Constipation is a common symptom affecting 2-27% of general population in Western countries. According to a population-based study on bowel habits in a Korean community, the prevalence was 16.5% for self-reported constipation and 9.2% for functional constipation. There is a broad range of causes for constipation. There are three subtypes in functional constipation, although overlap is not uncommon. Physiologic studies such as colonic transit test, anorectal manometry, balloon expulsion test, and defecography can be helpful in further evaluating and classifying functional constipation. Slow transit constipation is characterized by prolongation of transit time through- out the colon, caused by either myopathy or neuropathy. Functional defecation disorder is characterized as an inability to initiate defecation following the urge to do so, a feeling of incomplete evacuation, tenesmus, excessive straining or manual evacuation. Normal transit constipation is the most common subtype and characterized by constipation occurring in the presence of normal colonic transit time and normal defecatory function. It is important for clinicians to choose appropriate treatment for constipation which are most efficacious for the individual patient. Most patients with functional constipation respond to laxatives, but a small proportion may be resistant to this treatment. In patients with functional defecation disorder, biofeedback is helpful. Sacral nerve stimulation may be helpful in some patients with slow transit constipation. Patients who are resistant to all the conservative modalities may require surgical intervention. Extensive clinical and physiological preoperative assessment of patients with slow colonic transit time is essential before considering surgery, including an assessment of small bowel motility and identification of coexistent defecatory disorder.
Biofeedback (Psychology) ; Constipation/*classification/etiology/*therapy ; Defecation/physiology ; Defecography ; Diagnosis, Differential ; Gastrointestinal Transit/physiology ; Humans

OBJECTIVE: To understand the difference of defecation physiology between postpartum and postoperative women. METHODS: Between July 1998 to April 1999, we performed defecogram and pudendal nerve motor latency to 31 women, who were 8 postoperative women, 9 post cesarean-section state women, and 14 normal vaginal delivery-state women. RESULTS: According to the defecogram results, only squeezing angles of the anorectal angle were significantly increased(96.0 vs 72.3, 74.9 degree) in normal vaginal delivery-state women compared to post cesarean-section state and postoperative women, but rest and evacuation angles were not. And to pudendal nerve latency, there were no statistically significant difference. CONCLUSION: We concluded that the pudendal plexus was damaged during labor, therefore its ability to control puborectalis muscle was damaged. So, the anorectal angles of squeezing of postpartum women were significantly increased, compared to those of post cesarean section women or postoperative women.
Cesarean Section ; Defecation* ; Female ; Humans ; Physiology* ; Postpartum Period* ; Pregnancy ; Pudendal Nerve*

OBJECTIVE: It has been suggested that hysterectomy has a disturbing influence on bowel function, mainly constipation. We performed a prospective study to assess the changes of ano-rectal physiology after hysterectomy. METHODS: Fourteen consecutive patients were assessed before and two months after hysterectomy. A detail questionnaire was devised to allow assessment of bowel function and ano-rectal pressure test and balloon expulsion test were performed before and after hysterectomy. The parameters measured in ano-rectal pressure test included the minimal sensible volume, ano-rectal resting pressure, maximal squeezing pressure, recto-anal inhibitory reflex and balloon expulsion test. Data analysis was carried out by paired t-test. Statistical significance was inferred when the p value was<0.05. RESULTS: Among the fourteen patients, the straining in defecation was found in three patients after operation, other defication habits were not significantly changed after hysterectomy(P>0.05). There were no significant changes in ano-rectal pressure test after hysterectomy. The disturbance of balloon expulsion capacity was increased in four patients after hysterectomy(29%). CONCLUSION: Our results demonstrate that hysterectomy does not cause a decrease in ano-rectal pressure and rectal sensitivity, but has an adverse effect on rectal expulsion capacity in a some of patients.
Constipation ; Defecation ; Humans ; Hysterectomy* ; Physiology ; Prospective Studies ; Surveys and Questionnaire ; Reflex ; Statistics as Topic

PURPOSE: Anorectal manometry is a way of investigation for anti-rectal sphincters. In this paper we evaluated the usefulness of anorectal manometry in constipation patients and compared the anal spnincter function in control, constipation and encopresis patients. METHOD: We analysed the data of anorectal function studies in normal children (control, n=11), children with constipation (constipation group, n=20) and children with encopresis (encopresis group, n=16). RESULTS: The specific manometric parameters in normal children were like as follows; external anal sphinter pressure 21.0+/-8.00 mmHg, internal anal sphicter pressure 30.0+/- 14.57 mmHg, conscious rectal sensitivity threshold 11.4+/-4.52 mmHg. The above results were not different from that of previous studies except conscious rectal sensitivity threshold, which was slightly lower than that of others. Internal and external anal sphincter pressure were elevated significantly in constipation and encopresis groups than in control, which results was the same in conscious rectal sensitivity threshold. But the values of rectoanal inhibitory threshold and percent relaxation of rectoanal inhibitory reflex were not different among control group, constipation group and encopresis group. External sphincter activity was increased during the act of bearing down for defecation in none of the child in control group, in 6 of 17 children in constipation group and 5 of 12 children in encopresis group. CONCLUSION: With the results of above we could say that complete history taking and physical examination are important in diagnosis of constipation, and we could say also that the anorectal manometry was a valuable tool to understand the physiology of normal defecation and the pathophysiology of constipation and encopresis.
Anal Canal ; Child* ; Constipation* ; Defecation ; Diagnosis ; Encopresis ; Humans ; Manometry* ; Physical Examination ; Physiology ; Reflex ; Relaxation

PURPOSE: The aim was to evaluate the discriminating accuracy of anorectal manometry (ARM) between nonconstipated (NC) subjects and functionally constipated (FC) subjects, and between FC subjects with and without functional defecation disorder (FDD). METHODS: Among female patients who visited anorectal physiology unit, those who could be grouped to following categories were included; FC group with FDD (+FDD subgroup), or without FDD (−FDD subgroup) and NC group. ARM was performed and interpreted not only with absolute pressure values, but also pattern classification and quantification of pressure changes in the rectum and anus during attempted defecation. RESULTS: There were 76 subjects in NC group and 75 in FC group. Among FC group, 63 subjects were in −FDD subgroup and 12 in +FDD subgroup. In pattern classification of pressure changes, type 0, as ‘normal’ response, was only slightly more prevalent in NC group than in FC group. When all ‘abnormal’ types (types 1–5) were considered together as positive findings, the sensitivity and specificity of pattern classification in diagnosing FC among all subjects were 89.3% and 22.7%. Those values in diagnosing FDD among FC group were 91.7% and 11.1%. Manometric defecation index (MDI) as a quantification parameter was significantly different between −FDD and +FDD subgroups. Other conventional absolute pressures were mostly comparable between the groups. CONCLUSION: Among all parameters of ARM, MDI was useful to diagnose FDD in FC patients. Other parameters including the pattern classification were questionable in their ability to diagnose FDD.
Anal Canal ; Arm ; Classification ; Constipation ; Defecation* ; Female ; Humans ; Manometry* ; Physiology ; Rectum ; Sensitivity and Specificity

A manometric assessment of anal pressure is known to be an objective method in evaluating anorectal physiology and the function of the anal sphincter. We employed anal menometry to study the anal pressure in patients with hemorrhoids, anal fistulas, anal fissures, constipation, and fecal incontinence. This study was performed in the period from April 1994 to May 1996. The total number of patients with defecation disorder or anal disease assessed in this period at our rectal clinic by using anal manometry was 227; A control group was comprised of 10 patients with no known anal diseases or symptoms. The patient group was catergorized as follows:123 cases of hemorrhoids, 24 cases of anal fistulas, 35 cases of anal fissures, 29 cases of constipation, and 16 cases of fecal incontinence. We measured the maximal anal resting pressure (MARP) and the maximal anal squeeze pressure (MASP) in these patients as well as in the control group. We found the MARP to be higher in patients with hemorrhoids, anal fistulas, and anal fissures, compared to the control group, while the MARP was lower in the constipation group; however, these results were not statistically significant. The anal pressures of hemorrhoid patients were studied with respect to symptom, classification, past history, and the duration of symptoms. The results were as follows:The MARP was found to be increased in hemorrhoid patients with prolapse and pain and for thrombosed external hemorrhoids while it was decreased in patients with a previous hemorrhoidectomy. Furthermore, the MARP was increased in anal fissure patients when the duration of the symptom was short. In conclusion, anal manometric assessment of patients with anal diseases or defecation disorders could be valuable in determining the surgical procedure; furthermore, it could be valuable in evaluating postoperative results in fecal incontinence patients.
Anal Canal ; Classification ; Constipation ; Defecation* ; Fecal Incontinence ; Fissure in Ano ; Hemorrhoidectomy ; Hemorrhoids ; Humans ; Manometry ; Physiology ; Prolapse ; Rectal Fistula

Dyssynergic defecation is common and affects up to one half of patients with chronic constipation. This acquired behavioral problem is due to the inability to coordinate the abdominal and pelvic floor muscles to evacuate stools. A detailed history, prospective stool diaries, and a careful digital rectal examination will not only identify the nature of bowel dysfunction, but also raise the index of suspicion for this evacuation disorder. Anorectal physiology tests and balloon expulsion test are essential for a diagnosis. Newer techniques such as high-resolution manometry and magnetic resonance defecography can provide mechanistic insights. Recently, randomized controlled trials have shown that biofeedback therapy is more effective than laxatives and other modalities, both in the short term and long term, without side effects. Also, symptom improvements correlated with changes in underlying pathophysiology. Biofeedback therapy has been recommended as the first-line of treatment for dyssynergic defecation. Here, we provide an overview of the burden of illness and pathophysiology of dyssynergic defecation, and how to diagnose and treat this condition with biofeedback therapy.
Biofeedback, Psychology ; Constipation ; Cost of Illness ; Defecation* ; Defecography ; Diagnosis* ; Digital Rectal Examination ; Humans ; Laxatives ; Manometry ; Muscles ; Pelvic Floor ; Physiology ; Problem Behavior ; Prospective Studies

OBJECTIVETo evaluate the efficacy and safety of electroacupuncture at Tianshu (ST25) for patients with functional constipation (FC).

METHODSNinety-six patients with FC were randomized to receive deep needling on bilateral ST25 (group A, 48 cases) or shallow needling on bilateral ST25 (group B, 48 cases) with electroacupuncture once daily for 4 weeks. The proportion of patients with four or more complete spontaneous bowel movements (CSBMs) per week, and scores of constipation symptoms and satisfaction with treatment were compared between two groups. Safety was also assessed.

RESULTSThe proportion of patients with four or more CSBMs per week was 52.1% in group A, significantly higher than 25.0% in group B during the 4-week treatment (P<0.05). The constipation symptom score of patients were significantly improved in group A as compared with group B at week 2-4 (P<0.05). Patients in group A were more satisfied with their treatment compared with those in group B at week 1-4 (P<0.05). Five patients in group A felt significant pain and discomfort. No other adverse reaction was observed in both groups.

CONCLUSIONUsing electroacupuncture at ST25 to treat patients with FC is effectively, and deep needling had more stable effect than shallow needling.

Adult ; Aged ; Constipation ; physiopathology ; therapy ; Defecation ; physiology ; Electroacupuncture ; adverse effects ; Humans ; Middle Aged ; Patient Satisfaction ; Pilot Projects ; Treatment Outcome ; Young Adult

The purpose of this study is to evaluate the predictive capability of anorectal physiologic tests for unfavorable outcomes prior to the initiation of biofeedback therapy in patients with dyssynergic defecation. We analyzed a total of 80 consecutive patients who received biofeedback therapy for chronic idiopathic functional constipation with dyssynergic defecation. After classifying the patients into two groups (responders and non-responders), univariate and multivariate analyses were performed to determine the predictors associated with the responsiveness to biofeedback therapy. Of the 80 patients, 63 (78.7%) responded to biofeedback therapy and 17 (21.3%) did not. On univariate analysis, the inability to evacuate an intrarectal balloon (P=0.028), higher rectal volume for first, urgent, and maximal sensation (P=0.023, P=0.008, P=0.007, respectively), and increased anorectal angle during squeeze (P=0.020) were associated with poor outcomes. On multivariate analysis, the inability to evacuate an intrarectal balloon (P=0.018) and increased anorectal angle during squeeze (P=0.029) were both found to be independently associated with a lack of response to biofeedback therapy. Our data show that the two anorectal physiologic test factors are associated with poor response to biofeedback therapy for patients with dyssynergic defecation. These findings may assist physicians in predicting the responsiveness to therapy for this patient population.
Adult ; Aged ; Anal Canal/*physiopathology ; Ataxia/*physiopathology/therapy ; *Biofeedback, Psychology ; *Constipation/physiopathology/therapy ; Defecation/*physiology ; Defecography/methods ; Female ; Humans ; Male ; Middle Aged ; Multivariate Analysis ; Predictive Value of Tests ; Rectum/*physiopathology ; Treatment Outcome

PURPOSE: This study was designed to analyze the short-term clinical and functional outcomes of perineal rectosigmoidectomy with levatoroplasty for complete rectal prolapse. METHODS: The data were prospectively collected and consisted of the clinical data, the functional status before and after surgery, the operation record, and the postoperative course. The functional status was evaluated by using Wexner's constipation score (0-30), Wexner's incontinence score (0-20), anorectal manometry, and pudendal nerve terminal motor latency. Follow-up was performed at 3-6 months after the operation by using both a standardized questionnaire completed in the outpatient clinic or telephone interview (n=23) and an anorectal physiology test (n=7). RESULTS: During a one-year period, 23 patients (male=10) underwent perineal rectosigmoidectomy with levatoroplasty for complete rectal prolapse. The median duration of the operations was 88 minutes. The median length of postoperative hospital stay was 6 days. There was one urinary tract infection and no mortalities. The constipation score was significantly decreased after the operation (9.8 vs 3.8; P<0.001), and constipation was improved in 90 percent (19/21) of the cases. The incontinence score was significantly decreased after surgery (mean preop.=11.6, postop.=3.7; P<0.001) and incontinence was improved in 17 of 21 patients with impaired continence (81 percent). Anal sphincter function was not improved but rectal reservoir capacity was significantly decreased after surgery (rectal urgent volume (45.7 cc vs 37.1 cc; P=0.045), maximal tolerable volume (120 cc vs 85.7; P=0.011). Most patients (83 percent) felt that the operation had improved their symptoms. The major reasons for dissatisfaction after surgery were frequent defecation, fecal soiling, persistent or aggravated fecal incontinence, and recurrence. One patient had a complete recurrence (4.3 percent), and another patient had a mucosal prolapse which was treated. CONCLUSIONS: Perineal rectosigmoidectomy with levatoroplasty for complete rectal prolapse is a safe technique with acceptable short-term functional results; however, it is not recommended for rectal prolapse patients with diarrhea-predominant irritable bowel syndrome.
Ambulatory Care Facilities ; Anal Canal ; Constipation ; Defecation ; Fecal Incontinence ; Follow-Up Studies ; Humans ; Interviews as Topic ; Irritable Bowel Syndrome ; Length of Stay ; Manometry ; Mortality ; Physiology ; Prolapse ; Prospective Studies ; Pudendal Nerve ; Surveys and Questionnaires ; Rectal Prolapse* ; Recurrence ; Soil ; Urinary Tract Infections