Paradoxical Sphincter Reaction
Paradoxical sphincter reaction is a common finding in patients with rectal emptying difficulties and is considered by some authors to Figure 11.2. Anal plug surface electrode. Figure 11.2. Anal plug surface electrode. Figure 11.3. Surface EMG demonstrating paradoxical sphincter reaction. The EMG activity is increased also at straining it would normally decrease . Figure 11.3. Surface EMG demonstrating paradoxical sphincter reaction. The EMG activity is increased also at straining it would...
Beyond Kegels
The Beyond Kegel, a complete rehabilitation program for pelvic muscle dysfunction developed by Hulme, is based on the principle that the support system for the pelvic organs includes more than just the pelvic floor muscles. This support system, which is called the pelvic muscle force field PMFF , includes the obturator inter-nus, pelvic diaphragm levator ani , urogenital diaphragm, and adductor muscles. In summary, these muscles function as an interdigitated and interrelated synergistic unit,...
Manometry Catheters
In principle, smaller catheters are superior to larger ones and flexible are preferred over rigid. The latter have the advantage of easy insertion but are associated with patient discomfort and are often refused. Flexible catheters are more comfortable for the patient but tend to twist in the anal canal. The outside diameter should not Figure 8.4. Water-perfused system a with computer screen b and polygraph c . Figure 8.4. Water-perfused system a with computer screen b and polygraph c . exceed...
Encopresis
Figure 8.13. Rectoanal inhibitory reflex. Impairment of the relaxation of the internal anal sphincter, suggesting congenital megacolon. Various terms have been used to describe this problem, including functional encopresis, primary nonretentive encopresis, and stool toileting refusal. Encopresis affects 1 to 3 of children, with higher rate in boys than in girls. It is characterized by the passage of large feces at intervals of less than twice per week and deferring bowel movements by...
Colonic Scintigraphy
More recently, radioscintigraphy has been used to provide a more detailed assessment of overall and regional colonic transit with an acceptable radiation exposure. Two approaches have been used. To avoid dispersion of radiolabel during its passage through the stomach and small bowel, orocecal intubation was utilized to instill liquid radioisotopes, such as mIn-DTPA, directly into the large bowel.42 This method has been adapted by simply following an mIn-liquid meal emptied from the stomach.43...
Evolution of the Enteric Nervous System
The enteric nervous system ENS is unique, as it can function without input from the brain or spinal cord. It also has all the neurotransmitters that are found in the central nervous system CNS .5,6 The evolution of the ENS has been long debated. Okamoto and Ueda7 showed that the extramural parasympathetic innervation develops in the 5th and 6th weeks of embryogenesis. Studies in the chick and quail embryos have defined the embryogenesis of the ENS.8 The ENS develops as a result of the migration...
Colonoscopy
Colonoscopy is a complementary study to a barium enema for exclusion of colonic pathology. Compared to barium enema, colonoscopy has a higher risk of complications and is more expensive, although both are probably comparable in the diagnosis of lesions associated with constipation.53'54 In patients with anthraquinone laxative abuse, the rectal mucosa may present with characteristic aspects of melanosis coli, a brown-black spotty coloration due to deposits of lipofuscin in the lamina propria.
FluidFilled and AirFilled Balloon Systems
One of the most common methods of measuring anorectal pressure utilizes a closed balloon system. The pressure result obtained with balloon recording is an average of all pressures acting into the balloon radial asymmetry cannot be detected. However, larger balloons are unphysiologic as the probe itself may cause reflex contractions but the results obtained are more representative of a greater area of the sphincter. It is of tremendous importance to understand that a compliance hysteresis...
Segmental Colonic Resection
If a particular segment of the colon could be reliably identified as the cause of constipation, then segmental colectomy could offer some advantage by preventing severe diarrhea or incontinence that occurs in a small number of cases after subtotal colectomy and ileorectal anastomosis. Another potential advantage of a limited colonic resection is a reduction in the de-peritonealized area that may reduce the risk of postoperative adhesions. In general, the published functional results of...
Treatment of Combined Colonic Inertia and Obstructed Defecation
Transit studies and anorectal physiology tests can subdivide severely constipated patients into three groups colonic inertia causing slow transit, obstructed defecation, and a combination of both. Patients with obstructed defecation may have mechanical outlet obstruction related to the presence of anatomic abnormalities such as a rectocele, or functional outlet obstruction. The principles of treating slow-transit constipation or obstructed defecation alone are generally agreed upon. The optimal...
References Iik
1. McMillan SC, Tittle M. A descriptive study of the management of pain and pain-related side effects in a cancer center and a hospice. Hosp J 1995 10 89-108. 2. Sandler RS, Drossman DA. Bowel habits in young adults not seeking health care. Dig Dis Sci 1987 32 841. 3. Huizinga JD, Daniel EE. Motor functions of the colon. In Philips SF, Pemberton JH, Shorter RG, eds. The Large Intestine Physiology, Pathophysiology, and Disease. New York Raven Press, 1991 93-114. 4. Kellow JE, Borody TJ, Phillips...
Laparoscopic Colectomy
Improved technology such as ultrasonic dissecting shears has made laparoscopic colectomy feasible. The potential benefits of laparoscopic colorectal resection include less postoperative pain, better cosmesis, improved pulmonary function, earlier return of bowel function, decrease in length of hospital stay, and earlier return to normal activities.56 Other potential benefits include fewer abdominal adhesions and incisional hernias. These benefits are offset by drawbacks, which include increased...
Pudendal Nerve Terminal Motor Latency
Pudendal nerve terminal motor latency PNTML is a measurement of time, or latency, from stimulation of the pudendal nerve at the level of the ischial spine to the muscle response in the external anal sphincter.5,23 A disposable electrode is placed on the examiner's gloved index finger Fig. 11.4 and inserted into the anal canal Fig. 11.5 . The stimulation is transrectally performed with the electrode located at the ischial spine while the response is recorded at the base of the examiner's finger....
References Pjd
1. Burhenne HJ. Intestinal evacuation study a new roentgenologic technique. Radiol Clin 1964 33 79-84. 2. Phillips SF, Edwards DA. Some aspects of anal continence and defaecation. Gut 1965 6 396-406. 3. O'Connell PR, Kelly KA, Brown ML. Scintigraphic assessment of neorectal motor function. J Nucl Med 1986 27 460-464. 4. Lienemann A, Anthuber C, Baron A, Kohz P, Reiser M. Dynamic MR colposystorectography assessing pelvic-floor descent. Eur Radiol 1997 7 1309-1317. 5. Barkel DC, Pemberton JH,...
Bloating
The incidence of abdominal bloating varies in different studies. It was noted to be unchanged after surgery in two studies.17,30 Pluta et al40 Figure 15.2. Pain categories before and after colectomy for colonic inertia. There was a significant shift to the less severe categories of pain after surgery, with no patient remaining in the severe category. reported that in 24 patients with severe bloating preoperatively, postoperative bloating continued to be severe in two patients, significant but...
Subtotal Colectomy
Subtotal colectomy and ileorectal anastomosis IRA result in improvement in the frequency of evacuation in over 90 of patients, with a high degree of satisfaction in the majority of cases.15-23 Severe diarrhea occurs in up to 10 of cases, which may be associated with incontinence if anal sphincter tone is reduced. Subtotal colectomy with cecorectal or ileosigmoid anastomosis is associated with recurrent constipation in up to 30 of cases. A number of outcome measures need to be examined in...
EnterocelePeritoneocele
A peritoneocele is a caudal invagination of the peritoneum, between the posterior vaginal wall Figure 9.3. Rectal intussusception or internal prolapse, increasingly pronounced with straining. Note the initial appearance of an anterior rectocele,fol-lowed by the teacup appearance of the middle image. Figure 9.3. Rectal intussusception or internal prolapse, increasingly pronounced with straining. Note the initial appearance of an anterior rectocele,fol-lowed by the teacup appearance of the middle...
Diaphragmatic Breathing Physiological Quieting
The breathing cycle is intimately connected to both sympathetic and parasympathetic action of the autonomic nervous system.19 Bowel and bladder function is also mediated by the autonomic nervous system.10 Conscious deep diaphragmatic breathing is one of the best ways to quiet the autonomic nervous system. This breathing effectively initiates a cascade of visceral relaxation responses. The aim of this exercise is to make the shift from thoracic breathing to abdominal breathing.19 Patients are...
Bulking Agents
Fiber supplementation should be foundational therapy for most if not all constipated patients.7 A constipated patient should be started at a relatively low dose and slowly increased to a typical daily dose over several days to 1 week. Starting low will help to decrease bloating. After 2 to 4 weeks on therapy, if the patient is still having symptoms, the dose should be doubled in a split dose. Many patients have relief with fiber alone. Continued problems thereafter can be treated with...
Measurement Parameters
Appropriate parameters to be measured during defecography have evolved over time, based on the contributions of numerous authors. Accordingly, consistent objective measures and their implications are not yet universally accepted due to a lack of uniform technique.3'5'17 However, the following definitions are generally considered standard based on their widespread use Anal canal length The distance from the anal verge defined by barium marking the skin or a marker placed on the perineum to the...
Electronic Barostat System
A polyethylene bag in the rectum is fixed to a multilumen tube, which is connected to a baro-stat device. The pressure in the bag is measured via a separate lumen of the tube. The barostat is connected to a computer, where the pressure, volume, and compliance mL mmHg are constantly monitored and recorded as the pressure-volume curve. The bag can be distended in steps to either a fixed pressure isobaric or a fixed volume iso-volumetric . It is also able to keep the pressure in the rectal beg at...
Manovolumetry
In the manovolumetry system, the rectal volume is recorded as a dynamic response to a graded rectal distention at atmospheric pressure. This resembles the physiologic events in the intestine, Figure 10.1. Pressure-volume response range in normal subjects n 45, mean SD measured with the manovolumetry method. Reprinted from Hallbook O, Sjodahl R. Techniques of rectal compliance measurement. Semin Colon Rectal Surg 1992 3 88-91, 1992, with permission from Elsevier. Figure 10.1. Pressure-volume...
Constipation
Etiology, Evaluation, and Management Foreword by David C.C. Bartolo, MS, FRCS, FRCSE FRCS Ed 21st Century Oncology Chair in Colorectal Surgery Chairman, Department of Colorectal Cleveland Clinic Florida, Weston, FL, USA Professor of Surgery Ohio State University Health Sciences Center at the Cleveland Clinic Foundation Columbus, OH, USA Clinical Professor of Surgery University of South Florida College of Medicine Tampa, FL, USA Clinical Professor of Surgery Charles E. Schmitt College of Science...
Rectal Prolapse
Internal rectal intussusception is an early stage of rectal prolapse, where the proximal rectum has prolapsed into the ampulla but has not progressed through the anal canal. Symptoms include constipation and an incomplete sense of evacuation. Less commonly reported are incontinence, pain, and soiling. Endoscopy may reveal a solitary rectal ulcer on the anterior rectal wall 8 to 10 cm above the anal verge. Defecography is the diagnostic test of choice and shows the rectum intussuscepting several...
Rectocele
A rectocele may be an important cause of obstructive defecation that presents as constipation. A rectocele is a herniation of the anterior wall of the rectum into the lumen of the vagina. A rectovaginal septum weakened by multiple childbirths and the aging process may enable stool to become trapped in this herniation, leading to a sense of incomplete evacuation. Continued straining may further weaken the rectovaginal septum and lead to progressive enlargement of the herniation. Because patients...
Anismus
Paradoxical contraction of the puborectalis is a functional disorder of the pelvic floor with some controversial aspects the nonrelaxation of the puborectalis during straining can be observed in normal or asymptomatic patients.37 However, the characteristic history of prolonged periods of straining, necessitating the use of suppositories or enemas, and tenesmus in females, is an indication of such functional outlet obstruction. Together with a clinical history, electromyogra-phy, and...
Sigmoidocele
The existence and clinical implications of sig-moidocele are controversial. We have demonstrated that a deep rectovaginal pouch may contain small bowel at one time and sigmoid at another time, in the same patient. Jorge et al19 maintain that, as opposed to the small bowel, the herniated sigmoid is more prone to stasis, owing to its larger diameter and more solid contents. Jorge et al19 undertook a study to assess the incidence and clinical significance of sigmoi- Figure 9.5. Deep rectovaginal...
Conclusion
The epidemiology of constipation demonstrates a consistent pattern with several key points. No true population-based incidence or natural history studies have been published to date. The prevalence of constipation ranges from 3 to 27 , averaging approximately 15 , the variance resulting from differing case definitions of constipation and the effects of varying ascertainment methods. Constipation increases progressively with age, and this increase is particularly marked after the age of 65...
Descending Perineum Syndrome
Weakness of pelvic floor support may result in the descending perineum syndrome. This muscular weakness is reportedly related to injury of the sacral nerves or pudendal nerves or due to damage to the musculature itself during childbirth or chronic straining while defecating. Obstruction to defecation may occur through widening of the anorectal angle, weakening of the perineal body, and a more vertical orientation of the rectum, which are all results of pelvic floor weakness.14 A perineal...
Nonrelaxing Puborectalis Syndrome Anismus
The constellation of symptoms associated with rectoceles prolonged repeated straining at bowel movements, sensation of incomplete evacuation, and the need for digital manipulation is also seen in puborectalis syndrome. Synonyms include nonrelaxing puborectalis syndrome,par-adoxical puborectalis syndrome, spastic pelvic floor syndrome, and anismus. During normal evacuation, distention of the rectum by fecal matter induces relaxation of the internal anal sphincter, followed by contraction of the...