed features of FDD: 82 dyssynergic defecation (DD) and thirty-eight inadequate defecatory propulsion (IDP). Thirty-three structural outlet obstructions (SOO) were identified using barium defecography.
Pain during defecation was strongly associated with DD, with an OR of 7.85 (p<0.001) and an accuracy of 75.2% in diagnosing a FDD (Tab.1).
DRE-pain was strongly associated with DD, with an OR of 11.78 (p<0.001) and an accuracy of 77.3% in diagnosing DD (Tab.1). Furthermore, DRE-pain showed a very good reproducibility between T0 and T30 (Cohen’s K=0.87).
The combination of pain during defecation and DRE-pain showed an even stronger association to DD compared to single items, with an OR of 20.84 and an accuracy of 82.8% in diagnosing DD (p<0.001, Tab.1).
Neither pain during defecation nor DRE-pain were predictive of IDP.

Table 1 - Association and diagnostic devaluation of reported pain during defecation and DRE-pain

Abbreviations: DD=dyssynergic defecation; OR=odds ratio; 95% CI=95% confidence interval; Sens.=sensitivity; Spec.=specificity; PPV=positive predictive value; NPV=negative predictive value; Acc.=accuracy; DRE-pain= pain/tenderness consequent to a traction on the levator ani muscles during digital rectal examination

Conclusion

Anorectal pain during defecation or elicited during DRE were shown to be predictive of a DD diagnosis in FC patients. An early referral to anorectal physiology testing may be considered in patients presenting these clinical features, leading to an improvement in their management.

Introduction

Anorectal manometry (ARM) is required to diagnose functional defecation disorders (FDD) in constipated patients. The International Anorectal Physiology Working Group introduced into clinical practice a standardized sequence of manoeuvres to perform ARM (London Protocol) (1). The London protocol suggests performing three push attempts, each of 15s duration, to assess recto-anal coordination and therefore to diagnose FDD, with a consensus <75% between experts. However, some papers consider a 5s push sufficient to detect FDD (2,3).

Aims & Methods

Therefore, the aim of this study was to assess the diagnostic accurac of a simplified ARM protocols featuring three pushes attempts (each of 5s) in comparison with IAPWG recommendations.
High-Definition ARM (HD-ARM) traces from 105 constipated patients (82 F, mean aged 53.5 ± 16.7 years) who had performed HD-ARM for clinical practice were retrospectively reviewed. HD-ARM were performed according to the IAPWG Protocol. All patients underwent the balloon expulsion test at the end of HD-ARM as suggested by IAPWG protocol. HD-ARM traces were re-evaluated considering the first five seconds of each push (as if each push featured only five seconds).
New diagnosis was made based on this modified protocol and compared with the one made according to London Protocol, to evaluate whether these modifications could affect the final diagnosis.

Results

According to the London Protocol, the qualitative best pushes were the first, the second or the third in 35.2%, 28.6% and 36.2% of patients, respectively. Eighty-seven patients (82.9%) failed the balloon expulsion test.
Mean rectal pressure did not differ between the modified protocol and the London protocol (37.1 ± 23 vs 34.3 ± 23.2, p=0.38). However, we observed a significant increase in the mean anal pressure with the modified version of the protocol compared to the London protocol (75.6 ± 33.1 vs 90.8 ± 37.3, p<0.002).
Regarding the diagnostic accuracy, we observed a moderate concordance between the modified protocol and the London protocol k=0.77, Table 1). In details, if we had used this modified version of protocol, 18 patients (17.1%) would have changed their final diagnosis (Table 1).

Table 1. Cohen's K diagnosis concordance according to London Protocol (k=0.773)

Conclusion

Based on our results, a simplified ARM protocol using three 5s pushes shows moderate diagnostic agreement with the standard London protocol. While rectal pressures remained similar, anal pressures increased significantly, and 17.1% of patients received a different diagnosis. Therefore, the simplified protocol could reduce the diagnostic accuracy for FDD.

References

1. Carrington EV et al. Neurogastroenterol Motil. 2020 Jan;32(1):e13679.
2. Grossi U, et al. Gut. 2016 Mar;65(3):447-55.
3. Carrington EV, et al. Neurogastroenterol Motil. 2014 May;26(5):625-35.

Introduction

Functional Defecation Disorders (FDD) are a frequent cause of refractory chronic constipation (CC). FDD diagnosis requires focused anorectal physiology testing, which is not easily available outside referral centers. Therefore, easy-to-perform tools to select patients needing anorectal physiology testing would be very welcome.

Aims & Methods

Our aim was to evaluate accuracy and Odds Ratio (OR) of a straining questionnaire (SQ) and a digital rectal examination augmented by abdomen palpation on straining (augmented-DRE) on predicting a FDD in refractory CC patients.
Two-hundred and thirty-eight CC patients failing a 4-week conservative treatment were enrolled. A SQ (Which muscles do you mainly use when you push to defecate?) was administered to all patients before entering the study (T0) and after a 30-day fiber/laxative trial (T30). The possible answers were: “belly muscles”; “anal muscles”; “both”; “Don’t know/No answer”.
Augmented-DRE and BET were performed at T0 and at T30.
At T30, all patients underwent anorectal manometry.
OR and accuracy were calculated for SQ, augmented-DRE and combinations in predicting and diagnosing both dyssynergic defecation (DD) and inadequate defecatory propulsion (IDP).
Sixty-one healthy volunteers (HVs) underwent SQ and BET.

Results

One-hundred and twenty patients showed features of Rome III FDD: 82 DD and 38 IDP.
“Anal Muscles” response was associated to both DD and IDP, with an OR of 13.6 and 5.85 (p<0.001) and an accuracy of 78.5% and 66.4%, respectively.
“Failed anal relaxation” on augmented-DRE was associated with a DD, with an OR of 21.4 and an accuracy of 73.1%. “Failed abdominal contraction” on augmented-DRE was associated with an IDP with an OR>100 and an accuracy of 97.1%.
SQ and augmented-DRE were reproducible between T0 and T30 (k=0.97 and k=0.517, respectively).
Regarding combinations of SQ and augmented-DRE, the combination increased the accuracy of the diagnostic tool for DD compared to SQ or augmented-DRE alone (Table-1).
All HVs had a negative BET and one answered SQ with “Anal strain”.

Table-1 – Accuracy and diagnostic test evaluator of SQ and augmented-DRE in predicting and diagnosing FDD

Conclusion

Our data support screening CC patients for DD and IDP, at all levels of care, by SQ and augmented-DRE, to improve the management and appropriateness of the referral to anorectal physiology testing.

Introduction

Dyssynergic defecation (DD) is identified in approximately 30% of patients presenting with chronic constipation. Patients with DD usually poorly responded to standard laxative and biofeedback can be offered as the specific treatment. The diagnostic of DD relies on physiological tests including anorectal manometry (ARM) or defecography, which is not universally accessible. As there are lack of single predictive symptom for DD, hence, we aimed to establish a diagnostic score to help with DD diagnosis.

Aims & Methods

This is a retrospective study conducted at Siriraj Hospital. Derivation cohort included 402 refractory constipation patients who were referred to our center for ARM from 2017-2023. While validation cohort of 100 patients were recruited during 2014-2016. Clinical characteristics and results of physiological tests [ARM, balloon expulsion test (BET), and colonic transit time (CTT)] were collected. The interpretation of ARM was conducted in accordance with the London classification. Univariable and multivariable logistic regression analyses were utilized and indicative features of DD were identified. The scoring system was formulated from beta-coefficients and simplified into an integer-point format. The diagnostic performance of this score was then assessed using both cohorts.

Results

The derivation cohort had DD prevalence of 52.49%. 82.09% of this cohort were female and the average age of 52.39 years. Logistic regression analysis identified significant associations between DD and the following clinical characters: duration of symptoms less than two years (OR 1.88; 95% CI=1.02-3.49), had three or more bowel movements per week (OR 4.67; 95% CI=2.47-8.86), straining (OR 7.76; 95% CI=3.57-16.90), sensation of incomplete evacuation (OR 1.95; 95% CI=1.02-3.73), sensation of anorectal blockage (OR 3.71; 95% CI=1.75-7.88), and the use of manual maneuvers to facilitate defecation (OR 2.55; 95% CI=1.37-4.78). An 11-point diagnostic scoring system was developed: 3 points are assigned for straining during defecation; 2 points each for frequent bowel movements, the sensation of anorectal obstruction, and the use of manual maneuvers; 1 point each for a symptom duration of less than two years and the sensation of incomplete evacuation. The diagnostic performance of the score was robust, with an area under the receiver operating characteristic curve (AUROC) of 0.91 (95% CI, 0.88–0.93) in the derivation cohort and 0.88 (95% CI, 0.81–0.95) in the validation cohort. The optimal cutoff was determined to be ≥ 5 points, resulting in a sensitivity of 93.4% (95% CI = 89.1-96.3), a specificity of 72.8% (95% CI = 65.9-79.0), a positive predictive value (PPV) of 79.1% (95% CI = 73.5-84.0), and a negative predictive value (NPV) of 90.8% (95% CI = 85.1-94.9). The score also exhibited excellent calibration performance.


Univariable and multivariable analysis of clinical predictors for defecation disorder

Characteristic	Univariable Analysis		Multivariable Analysis			Score
	Crude OR	p-value	Adjusted OR	p-value	Regression coefficient
Demographic features Age > 35 Female Sex	1.47 (0.85-2.52) 1.08 (0.65-1.81)	0.165 0.753
Clinical features Duration ≤ 2years BM > 3 times/week BSFS > 3 Straining Incomplete evacuation Digital evacuation Sensation of blockage Present of urge Proctalgia Previous anorectal surgery Spinal cord disease Psychiatric disease	3.72 (2.39-5.79) 10.45 (6.57-16.60) 1.65 (1.02-2.66) 17.28 (9.62-31.02) 7.38 (4.74-11.49) 7.13 (4.55-11.18) 10.55 (5.74-19.38) 10.79 (4.99-23.35) 3.22 (1.26-8.22) 9.89 (2.28-42.92) 2.76 (0.55-13.87) 11.38 (0.61-3.16)	<0.001 <0.001 0.039 <0.001 <0.001 <0.001 <0.001 <0.001 0.014 0.002 0.216 0.439	1.88 (1.02-3.49) 4.67 (2.47-8.86) 1.31 (0.64-2.66) 7.76 (3.57-16.90) 1.95 (1.02-3.73) 2.55 (1.37-4.78) 3.71 (1.75-7.88) 2.53 (0.88-7.29) 1.48 (0.43-5.07) 2.19 (0.39-12.35)	0.044 <0.001 0.458 <0.001 0.044 0.003 0.001 0.085 0.529 0.374	0.63 1.54 2.05 0.67 0.95 1.31	1 2 3 1 2 2
Medication Using of rectal suppository	0.93 (0.53-1.62)	0.793
Endoscopic features SRUS Anal fissure Hemorrhoid	1.75 (0.73-4.22) 3.72 (0.78-17.76) 1.37 (0.77-2.46)	0.213 0.099 0.286	3.03 (0.28-32.73)	0.362

Conclusion

We proposed the first diagnostic score for DD diagnosis. As its simplicity and excellent diagnostic performance, this can be served as a practical tool for all physicians to facilitate early identification of DD. Further diagnostic confirmation by standard physiological tests and quicken triaging patients for biofeedback therapy.

References

Carrington EV, Heinrich H, Knowles CH, et al. The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function. Neurogastroenterol Motil. 2020 Jan;32(1):e13679.

Disclosure

The authors declare that they have no conflicts of interest

Introduction

Dynamic transperineal ultrasound (DTP-US) enables the calculation of the pubo-rectal muscle (PR) length and the ano-rectal angle (ARA) width, offering a static and dynamic evaluation of the pelvic floor. DTP-US is usually followed by a Gel Expulsion Test (GET), in the same way that high-resolution anorectal manometry (HR-AM) is usually followed by balloon expulsion test (BET).
DTP-US+GET may be an innovative way of testing constipated patients for functional defecation disorders (FDD) diagnosis.

Aims & Methods

Our aims were: to determine normal values for DTP-US; to explore accuracy of DTP-US+GET in diagnosing a Rome IV FDD. To obtain normal values, 17 healthy females (HVs) underwent DTP-US+GET.
Fifty-six females meeting Rome IV criteria for functional constipation (FC) underwent DTP-US+GET.
Measurements were acquired in supine (SUP) and left lateral (LL) positions. At rest, during squeezing and during straining were evaluated: PR length; ARA width; variation in length of PR and in width of ARA between rest and squeezing or straining (expressed as a percentage of the resting measurement).
All 56 FC patients previously underwent HR-AM+BET. DTP-US examiners were blinded to HR-AM+BET result.
GET was performed in a sitting position filling the rectum with ultrasound gel (120 ml). GET was considered positive if patient was unable to evacuate gel after 30 seconds.

Results

No differences were observed in mean age between HVs and FC groups (p=0.57).
Thirty-eight patients (67.86%) showed a FDD on HR-ARM+BET. Thirty-eight patients showed a positive GET. No HVs failed GET.
DTP-US straining results are summarized in Table-1. FDD patients showed different mean values for straining measurements compared with HVs (p<0.001): HVs showed an increase in PR length and an increase in ARA; FDD showed a length reduction in PR and a closure of ARA.
To diagnose FDD, at least 3 out of 4 abnormal values on percentage variations during straining and a positive GET were needed: abnormal DTP-US+GET showed a strong association with FDD (OR 198.33), with a sensibility of 92.11%, a specificity of 94.44% and an accuracy of 94.42% in diagnosing FDD.

Table-1 –DTP-US values and differences between HV and FDD group

	HV group (Mean [95% CI])	FDD group (Mean [95% CI])	p-value
PR Lenght Straining SUP	67.39 [63.19 - 71.59]	58.07 [54.08 - 62.06]	<0.01
ARA Straining SUP	117.24 [109.18 - 125.3]	97.19 [89.35 - 105.04]	<0.01
PR Lenght Straining DLS	71.08 [66.41 - 75.75]	59.24 [55.35 - 63.13]	<0.01
ARA Straining DLS	113.23 [106.81 - 119.47]	85.8 [79.47 - 92.12]	<0.01
Δ PR Lenght Straining SUP	9.33 [5.77 - 12.83]	-1.21 [-5.42 - 3.01]	<0.01
Δ ARA Straining SUP	15.88 [8.64 - 23.12]	-7.42 [-13.09 - -1.75]	<0.01
Δ PR Lenght Straining DLS	14.91 [8.23 - 21.5]	-2.15 [-6.25 - 1.95]	<0.01
Δ ARA Straining DLS	20.34 [10.63 - 30.05]	-3.89 [-9.0 - 2.11]	<0.01

Conclusion

DTP-US+GET is an innovative and promising new technique to diagnose FDD in constipated patients. It can be performed by a skilled gastroenterologist, is not expensive and requires only a convex probe, with no radiation exposure. In this pilot study, we provided normal values for DTP-US and tested these values to diagnose FDD in a set of constipated patients, obtaining a diagnostic accuracy of 94.42%.

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

Anorectal manometry (ARM) is one of the required investigations to diagnose defecation disorders according to Rome IV criteria. The International Anorectal Physiology Working Group (IAPWG) introduced into clinical practice a standardized sequence of manoeuvres to perform ARM (London Protocol) (Carrington EV, 2020). IAPWG Protocol suggested the need of performing three push attempts, each of 15s duration, to assess recto-anal coordination, with a consensus <75% between experts.

Aims & Methods

The aim of this study was to assess the diagnostic accuracy, compared to IAPWG recommendations, of simplified ARM protocols featuring:

• only two push attempts (each of 15 seconds);
• three pushes attempts (each of 10s);
• two pushes attempts (each of 10s)

High-Definition ARM (HD-ARM) traces from 150 patients (118 F, mean aged 54 years) who underwent ARM for faecal incontinence (n=37) or constipation (n=105) were retrospectively reviewed. All traces were performed according to the IAPWG Protocol. Firstly, we evaluated if the mean rectal and anal pressures were different among the three pushes. Subsequently, ARM traces were re-evaluated considering the following modifications to the IAPWG protocol:

• considering only the first two pushes (as if the third had never been performed);
• considering the first ten seconds of each push (as if each push featured only ten seconds);
• considering the first ten seconds of the first two pushes (as if the third had never been performed and the first two featured only ten seconds).

In all three cases, the best push (defined as the most qualitatively normal) among the available pushes was chosen.
New diagnoses were made based on these modified protocols and compared with the standard to evaluate whether these modifications could affect the final diagnosis.

Results

According to the IAPWG London Protocol, the qualitative best pushes were the first, the second or the third in 58, 45 and 47 patients, respectively. No statistically significative differences were found in anal and rectal pressures among the three pushes.
No statistically significative differences were found in anal and rectal pressures comparing the three modified protocols with the IAPWG’s one.
Regarding the diagnostic accuracy, all the proposed modified London Protocol showed an almost perfect concordance compared with the standard of practice (K=0.97, Tab.1). This result was confirmed for the constipated and incontinent patients’ subgroup.

Table 1 - Cohen's K concordance according to London Protocol among all patients and in constipated patients

		No disorders of rectoanal co-ordination	Normal expulsion with abnormal manometric pattern of rectoanal co-cordination	Abnormal expulsion with normal manometric pattern of rectoanal co-ordination	Abnormal expulsion with poor propulsion	Absormal expulsion with dyssynergia	Abnormal expulsion with poor propulsion and dyssynergia	Comparison of proportions (Kappa Cohen agreement)
All patients N=150	3 Push 15 sec	5	18	16	25	44	42	-
	2 Push 15 sec	5	18	14	25	45	43	k=0.974
	3 Push 10 sec	5	18	15	25	45	42	k=0.974
	2 Push 10 sec	4	19	15	25	45	42	k=0.966
Constpated patients N=105	3 Push 15 sec	3	15	10	14	30	33	-
	2 Push 15 sec	3	15	9	14	30	34	k=0.975
	3 Push 10 sec	3	15	9	14	30	34	k=0.975
	2 Push 10 sec	3	15	9	14	30	34	k=0.975

Conclusion

Based on our results, it seems that two pushes of ten second each may be enough to reach an accurate manometric diagnosis of defecation disorders. Performing only 2 push manoeuvres of 10s each may reduce the examination length of 55s, reducing patient’s discomfort and, likely, improving HD-ARM’s acceptability.