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High-resolution anorectal manometry (HR-ARM) is the gold standard for anorectal functional disorders’ evaluation, despite being limited by its accessibility and complex data analysis. The London Protocol and Classification were developed to standardize anorectal motility patterns classification. This proof-of-concept study aims to develop and validate an artificial intelligence model for identification and differentiation of disorders of anal tone and contractility in HR-ARM. A dataset of 701 HR-ARM exams from a tertiary center, classified according to London Classification, was used to develop and test multiple machine learning (ML) algorithms. The exams were divided in a training and testing dataset with a 80/20% ratio. The testing dataset was used for models’ evaluation through its accuracy, sensitivity, specificity, positive and negative predictive values and area under the receiving-operating characteristic curve. LGBM Classifier had the best performance, with an accuracy of 87.0% for identifying disorders of anal tone and contractility. Different ML models excelled in distinguishing specific disorders of anal tone and contractility, with accuracy over 90.0%. This is the first worldwide study proving the accuracy of a ML model for differentiation of motility patterns in HR-ARM, demonstrating the value of artificial intelligence models in optimizing HR-ARM availability while reducing interobserver variability and increasing accuracy. [ABSTRACT FROM AUTHOR]

Background: Since the ileal pouch anal anastomosis (IPAA) was first described, anorectal manometry (ARM) has been used to study its physiology and function. Few studies have investigated if preoperative ARM can predict pouch function. Methods: Pubmed, EMBASE, and the Cochrane Library databases were systematically searched. Papers detailing preoperative ARM results and postoperative functional outcomes of patients with IPAA were included. Meta-analysis with meta-regression was performed, assessing the relationship between preoperative manometric results and objective postoperative functional outcomes including frequency, seepage, pad usage and medications, and functional scoring systems including Wexner Incontinence and Oresland Scores. Results: Results from 31 studies were analysed. Mean resting pressure (MRP) decreased significantly (− 23.16 mmHg, 95% CI − 27.98 to − 18.35, p < 0.01) after pouch formation but before ileostomy reversal, with subsequent minor increase (3.51 mmHg, 95% CI 0.93 to 6.09, p = 0.01) by 6 months after reversal of ileostomy. Pooled bowel frequency was 5.4 per 24 h (4.90–5.91), day and night-time soiling, incontinence, and pad usage rates were 16% (9–24%), 26% (19–33%), 12% (4–20%), and 21% (13–30%) respectively. Pooled Oresland and Wexner Scores were 3.81 (2.92–4.70) and 3.45 (2.71–4.19). A significant association between preoperative MRP and Wexner Score was observed (p < 0.001). As a result of risk of bias, study heterogeneity, and variation in manometry systems, certainty of evidence was low or very low. Conclusion: Preoperative predictors of function inform patient and clinician decision-making. Further investigations into the association between preoperative MRP and Wexner Score using modern ARM techniques are warranted. [ABSTRACT FROM AUTHOR]

Introduction: Spina bifida is a condition that impacts the development of the neural tube leading to urological and gastrointestinal symptoms. Both systems are influenced together due to their shared innervation and embryological origin. Despite its impact on health and well-being there has been limited research on the relationship between manometry results and urodynamic tests, in this patient population. The aim of this study was to delineate the association of neurogenic bladder/bowel dysfunction with anorectal manometry and urodynamics. Materials and methods: Urodynamics and anorectal manometry were used to analyse the neurogenic bowel and bladder dysfunctions in 29 paediatric patients with spina bifida. Those children who had previous anorectal surgical interventions were excluded from the study. Patients were grouped according to the level of spinal defect to lower or upper defect. In this study, parameters such as bladder compliance, postvoid residual volume, detrusor activity, anorectal pressures, and rectal compliance were considered. Group comparison tests were performed using standardized paediatric protocols for data analysis as well as correlation tests. A p-value less than 0.05 was considered significant at all levels. Results: A total of 29 patients with spina bifida were identified. Of these, 14 were male and 15 were female. Bladder function differed among the patients in the lower defect (LD, n:18) and upper defect (UD, n:11) groups. LD group exhibited lower bladder volumes (175.45 ± 106.19 mL) compared to the UD group (266.83 ± 102.54 mL, p < 0.05). All LD and 72.7% of UD had detrusor sphincter dyssynergia. There was positive correlation between functional bladder parameters and bowel dysfunction, such as rectoanal inhibitory reflex (RAIR) and maximum filling pressures of the bladder (rho = 0.569, p < 0.05). There was also a significant correlation between rectal compliance and bladder volumes. Conclusions: Association of neurogenic bowel and bladder dysfunction is a complex issue which requires personalized approach for managing the consequences. In children with neurogenic bladder dysfunction increased RAIR activity may be a sign for colonic dysmotility of neurogenic origin. This study may also pave the way for delineation of the mechanism under the generation of RAIR which is thought to be only intrinsic in origin. To optimize treatment modalities, full assessment with anorectal manometry and urodynamic studies should be done in patients with spina bifida. Clinical trial registration: This study was not performed on volunteer patients. Clinical study enrolment is not required as this study was obtained from urodynamics and anorectal manometry performed in patients with neurogenic bladder/bowel and during clinical follow-up. Highlights: What is currently known about this topic?: Spina bifida involves neuroembryological development that affects shared sacral innervations, causing bladder and bowel dysfunctions. What new information is contained in this article?: This research work reveals how anorectal manometry is related to urodynamic findings in children with spina bifida hence proposes individualized treatment choices for the purpose of better clinical outcome. [ABSTRACT FROM AUTHOR]

Introduction and Hypothesis: Standardized digital rectal examination (DRE) correlates with anorectal manometry (ARM) measures. However, less is known about the relationship between DRE/ARM measures and patient-reported outcomes (PROs), especially among women with fecal incontinence (FI). Our aims were to evaluate associations between DRE and ARM measures and compare PROs with diagnostic evaluation measures for women with FI. Methods: We analyzed data from the parent clinical trial, Controlling Anal incontinence by Performing Anal exercises with Biofeedback or Loperamide (CAPABLe). We pooled data from randomized women who completed standardized ARM, DRE, and validated PROs at baseline and 12 and 24 weeks post-treatment initiation. PROs included FI severity, impact on quality of life, and bowel diary data. We analyzed ARM pressure and volume data and DRE using the Digital Rectal Examination Scoring System (DRESS) resting and squeeze mean scores. We used Spearman Rank Correlation to measure associations between the ARM measures and mean DRESS scores, and between PROs and ARM/DRESS scores. Results: Among 291 randomized women with ARM and DRE data, the correlation between DRESS and ARM resting measures was 0.196 (p<0.001) and between squeeze measures was 0.247 (p<0.001). At most timepoints, PROs more consistently correlated with squeeze ARM pressures and squeeze DRESS scores than resting measures. Conclusions: We found weak correlations between ARM and DRE measures and between those measures and PROs. Although DRE and ARM are commonly used diagnostic measures among women with FI, the weak correlations with patient-reported symptoms raises questions about their utility in clinical care. [ABSTRACT FROM AUTHOR]

Abstract Introduction Spina bifida is a condition that impacts the development of the neural tube leading to urological and gastrointestinal symptoms. Both systems are influenced together due to their shared innervation and embryological origin. Despite its impact on health and well-being there has been limited research on the relationship between manometry results and urodynamic tests, in this patient population. The aim of this study was to delineate the association of neurogenic bladder/bowel dysfunction with anorectal manometry and urodynamics. Materials and methods Urodynamics and anorectal manometry were used to analyse the neurogenic bowel and bladder dysfunctions in 29 paediatric patients with spina bifida. Those children who had previous anorectal surgical interventions were excluded from the study. Patients were grouped according to the level of spinal defect to lower or upper defect. In this study, parameters such as bladder compliance, postvoid residual volume, detrusor activity, anorectal pressures, and rectal compliance were considered. Group comparison tests were performed using standardized paediatric protocols for data analysis as well as correlation tests. A p-value less than 0.05 was considered significant at all levels. Results A total of 29 patients with spina bifida were identified. Of these, 14 were male and 15 were female. Bladder function differed among the patients in the lower defect (LD, n:18) and upper defect (UD, n:11) groups. LD group exhibited lower bladder volumes (175.45 ± 106.19 mL) compared to the UD group (266.83 ± 102.54 mL, p

The Anorectal manometry test is an important method for evaluating interventions and surgical treatments for defecation disorders to clarify the functional or neurological causes of defecation disorders. Rectal sensation tests, recto-anal excitatory reflex, and balloon expulsion test are also included in anorectal manometry tests. There are various types of manometry catheters for measuring anorectal pressure, and recently, multiple-channel catheters such as high-resolution anorectal manometry and two or three-dimensional high-definition anorectal manometry have been used widely. These display internal pressure changes as two-dimensional color changes rather than as traditional waveforms. It is important to consider the characteristics of the testing devices, and to select appropriate test items. [ABSTRACT FROM AUTHOR]

Constipation is a common disease that strongly impacts patients' quality of life. However, its management can be difficult in practice. The assessment of chronic constipation in adults is primarily clinical. The interview must confirm the symptom, specify the severity and the impact; the examination must focus on the pathophysiological mechanism(s) involved. Additional examinations will only be requested in the event of doubt regarding the anomalies responsible for the constipation, or in the absence of a satisfactory response to first-line treatment. The first-line treatment of chronic constipation is based on the combination of hygienic and dietary measures and osmotic laxatives or ballasts taken over a prolonged period. In the event of rectal evacuation disorders, biofeedback rehabilitation is effective. Measuring colonic transit time, anorectal manometry, associated with an evacuation test, and defecography are useful functional examinations to clarify constipation and target treatment. The treatment of chronic constipation must always be medical as first intention. Invasive treatment of transit constipation involves total colectomy, diverting stomas and stomas for antegrade colonic irrigation. It must be a resort treatment, offered to selected patients. [ABSTRACT FROM AUTHOR]

Artificial intelligence (AI) has emerged as a transformative tool across several specialties, namely gastroenterology, where it has the potential to optimize both diagnosis and treatment as well as enhance patient care. Coloproctology, due to its highly prevalent pathologies and tremendous potential to cause significant mortality and morbidity, has drawn a lot of attention regarding AI applications. In fact, its application has yielded impressive outcomes in various domains, colonoscopy being one prominent example, where it aids in the detection of polyps and early signs of colorectal cancer with high accuracy and efficiency. With a less explored path but equivalent promise, AI-powered capsule endoscopy ensures accurate and time-efficient video readings, already detecting a wide spectrum of anomalies. High-resolution anoscopy is an area that has been growing in interest in recent years, with efforts being made to integrate AI. There are other areas, such as functional studies, that are currently in the early stages, but evidence is expected to emerge soon. According to the current state of research, AI is anticipated to empower gastroenterologists in the decision-making process, paving the way for a more precise approach to diagnosing and treating patients. This review aims to provide the state-of-the-art use of AI in coloproctology while also reflecting on future directions and perspectives. [ABSTRACT FROM AUTHOR]

Objective The purpose of the study was to determine if antegrade continence enema (ACE) alone is an effective treatment for patients with severe functional constipation and segmental colonic dysmotility. Methods A retrospective study of patients with functional constipation and segmental colonic dysmotility who underwent ACE as their initial means of management. Data was collected from six participating sites in the Pediatric Colorectal and Pelvic Learning Consortium. Patients who had a colonic resection at the same time as an ACE or previously were excluded from analysis. Only patients who were 21 years old or younger and had at least 1-year follow-up after ACE were included. All patients had segmental colonic dysmotility documented by colonic manometry. Patient characteristics including preoperative colonic and anorectal manometry were summarized, and associations with colonic resection following ACE were evaluated using Fisher's exact test and Wilcoxon rank-sum test. p -Values of less than 0.05 were considered significant. Statistical analyses and summaries were performed using SAS version 9.4 (SAS Institute Inc., Cary, North Carolina, United States). Results A total of 104 patients from 6 institutions were included in the study with an even gender distribution (males n = 50, 48.1%) and a median age of 9.6 years (interquartile range 7.4, 12.8). At 1-year follow-up, 96 patients (92%) were successfully managed with ACE alone and 8 patients (7%) underwent subsequent colonic resection for persistent symptoms. Behavioral disorder, type of bowel management, and the need for botulinum toxin administered to the anal sphincters was not associated with the need for subsequent colonic resection. On anorectal manometry, lack of pelvic floor dyssynergia was significantly associated with the need for subsequent colonic resection; 3/8, 37.5% without pelvic dyssynergia versus 1/8, 12.5% (p = 0.023) with pelvic dyssynergia underwent subsequent colonic resection. Conclusion In patients with severe functional constipation and documented segmental colonic dysmotility, ACE alone is an effective treatment modality at 1-year follow-up. Patients without pelvic floor dyssynergia on anorectal manometry are more likely to receive colonic resection after ACE. The vast majority of such patients can avoid a colonic resection. [ABSTRACT FROM AUTHOR]

Objective: Endoscopic submucosal dissection (ESD) is a specific procedure that uses an electrosurgical knife for en-bloc resectioning large tumors. However, no study has examined the effect of ESD on the defecation function of patients with rectal tumors. We aimed to investigate the potential effects caused by ESD by analyzing changes in the morphology and movement of the anorectum pre- and post-ESD. Methods: This prospective observational study included 11 patients with anorectal tumors who underwent ESD between April 2020 and February 2022. Pre-ESD assessments included anorectal manometry and defecography. Post-ESD assessments were conducted 2 months later, including anorectal manometry, defecography, and proctoscopy for ulcer and stenosis evaluation. Results: The median patient age was 73 years, including seven males and four females. Eight patients (73%) had a tumor in the lower rectum, and the extent of resection was less than 50% of the rectal lumen. Resection reached the dentate line in six cases (55%). In the patients with post-ESD mucosal defects involving the dentate line, the median of functional anal canal length significantly decreased from (3.4 cm pre-ESD to 2.8 cm post-ESD, p = 0.04). Defecography revealed one case with incomplete evacuation (<50%) and incontinence post-ESD. Interestingly, patients with pre-existing rectoceles noted resolution of lesions post-ESD. None of the patients reported daily constipation or fecal incontinence. Conclusions: While rectal ESD is unlikely to cause significant real-world defecation difficulties, alterations in rectal and anal canal morphology and function may occur if the dentate line is involved in the resection range. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim was to evaluate the outcomes of conventional anorectal manometry (ARMM) testing and biofeedback therapy in adolescents with functional constipation. METHODS: A retrospective analysis of ARMM findings in patients aged 10-18 years with intractable constipation over a 4-year period was conducted. RESULTS: Of the 41 patients (mean age, 13.5±2.44 years) included, 20 (48.7%) were male. Rectoanal inhibitory reflex (RAIR) was positive in all patients. Group 1 had 31 patients with dyssynergic defecation (DD) and Group 2 had 10 patients without DD. Anal canal resting pressure, squeeze test pressure, rectal defecation pressure, and first and urge sensation volumes were similar between the groups. Maximum tolerated volume and the relaxation percentage of RAIR were higher in Group 1 than in Group 2 (p<0.05). Among 31 patients referred for biofeedback therapy, 8 (25.6%) completed the program with complete resolution of their symptoms. The mean follow-up period for these patients was 21±14.7 months. CONCLUSION: DD is relatively common in patients with psychosocial adjustment disorders, and it can be diagnosed via ARMM. Despite the low rate of adherence to the therapy in the presented series, biofeedback therapy was highly effective in resolving the symptoms including soiling. [ABSTRACT FROM AUTHOR]

This article provides an overview of anorectal manometry (ARM), a diagnostic test used to assess anorectal function. It discusses when and how to perform the test, as well as its usefulness in evaluating conditions such as constipation and fecal incontinence. The article also covers the equipment needed for ARM, the training required for those performing the test, and the protocols for patient preparation and test procedures. Additionally, it outlines the analysis of ARM results and the interpretation of findings. This document provides information on how to interpret anorectal manometry and the rectal balloon expulsion test. It discusses the different sensations and measurements involved in these tests and their significance in diagnosing and guiding therapy for anorectal disorders. The document also mentions the London Classification, which categorizes anorectal disorders based on major findings, minor findings, and inconclusive findings. It emphasizes the clinical utility of these tests in understanding the underlying causes of anorectal symptoms and customizing treatment plans. [Extracted from the article]

Objective: Anorectal manometry serves as a diagnostic tool, particularly in identifying chronic constipation associated with rectal evacuation disorders. We aimed to share the anal motility results of patients presenting with constipation complaints in our tertiary referral center's motility laboratory. Methods: Between January 2018 and December 2022, a total of 87 patients presenting with constipation complaints underwent anal motility measurements at İzmir Tepecik Training and Research Hospital, Clinic of Gastroenterology. Eighty-nine patients without constipation complaints were included in the study. Results: It was determined that 87 patients presented with constipation complaints. The mean age of these patients was 45.42 ± 16.34 years. Of these patients, 61 were female and 26 were male. Regarding motility measurements, an increase in resting pressure, a higher volume at which they first felt the urge to defecate, a decrease in the maximum tolerable volume, and an increase in the incidence of dyssynergia, predominantly type I dyssynergia, were observed in constipated patients. However, no statistically significant relationship was found between patients' resting pressures, initial sensation measurements, maximum tolerable volume, dyssynergia, average resting pressure, squeezing pressure, and constipation (respectively; P: .28, P: .39, P: .76, P: .41, P: .095). Conclusion: In our study, our anorectal motility results were not found to be associated with the presence of constipation. However, with a larger number of patients compared to many studies and the results obtained from anorectal manometry performed at very few centers, we believe that some of our findings will be instructive for constipation patients. [ABSTRACT FROM AUTHOR]

BACKGROUND & AIMS: Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings. METHODS: Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations. RESULTS: ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices. CONCLUSIONS: Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.

INTRODUCTION: We aimed to evaluate the cost-effectiveness/cost-savings of point-of-care anorectal function testing with an investigational device (RED) to triage therapy for chronic constipation in general gastroenterology. METHODS: A Markov model was constructed to evaluate cost-effectiveness/cost-savings over a 1-year time horizon comparing empiric drug/pelvic floor physical therapy to testing guided care. RESULTS: RED appears to inform the cost-effective strategy for chronic constipation. Compared with usual care without RED, it reduces insurer costs by $810 and patient costs by $6,903. DISCUSSION: Point-of-care testing using RED appears cost-effective/cost-saving to triage chronic constipation care in general gastroenterology. [ABSTRACT FROM AUTHOR]

Background: Whether patients with defecatory disorders (DDs) with favorable response to a footstool have distinctive anorectal pressure characteristics is unknown. We aimed to identify the clinical phenotype and anorectal pressure profile of patients with DDs who benefit from a footstool. Methods: This is a retrospective review of patients with high resolution anorectal manometry (HR‐ARM) and balloon expulsion test (BET) from a tertiary referral center. BET was repeated with a 7‐inch‐high footstool in those who failed it after 120 s. Data were compared among groups with respect to BET results. Key Results: Of the 667 patients with DDs, a total of 251 (38%) had failed BET. A footstool corrected BET in 41 (16%) of those with failed BET. Gender‐specific differences were noted in anorectal pressures, among patients with and without normal BET, revealing gender‐based nuances in pathophysiology of DDs. Comparing patients who passed BET with footstool with those who did not, the presence of optimal stool consistency, with reduced instances of loose stools and decreased reliance on laxatives were significant. Additionally, in women who benefited from a footstool, lower anal pressures at rest and simulated defecation were observed. Independent factors associated with a successful BET with a footstool in women included age <50, Bristol 3 or 4 stool consistency, lower anal resting pressure and higher rectoanal pressure gradient. Conclusion & Inferences: Identification of distinctive clinical and anorectal phenotype of patients who benefited from a footstool could provide insight into the factors influencing the efficacy of footstool utilization and allow for an individualized treatment approach in patients with DDs. [ABSTRACT FROM AUTHOR]

Background: Patient selection is extremely important in obstructed defecation syndrome (ODS) and rectal prolapse (RP) surgery. This study assessed factors that guided the indications for ODS and RP surgery and their specific role in our decision-making process using a machine learning approach. Methods: This is a retrospective analysis of a long-term prospective observational study on female patients reporting symptoms of ODS who underwent a complete diagnostic workup from January 2010 to December 2021 at an academic tertiary referral center. Clinical, defecographic, and other functional tests data were assessed. A supervised machine learning algorithm using a classification tree model was performed and tested. Results: A total of 400 patients were included. The factors associated with a significantly higher probability of undergoing surgery were follows: as symptoms, perineal splinting, anal or vaginal self-digitations, sensation of external RP, episodes of fecal incontinence and soiling; as physical examination features, evidence of internal and external RP, rectocele, enterocele, or anterior/middle pelvic organs prolapse; as defecographic findings, intra-anal and external RP, rectocele, incomplete rectocele emptying, enterocele, cystocele, and colpo-hysterocele. Surgery was less indicated in patients with dyssynergia, severe anxiety and depression. All these factors were included in a supervised machine learning algorithm. The model showed high accuracy on the test dataset (79%, p < 0.001). Conclusions: Symptoms assessment and physical examination proved to be fundamental, but other functional tests should also be considered. By adopting a machine learning model in further ODS and RP centers, indications for surgery could be more easily and reliably identified and shared. [ABSTRACT FROM AUTHOR]

Background: Pediatric colorectal specialists care for patients with a variety of defecation disorders. Anorectal (AR) manometry testing is a valuable tool in the diagnosis and management of these children. This paper provides a summary of AR manometry techniques and applications as well as a review of AR manometry findings in pediatric patients with severe defecation disorders referred to a pediatric colorectal center. This is the first study describing multi-year experience using a portable AR manometry device in pediatric patients. Methods: An electronic medical record review was performed (1/2018 to 12/2023) of pediatric patients with defecation disorders who had AR manometry testing. Demographics, diagnostic findings, and outcomes are described. Key Results: A total of 297 unique patients (56.9% male, n = 169) had AR manometry testing. Of these, 72% (n = 188) had dyssynergic defecation patterns, of which 67.6% (n = 127) had fecal soiling prior to treatment. Pelvic rehabilitation (PR) was administered to 35.4% (n = 105) of all patients. A total of 79.5% (n = 58) of the 73 patients that had fecal soiling at initial presentation and completed PR with physical therapy and a bowel management program were continent after therapy. AR manometry was well tolerated, with no major complications. Conclusions: AR manometry is a simple test that can help guide the management of pediatric colorectal surgical patients with defecation disorders. As a secondary finding, PR is a useful treatment for patients with dyssynergic stooling. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The natural history of rectal intussusception (RI) is poorly understood. We hypothesized that decline in pelvic floor integrity and function leads to increasing RI grades. METHODS: Retrospective analysis of a registry of patients with defecatory disorders with high-resolution anorectal manometry and magnetic resonance defecography was performed. Association of risk factors on increasing RI grades was assessed using logistic regression. RESULTS: Analysis included a total of 238 women: 90 had noRI, 43 Oxford 1--2, 49 Oxford 3, and 56Oxford 4--5. Age (P 5 0.017), vaginal delivery (P 5 0.008), and prior pelvic surgery (P 5 0.032) were associated with increased Oxford grades. Obstructive defecation symptoms and dyssynergic defecation were observed at relatively high rates across groups. Increased RI grades were associated with less anal relaxation at simulated defecation yet, higher rates of normal balloon expulsion (P < 0.05), linked to diminished anal sphincter. Indeed, increased RI grades were associated with worsening fecal incontinence severity, attributed to higher rates of anal hypotension. Levator ani laxity, defined by increased levator hiatus length and its excessive descent at straining,was associated with increasing RI grades, independent of age, history of vaginal delivery, and pelvic surgeries and could independently predict increased RI grades. Concurrent anterior and posterior compartments, and visceral prolapse were associated with higher Oxford grades. DISCUSSION: Our data suggest that decline in pelvic floor integrity with abnormal levator ani laxity is associated with increased RI grades, a process that is independent of age, history of vaginal deliveries, and/or pelvic surgeries, and perhaps related to dyssynergic defecation. [ABSTRACT FROM AUTHOR]

Résumé: Les douleurs anorectales fonctionnelles rentrent dans le cadre plus large des douleurs pelvi-périnéales chroniques. Elles sont caractérisées par un examen clinique normal et une imagerie aspécifique. La manométrie anorectale bien que peu prescrite apporte de nombreuses informations sur les mécanismes de ces douleurs. Les principales anomalies trouvées sont représentées par une hypertonie anale de repos, des ondes ultra-lentes ainsi qu'une dyssynergie anorectale. D'autres anomalies sont parfois trouvées mais peu étudiées : troubles de la sensibilité, modification des réflexes, anomalies portant sur le muscle puborectal et/ou troubles de la statique pelvienne. L'intérêt de la manométrie anorectale dans les douleurs anorectales est donc majeur autant sur le plan physiopathologique que sur le plan thérapeutique. Une meilleure diffusion de cet examen ainsi que des études sur de plus larges effectifs participerait à l'amélioration globale des pratiques. Functional anorectal pain belongs to the broader framework of chronic pelvi-perineal pain Such pain is characterized by a normal clinical examination with non-specific imaging. Anorectal manometry is not prescribed as much as it should although it could add numerous and useful data. Main anomalies described are increased anal basal pressure, ultra-slow waves and anorectal dyssynergia. Others anomalies are sometimes described: rectal sensitivity disorders, abnormal reflex, dysfunction of the puborectalis muscle and/or pelvic floor disorders. Anorectal manometry contributions in anorectal pain are thus important both on the physiopathological and therapeutical sides. Only a better diffusion of this exam and studies with more patients will allow good quality studies and improvement in our practice. [ABSTRACT FROM AUTHOR]

Fecal incontinence (FI) is often underreported and underestimated in men. Our aims were to clarify the causes and the physiological characteristics of FI in men and to underline the differences between etiological and physiological factors in men and women diagnosed with FI. The study cohort encompassed 200 men and 200 women who underwent anatomical and physiological evaluation for FI in a tertiary referral center specializing in pelvic floor disorders. All patients underwent endoanal ultrasound and anorectal manometry. Evacuation proctography was performed in some patients. Demographic, medical, anatomical, and physiological parameters were compared between the two study groups. Urge incontinence was the most frequent type of FI in both genders. In men, anal fistula, history of anal surgeries, rectal tumors, and pelvic radiotherapy were common etiologic factors, whereas history of pelvic surgeries was more common in women. Associated urinary incontinence was reported more frequently by women. External anal sphincter defects, usually anterior, were more common in women (M: 1.5%, F: 24%, P < 0.0001), whereas internal anal sphincter defect prevalence was similar in men and women (M: 6%, F: 12%, P = 0.19). Decreased resting and squeeze pressures were less common in men (M: 29%, F: 46%, P < 0.0001: M: 44%, F: 66%, P < 0.0001). The incidence of rectal hyposensitivity was higher in men (M: 11.1%, F: 2.8%, P < 0.0001), whereas rectal hypersensitivity was higher in women (M: 5.8%, F: 10.8%, P < 0.0001). Anorectal dyssynergia was more common in men (M: 66%, F: 37%, P < 0.0001). Significantly different etiological factors and physiological characteristics for FI were found in men. Acknowledging these differences is significant and may yield better treatment options. [ABSTRACT FROM AUTHOR]

Background: Defecation dysfunction may contribute to chronic constipation (CC), but the impact of obesity on anorectal physiology in CC remains unclear. We aimed to evaluate the relationship between obesity and anorectal function on physiologic testing in patients presenting with CC. Methods: This was a retrospective cohort study of consecutive adults who underwent high resolution anorectal manometry (HRAM) at a tertiary center for CC. Patient demographics, clinical history, surgical/obstetric history, medications, and HRAM results were reviewed. Patients were classified into obese (BMI > 30 kg/m2) vs non-obese (BMI < 30 kg/m2) groups at the time of HRAM. Fisher-exact/student t-test for univariate analyses and general linear regression for multivariable analysis were performed. Results: 383 adults (mean 50.3 years; 85.8% female) with CC were included. On HRAM, patients with obesity had lower anal sphincter resting tone (37.3 vs 48.5 mmHg, p = 0.005) and maximum squeeze pressure (104.8 mmHg vs 120.0 mmHg, p = 0.043). No significant differences in dyssynergia (61% vs 53%, p = 0.294) and failed balloon expulsion (18% vs 25%, p = 0.381) were found between obese and non-obese groups. On balloon distention testing, the maximum tolerated (163.5 vs 147.6 mL, p = 0.042) and urge sensation (113.9 vs 103.7 mL, p = 0.048) volumes were significantly increased among patients with obesity. After adjusting for potential confounders, obesity remained independently associated with increased maximum tolerated volume (β-coefficient 13.7, p = 0.049). Conclusion: Obesity was independently associated with altered rectal sensitivity among patients with CC. Altered rectal sensation may play an important role in CC among patients with obesity. Anorectal physiology testing should be considered to understand the pathophysiology and guide management. [ABSTRACT FROM AUTHOR]

Background: Digital rectal examination should be performed prior to anorectal manometry; however, real-world data is lacking. Aims: Characterize real world rates of digital rectal and their sensitivity for detecting dyssynergia compared to anorectal manometry and balloon expulsion test. Methods: A retrospective single-center study was conducted to examine all patients who underwent anorectal manometry for chronic constipation between 2021 and 2022 at one tertiary center with motility expertise. Primary outcomes consisted of the rate of digital rectal exam prior to anorectal manometry; and secondary outcomes included the sensitivity of digital rectal exam for dyssynergic defecation. Results: Only 42.3% of 142 patients had digital rectal examinations prior to anorectal manometry. Overall sensitivity for detecting dyssynergic defecation was 46.4%, but significantly higher for gastroenterology providers (p =.004), and highest for gastroenterology attendings (82.6%). Conclusions: Digital rectal examination is infrequently performed when indicated for chronic constipation. Sensitivity for detecting dyssynergic defecation may be impacted by discipline and level of training. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Anorectal function testing is traditionally relegated to subspecialty centers. Yet, it is an office-based procedure that appears capable of triaging care for the many patients with Rome IV functional constipation that fail empiric over-the-counter therapy in general gastroenterology, as an alternative to empirical prescription drugs. We aimed to evaluate cost-effectiveness of routine anorectal function testing in this specific population. METHODS: We performed a cost-effectiveness analysis from the patient perspective and a cost-minimization analysis from the insurer perspective to compare 3 strategies: (i) empiric prescription drugs followed by pelvic floor physical therapy (PFPT) for drug failure, (ii) empiric PFPT followed by prescription drugs for PFPT failure, or (iii) care directed by up-front anorectal function testing. Model inputs were derived from systematic reviews of prospective clinical trials, national cost data sets, and observational cohort studies of the impact of chronic constipation on health outcomes, healthcare costs, and work productivity. RESULTS: The most cost-effective strategy was upfront anorectal function testing to triage patients to appropriate therapy, in which the subset of patients without anal hypocontractility on anorectal manometry and with a balloon expulsion time of at least 6.5 seconds would be referred to PFPT. In sensitivity analysis, empiric PFPT was more cost effective than empiric prescription drugs except for situations in which the primary goal of treatment was to increase bowel movement frequency. If adopted, gastroenterologists would refer ~17 patients per year to PFPT, supporting feasibility. DISCUSSION: Anorectal function testing seems to be an emergent technology to optimize cost-effective outcomes, overcoming testing costs by phenotyping care. [ABSTRACT FROM AUTHOR]

The main advantage of the laparo-assisted transanal endorectal pull-through technique (LA - TERPT) for Hirschsprung Disease (HD) is the respect to the rectal-anal anatomy. Postoperative complications have been observed recently. The present study aims to determine how often these postoperative complications occur in these patients. From January 2009 to December 2018, a retrospective analysis was conducted on 36 children (25 males) with HD who underwent LA-TERPT. Data were collected on the age of diagnosis and surgery, sex, the presence of other pathologies, and cases of enterocolitis. In all cases, anorectal manometry (ARM) was performed to evaluate the anal tone. The median age at diagnosis was 2 months and the mean age at surgery was 5 months. Nine related pathologies were identified: five cases of Down syndrome, one case of hypertrophic stenosis of the pylorus, atresia of the esophagus, polydactyly, and anorectal malformation. A patient with total colonic aganglionosis was identified through laparoscopic serummuscular biopsies. Enterocolitis was diagnosed in 7 cases before and 6 after surgery. At follow-up, the complications recorded were: 5 cases of constipation (treated with fecal softeners), one case of anal stenosis (patient with anorectal malformation), 16 cases of soiling (treated with enemas) and 1 child with fecal incontinence (treated with a transanal irrigation system). The ARM was performed in all 36 cases and showed normal anal tone, except for one case with anal hypotonia. LA-TERPT is an important surgical technique for HD. According to the literature, soiling is the most main complication after HD surgery, probably due to “pseudo-incontinence” with normal anal sphincter tone.

Anorectal manometry is the most widely used technique for detecting abnormalities of sphincter function and recto-anal coordination. It enables the investigation of defaecatory difficulties, including anal incontinence and evacuatory difficulties, the assessment of patients with anal fistula and obstetric anal sphincter injury. Anorectal manometry is routinely used in combination with other tests, such as endoanal ultrasound or defaecatory imaging to understand the pathophysiology and aid treatment planning.There are various techniques and reporting protocols available but adopting standardised methods is essential for meaningful results and for comparing results between different units. This paper follows the workshop on anorectal manometry at the International Continence Society conference in Vienna in 2022. It aims to outline the various techniques and equipment available, with examples of high-resolution manometry cases and their interpretation.

Abstract Background Few studies have investigated healthy female individuals (HFI) and those with obstructed defecation syndrome associated with moderate rectocele in women (MRW), identified using three-dimensional high-resolution anorectal manometry (3D HRAM) parameters that correlate with age stratification. Objective We aimed to explore the clinical diagnostic values of the MRW and HFI groups using 3D HRAM parameters related to age stratification. Methods A prospective non-randomized controlled trial involving 128 cases from the MRW (treatment group, 68 cases) and HFI (control group, 60 cases) groups was conducted using 3D HRAM parameters at Tianjin Union Medical Center between January 2017 and June 2022, and patients were divided into two subgroups based on their ages: the ≥50 and < 50 years subgroups. Results Multivariate binary logistic regression analysis showed that age (P = 0.024) and rectoanal inhibitory reflex (P = 0.001) were independent factors affecting the disease in the MRW group. Compared to the HFI group, the receiver operating characteristic (ROC) curve demonstrated that the 3D HRAM parameters exhibited a higher diagnostic value for age (Youden index = 0.31), urge to defecate (Youden index = 0.24), and rectoanal pressure differential (Youden index = 0.21) in the MRW group. Conclusions Compared to the HFI group, the ROC curve of the 3D HRAM parameters suggests that age, urge to defecate, and rectoanal pressure differential in the MRW group have a significant diagnostic value. Because the Youden index is lower, 3D HRAM cannot be considered the gold standard method for diagnosing MRW.

Abstract Background Rectal cancer is commonly treated by chemoradiation therapy, followed by the low anterior resection anal sphincter-preserving surgery, with a temporary protecting ileostomy. After reversal of the stoma a condition known as low anterior resection syndrome (LARS) can occur characterized by a combination of symptoms such as urgent bowel movements, lack of control over bowel movements, and difficulty fully emptying the bowels. These symptoms have a significant negative impact on the quality of life for individuals who have survived the cancer. Currently, there is limited available data regarding the presence, risk factors, and effects of treatment for these symptoms during long-term follow-up. Aims To evaluate long term outcomes of low anterior resection surgery and its correlation to baseline anorectal manometry (ARM) parameters and physiotherapy with anorectal biofeedback (BF) treatment. Methods One hundred fifteen patients (74 males, age 63 ± 11) who underwent low anterior resection surgery for rectal cancer were included in the study. Following surgery, patients were managed by surgical and oncologic team, with more symptomatic LARS patients referred for further evaluation and treatment by gastroenterologists. At follow up, patients were contacted and offered participation in a long term follow up by answering symptom severity and quality of life (QOL) questionnaires. Results 80 (70%) patients agreed to participate in the long term follow up study (median 4 years from stoma reversal, range 1–8). Mean time from surgery to stoma closure was 6 ± 4 months. At long term follow up, mean LARS score was 30 (SD 11), with 55 (69%) patients classified as major LARS (score > 30). Presence of major LARS was associated with longer time from surgery to stoma reversal (6.8 vs. 4.8 months; p = 0.03) and with adjuvant chemotherapy (38% vs. 8%; p = 0.01). Patients initially referred for ARM and BF were more likely to suffer from major LARS at long term follow up (64% vs. 16%, p

Introduction: For several reasons, a patient may be taken to a colostomy for closure as soon as possible. However, their treatment may vary, and predicting adequate continence after colostomy closure can be difficult. The objective is to characterize preoperative manometry because, in Colombia, few cases describe its usefulness. Methods: A descriptive cross-sectional study of adult patients treated in two gastroenterology centers in Colombia between 2018 and 2020. Results: Of 316 patients, 13 were indicated manometry before colostomy closure, predominantly women (69%), with an average age of 51.69 years (standard deviation: 24.18). When evaluating the basal pressures of the anal sphincter, we noted 68% hypotonia, 16% hypertonia, and 16% normal pressures. The voluntary contraction test was abnormal in 25%, and a pattern of dyssynergic defecation was observed in 30%, all with type III patterns. The inhibitory rectoanal reflex was present in 92%, with an abnormal balloon expulsion test in 100% of patients. More than 70% of patients persisted with the colostomy in situ after the first year of construction and 30% beyond 36 months. Conclusions: The present study posits questions about the cost-effectiveness of anorectal manometry before colostomy closure, which requires corroboration by studies with more patients and more robust methodological designs. [ABSTRACT FROM AUTHOR]

Background Chronic constipation (CC) is a severe symptom in Parkinson's disease (PD), with an unclear pathogenesis. Abnormalities of the enteric nervous system (ENS) and/or intestinal epithelial barrier (IEB) may be pathophysiologically relevant in PD patients with CC. We investigated possible molecular changes of the IEB in PD/CCs compared with CCs and controls. Methods Twelve PD/CCs (2 female, age range 51-80 years), 20 CCs (15 female, age range 27-78 years), and 23 controls (11 female, age range 32-74 years) were enrolled. Ten PD/CCs and 10 CCs were functionally characterized by anorectal manometry (AM) and transit time (TT). Colon biopsies were obtained and assessed for gene and protein expression, and localization of IEB tight junction markers claudin-4 (CLDN4), occludin-1 (OCCL-1), and zonula occludens-1 (ZO-1) by RT-qPCR, immunoblot and immunofluorescence labeling. Results PD/CCs were clustered in 2 functional categories: patients with delayed TT and altered AM (60%), and a second group showing only modifications in AM pattern (40%). Gene expression of CLDN4, OCCL-1 and ZO-1 was higher in PD/CCs than controls (P<0.05). Conversely, PD/CCs showed a trend to decrease (P>0.05) in CLDN4 and OCCL-1 protein levels than controls, whereas ZO-1 protein was comparable. In PD/CCs compared with controls, decreasing tendency of vasoactive intestinal polypeptide mRNA, protein and immunoreactive fiber density were observed, although the difference was not statistically significant. Conclusion Transit and anorectal dysfunctions in PD/CCs are associated with difference in ZO-1, OCCL-1 and CLDN4 expression, thus supporting the role of an altered IEB as a contributory mechanism to possible neuronal abnormalities. [ABSTRACT FROM AUTHOR]

The main advantage of the laparo-assisted transanal endorectal pull-through technique (LA - TERPT) for Hirschsprung Disease (HD) is the respect to the rectal-anal anatomy. Postoperative complications have been observed recently. The present study aims to determine how often these postoperative complications occur in these patients. From January 2009 to December 2018, a retrospective analysis was conducted on 36 children (25 males) with HD who underwent LA-TERPT. Data were collected on the age of diagnosis and surgery, sex, the presence of other pathologies, and cases of enterocolitis. In all cases, anorectal manometry (ARM) was performed to evaluate the anal tone. The median age at diagnosis was 2 months and the mean age at surgery was 5 months. Nine related pathologies were identified: five cases of Down syndrome, one case of hypertrophic stenosis of the pylorus, atresia of the esophagus, polydactyly, and anorectal malformation. A patient with total colonic aganglionosis was identified through laparoscopic serum-muscular biopsies. Enterocolitis was diagnosed in 7 cases before and 6 after surgery. At follow-up, the complications recorded were: 5 cases of constipation (treated with fecal softeners), one case of anal stenosis (patient with anorectal malformation), 16 cases of soiling (treated with enemas) and 1 child with fecal incontinence (treated with a transanal irrigation system). The ARM was performed in all 36 cases and showed normal anal tone, except for one case with anal hypotonia. LA-TERPT is an important surgical technique for HD. According to the literature, soiling is the most main complication after HD surgery, probably due to "pseudo-incontinence" with normal anal sphincter tone. [ABSTRACT FROM AUTHOR]

As a new type of sphincter-saving resection aim to improve postoperative anorectal function for low rectal cancer, the anorectal function recovery outcomes after transanal conformal resection (TaCR) need further study. A total of 43 eligible cases who underwent TaCR or total intersphincteric resection (ISR) were divided into 2 groups. Group 1 included 21 cases who underwent total ISR; group 2 included 22 cases who underwent TaCR. The anorectal function recovery outcomes of the 2 groups before and after the operation were compared. According to Wexner scores: The patients required 6–7 months after surgery to achieve a satisfactory anorectal function in group 1, but the patients in group 2 only required 5–6 months. The recovery time of anorectal function in group 2 was shorter than that in group 1. According to the anorectal manometry (ARM): After 1 year of recovery, the patients' anal resting pressure (ARP) still could not return to preoperative level in group 1. In group 2, the time at which the patients' ARP after surgery started to show no significant decreases (p > 0.05) compared with preoperative levels was 12 months. The time at which the patients' maximum squeeze pressure (MSP) after surgery started to show no significant decreases (p > 0.05) compared with preoperative levels was 9 months after surgery in both groups. Our data showed that TaCR was associated with a better postoperative anorectal function compared with total ISR. And we had drawn the anorectal function recovery curves with time for the patients who underwent total ISR or TaCR, respectively; it may provide reference for ileostomy closure and other interventions. [ABSTRACT FROM AUTHOR]

Purpose: This study investigated anorectal manometry (AM) findings and bowel function of patients operated on for Hirschsprung’s disease (HD). Methods: A cross-sectional study was conducted at Children’s Hospital 2. Patients operated on for HD from January 2015 to January 2020 were reviewed. Their clinical characteristics, bowel function, and manometric findings were investigated and compared with the references. Results: Ninety-five patients and 95 references were enrolled. Mean ages were 6.6 ± 2.2 years and 7.2 ± 2.9 years,; fecal incontinence rates were 25.3% and 2.1%, and constipation rates were 12.6% and 4.2 for the patients versus the references, respectively. Anal resting pressures were significantly decreased in the patients compared to the references (53.2 ± 16.1 mmHg versus 62.2 ± 14.0 mmHg; p < 0.05). Among the patients, the anal resting pressure was significantly decreased in the incontinents than in the continents (46.0 ± 10.6 mmHg versus 55.6 ± 16.9 mmHg, p < 0.05). During the sensation test, the value of maximum tolerated volume was significantly decreased in the incontinents than in the continents (135.9 ± 47.9 mL versus 166.6 ± 58.3 mL, p < 0.05). Conclusion: AM is an objective method providing beneficial information that could guide a more adapted management in HD patients with defecation disorders. [ABSTRACT FROM AUTHOR]

Background: Pediatric colorectal specialists care for patients with a variety of defecation disorders. Anorectal (AR) manometry testing is a valuable tool in the diagnosis and management of these children. This paper provides a summary of AR manometry techniques and applications as well as a review of AR manometry findings in pediatric patients with severe defecation disorders referred to a pediatric colorectal center. This is the first study describing multi-year experience using a portable AR manometry device in pediatric patients. Methods: An electronic medical record review was performed (1/2018 to 12/2023) of pediatric patients with defecation disorders who had AR manometry testing. Demographics, diagnostic findings, and outcomes are described. Key Results: A total of 297 unique patients (56.9% male, n = 169) had AR manometry testing. Of these, 72% (n = 188) had dyssynergic defecation patterns, of which 67.6% (n = 127) had fecal soiling prior to treatment. Pelvic rehabilitation (PR) was administered to 35.4% (n = 105) of all patients. A total of 79.5% (n = 58) of the 73 patients that had fecal soiling at initial presentation and completed PR with physical therapy and a bowel management program were continent after therapy. AR manometry was well tolerated, with no major complications. Conclusions: AR manometry is a simple test that can help guide the management of pediatric colorectal surgical patients with defecation disorders. As a secondary finding, PR is a useful treatment for patients with dyssynergic stooling.

Introduction: There is no clarity about manometric findings in patients with proctalgia fugax; evidence shows different results. This study aims to evaluate dyssynergic defecation through anorectal manometry in Colombian patients in two gastroenterology centers in Bogotá, Colombia. Materials and methods: A cross-sectional descriptive observational study in adult patients with proctalgia fugax undergoing anorectal manometry and treated in two gastroenterology centers in Bogotá between 2018 and 2020. Results: 316 patients were included, predominantly women (65%), with a median age of 45.2 (range: 18-78; standard deviation [SD]: 28.3). Four percent of patients had hypertonicity, 50% were normotonic, and 46% were hypotonic. Regarding manometric parameters, 50% had normal pressure, and 46% had anal sphincter hypotonia; 76% had a normal voluntary contraction test. Dyssynergic defecation was documented in 5% of patients, and the most frequent was type I, followed by type III. A rectoanal inhibitory reflex was identified in all patients, 42% with altered sensory threshold and 70% with abnormal balloon expulsion. There was an agreement between the results of the anorectal manometry and the subjective report of the digital rectal exam by the head nurse who performed the procedure. Conclusions: The data obtained in the present study suggest that proctalgia is not related to the elevated and sustained basal contracture of the sphincter but neither to the alteration in voluntary contraction since most patients have typical values. [ABSTRACT FROM AUTHOR]

Purpose of Review: Patients with a history of gastrointestinal (GI) conditions report high rates of psychological trauma. This review discusses the impact of previous trauma, as well as interactions with the medical system, on a patient's physical and mental health. Trauma-informed strategies for improving patient care during gastroenterology procedures are provided. Recent Findings: History of trauma increases risk of developing GI conditions and re-traumatization during sensitive anorectal procedures (i.e., anorectal manometry, balloon expulsion testing). Trauma-informed strategies include consistent trauma screening for all patients, obtaining consent before and during procedures, creating a safe environment, allowing for privacy, and post-procedure debriefing. Summary: Due to high rates of psychological trauma in the gastroenterology setting and the risk of medical trauma from the GI procedures themselves, having an established trauma-informed plan of care for all patients can reduce risk of iatrogenic harm and improve quality of care for patients with GI conditions. [ABSTRACT FROM AUTHOR]

Introduction: Anorectal manometry (ARM) is sometimes performed before ostomy reversal in patients with an intersphincteric resection (ISR) to predict bowel function. However, no clinical predictive data exist regarding its utility. Methods: The single‐centre, retrospective data of ISR patients who had an ARM prior to ostomy reversal, and bowel functional assessment with the low anterior resection syndrome (LARS) and Wexner incontinence scores at least 6 months after reversal, were considered. Correlation statistics were performed with each of the manometric parameters and functional outcome categories. Results: Eighty‐nine patients were included. The median basal and squeeze pressures were 41 and 100 mmHg, respectively. Any LARS (score ≥20) and major incontinence (score ≥11) was observed in 51.7% and 16.9%, respectively. None of the manometric parameters (median basal or maximum squeeze pressure, anal canal length, volume at urge and the ability to expel) correlated with LARS or incontinence. Conclusions: Anorectal manometry (ARM) before ostomy reversal to predict bowel function at 6 months or beyond was not helpful in patients with an ISR and diverting stoma. No manometric parameter correlated with the LARS or Wexner incontinence scores. [ABSTRACT FROM AUTHOR]

Background: Patients with obstructed defecatory symptoms (ODS) are commonly referred to either gastroenterologists (GE) or colorectal surgeons (CS). Further management of these patients may be impacted by this choice of referral. Methods: An online survey of specialist practice was disseminated to GE and CS in Australia and New Zealand. A case vignette of a patient presenting with ODS was described, with multiple subsequent scenarios designed to delineate the responder's preferred approach to management of this patient. Key Results: A total of 107 responders participated in the study, 62 CS and 45 GE. For a female patient with ODS not responding to pharmacological treatment, GE were more likely than CS to refer patients for anorectal manometry, while CS were more likely to refer for dynamic imaging. A quarter of CS and GE referred patients directly to pelvic floor physiotherapy, without any pre‐treatment testing. Knowing the result of dynamic imaging, especially if a rectocele was demonstrated, substantially influenced management for both of the specialties: GE became more likely to refer the patients for CS consultation and less likely to refer directly for biofeedback or physiotherapy and CS were more likely to opt for an operative pathway over conservative management than they were prior to knowledge of the imaging findings. The majority (>75%) of GE and CS did not find it necessary to obtain a gynecological consultation, even in the presence of a rectocele. Conclusions & Inferences: Practice variation across medical specialties affects diagnostic and management recommendations for patients with ODS, impacting treatment pathways. Our findings provide an incentive toward establishing interdisciplinary, uniform, management guidelines. [ABSTRACT FROM AUTHOR]

Background The treatment for functional constipation (FC) generally relies on the classification by clinical symptoms, but whether the classification by clinical symptoms is consistent with that by colorectal and anal function examinations still remains unclear. Objective To examine the consistency between FC classification by clinical symptoms and colorectal and anal functional examinations. Methods Forty FC outpatients and inpatients completing colorectal and anal functional examinations in Department of Gastroenterology, Hebei General Hospital from January 2018 to August 2021 were enrolled in this retrospective study. Symptoms were acquired for classifying FC by use of a questionnaire survey, including the frequency of spontaneous defecation per week, shape and type of stool assessed using the Bristol Stool Scale, difficulty in defecation, sense of anorectal blockage during defecation, requirement for manual assistance in defecation, and the frequency and degree of feeling of incomplete evacuation. And the results detected by examinations, including anorectal manometry (ARM) , defecography and gastrointestinal transit time (GITT) were also used for FC classification. The consistency of FC classification by symptoms and the three examinations was assessed. Results The FC classification by symptoms was as follows: slow transit constipation (STC) 〔27.5% (11/40) 〕, defecation disorder constipation〔20.0% (8/40) 〕, mixed constipation〔37.5% (15/40) 〕, and normal-transit constipation (NTC) 〔15.0% (6/40) 〕. FC classified by ARM included defecation disorder constipation〔80.0% (32/40) 〕and NTC〔20.0% (8/40) 〕, and by defecography also only included defecation disorder constipation〔67.5% (27/40) 〕 and NTC 〔32.5% (13/40) 〕. By GITT, FC classification contained three types: STC〔20.0% (8/40) 〕, defecation disorder constipation 〔15.0% (6/40) 〕, and NTC〔65.0% (26/40) 〕. The weighted Kappa test indicated that the FC classification by symptoms was not consistent with that by ARM, defecography or GITT (Kappa=-0.123, P=0.502; Kappa=-0.040, P=0.794; Kappa=-0.140, P=0.215) , and there was no overall consistency between FC classification by symptoms and the three examinations (Kappa=-0.005, P=0.944) . Conclusion Mixed constipation was the major type of FC classified by symptoms, while defecation disorder constipation was the major type of FC classified by the three examinations. As there are differences between clinical symptom classification and examination classification, FC should be diagnosed based on both clinical symptoms and examination results, accompanied with the individualized analysis.

Abstract Introduction Functional gastrointestinal disorders (FGID) including impaired rectal evacuation are common in patients with Hypermobility Spectrum Disorder (HSD) or Hypermobile Ehlers-Danlos Syndrome (hEDS). The effect of connective tissue pathologies on pelvic floor function in HSD/hEDS remains unclear. We aimed to compare clinical characteristics and anorectal pressure profile in patients with HSD/hEDS to those of age and sex matched controls. Methods We conducted a retrospective review of all FGID patients who underwent high resolution anorectal manometry (HR-ARM) and balloon expulsion test (BET) for evaluation of impaired rectal evacuation. Patients with HSD/hEDS were age and sex matched to a randomly selected cohort of control patients without HSD/hEDS. An abnormal BET was defined as the inability to expel a rectal balloon within 2 minutes. Wilcoxon rank sum test and Fisher’s exact test were used to make comparisons and logistic regression model for predictive factors for abnormal evacuation. Results A total of 144 patients (72 with HSD/hEDS and 72 controls) were analyzed. HSD/hEDS patients were more likely to be Caucasian (p

Introduction: The use of a footstool has been advocated to optimize posture when sitting on the toilet and thus facilitate bowel evacuation. We aimed to assess the alterations in defecatory posture, and the changes in simulated defecation with use of a footstool in patients with constipation. Methods: Forty‐one patients (female 93%, mean 52 year, SD 14 year) with constipation referred to a tertiary neurogastroenterology unit were enrolled. A bowel questionnaire, Hospital Anxiety and Depression Scale, and Rome questionnaire were administered prior to anorectal manometry. Each patient underwent three rectal balloon expulsion tests in randomized order with no footstool, a 7‐inch, and a 9‐inch footstool. Additional assessments included angle between spine and femur, and visual analogue scales assessing ease of evacuation, urge to defecate, and discomfort with expulsion. Key Results: Defecatory posture was significantly altered by footstool use, with progressive narrowing of the angle between the spine and femur as footstool height increased (p < 0.001 for all comparisons). Compared with no footstool, the use of a footstool was not associated with a change in balloon expulsion time and there was no difference between the two footstool heights. Subjectively, no significant change was identified in any of the three perceptions of balloon expulsion between no footstool and footstool use. Conclusions and Inferences: Although the use of a footstool led to changes in defecatory posture, it did not improve subjective or objective measures of simulated defecation in patients with undifferentiated constipation. Therefore, the recommendation for its use during evacuation cannot be applied to all patients with constipation. [ABSTRACT FROM AUTHOR]

The maintenance of anorectal continence and defaecation is complex. The disruption of these mechanisms can result in symptoms of either faecal incontinence or obstructive defaecation. Both conditions can have significant impact on quality of life. This article details the clinical assessment of presenting patients to establish potential causes, grade the severity of the symptoms and to assess the impact on their quality of life. The appropriate specialized radiological and physiological investigations aim to evaluate the structural integrity and function of the anal sphincter, the anorectal and pelvic floor musculature and measure the transitory function of the colon. [ABSTRACT FROM AUTHOR]