ANORECTAL SYMPTOMS
Despite advances in diagnostic tests, a clinical interview is essential for characterizing the presence and severity of symptoms, establishing rapport with patients, selecting diagnostic tests, and guiding therapy. Although anorectal testing is necessary to diagnose defecatory disorders, a careful interview and examination often suffice for the initial management of fecal incontinence (FI). The emphasis here is on the patient’s dietary and bowel habits, as many anorectal symptoms are a consequence of disordered bowel habits (e.g., FI for semi-formed or liquid stools). When possible, bowel habits should be characterized by bowel diaries and by pictorial stool scales (1). Anorectal symptoms may be broadly characterized into constipation, FI, and anorectal pain.
Constipation
As discussed in the section on bowel disorders, patients may refer to a variety of symptoms by the term “constipation.” Anecdotal experience and some evidence suggest that certain symptoms (e.g., sense of anorectal blockage and anal digitation during defecation) are more suggestive of a defecatory disorder than others (e.g., sense of incomplete evacuation after defecation and excessive straining) (2,3). In addition to impaired rectal emptying, the sense of incomplete evacuation may also reflect rectal hypersensitivity (e.g., irritable bowel syndrome). Other symptoms (e.g., hard and/or infrequent stools) are perhaps more suggestive of normal or slow transit constipation rather than defecatory disorders. As even normal subjects may struggle to expel small hard pellets, difficulty in evacuation of soft, formed, or more so, liquid stools is more suggestive of an evacuation disorder. However, functional defecation disorders often cannot be distinguished from other causes of chronic constipation by symptoms alone. As such, anorectal testing should be considered, particularly in patients who fail to respond to fiber supplementation and empiric laxative therapy.
Fecal incontinence
Fecal incontinence refers to the recurrent uncontrolled passage of liquid or solid fecal material. Although distressing, involuntary passage of flatus alone should not be characterized as FI, because it is difficult to define when the passage of flatus is abnormal (4). Patients should be asked if they have FI, because more than 50% of patients will not disclose the symptom unless specifically asked (5). The frequency, amount (i.e., small stain, moderate amount (i.e., more than a stain but less than a full bowel movement), or a large amount (i.e., full bowel movement)), type of leakage, and presence of urgency should be ascertained. Semi-formed or liquid stools pose a greater threat to pelvic floor continence mechanisms than formed stools, whereas incontinence for solid stool suggests more severe sphincter weakness than for liquid stool. The awareness of the desire to defecate before the incontinent episode is variable, and may also provide clues to pathophysiology. Patients with urge incontinence experience the desire to defecate, but cannot reach the toilet on time. Patients with passive incontinence are not aware of the desire to defecate before the incontinent episode. Patients with urge incontinence have reduced squeeze pressures (6), and/or squeeze duration (7), and/or reduced rectal capacity with rectal hypersensitivity (8), whereas patients with passive incontinence have lower resting pressures (6). Nocturnal incontinence occurs uncommonly in idiopathic FI, and is most frequently encountered in diabetes mellitus and scleroderma.
Anorectal pain
As detailed in the algorithm, anorectal pain can be distinguished into levator ani syndrome and proctalgia fugax by distinctive clinical features. This classification system does not include coccygodynia, which refers to patients with pain and point tenderness of the coccyx (9), as a separate entity. Most patients with rectal, anal, and sacral discomfort have levator rather than coccygeal tenderness (10). There are many similarities between clinical anorectal and urogenital disorders characterized by chronic pain. Although the pathophysiology is largely unclear, tenderness to palpation of pelvic floor muscles in chronic pelvic pain and levator ani syndrome may reflect visceral hyperalgesia and/or increased pelvic floor muscle tension (11). Some patients with levator ani syndrome may have increased anal pressures (12). Finally, there is a strong association between chronic pelvic pain and psychosocial distress on multiple domains (e.g., depression and anxiety, somatisation, and obsessive-compulsive behavior) (13); whether this reflects an underlying cause or an effect of pain is unclear.
REFRACTORY CONSTIPATION AND DIFFICULT DEFECATION
Case history
A 32-year-old office worker is referred to a gastroenterologist by her primary care physician because of a 3-year history of chronic constipation, which has not responded well to therapy (Box 1, Figure 1). She has on average two bowel movements weekly but these are usually small, of hard or normal consistency, and passed with considerable straining. after attempts at defecation, she is left with a sensation of incomplete evacuation. She has not used manual maneuvers to facilitate defecation. She has no abdominal pain, but does experience abdominal bloating on the day before defecation. There has been no rectal bleeding or weight loss. She is otherwise well, with no known systemic diseases associated with constipation, and has had no pregnancies or pelvic or abdominal surgery. She takes no medications for constipation. There is no family history of gastrointestinal disease.
Her physical examination is normal. Digital rectal examination reveals normal anal resting tone and contractile response during squeeze. Simulated evacuation was accompanied not by relaxation but by paradoxical contraction of the puborectalis muscle and no perineal descent. Fiber supplements, PEG laxative and lactulose, prescribed at various times by her primary care physician, make her feel bloated and uncomfortable with no improvement in her constipation (Box 1). Bisacodyl gives her abdominal cramps, and a trial of lubiprostone made her nauseated, with neither improving her bowel habits. At times when she has not moved her bowels for several days she uses a glycerol suppository to aid evacuation.
CBC, ESR, and biochemistry panel, including metabolic screen, arranged by her primary care physician 12 months earlier, were normal. The symptoms were significantly affecting her quality of life and the gastroenterologist decided to arrange for further diagnostic testing. These physiologic tests include assessment of colonic transit, anorectal manometry, and the rectal balloon expulsion test (Box 2). Anorectal manometry demonstrates a recto-anal profile during expulsion efforts that features an inappropriate contraction of the anal sphincter (increase in anal sphincter pressure) despite an adequate propulsive force (intrarectal pressure of 50 mm Hg). Resting and squeeze anal sphincter pressures are 60 (normal 48–90) and 100 (normal 98–220) mm Hg, respectively. Rectal sensory thresholds for first sensation, the desire to defecate, and urgency are 30, 100, and 160 ml respectively; values above approximately 100, 200, and 300 ml for these thresholds are abnormal (14). The balloon expulsion test reveals that the patient is unable to expel the water-filled (50 ml) balloon within 2 min on each of two attempts (normal <60 s). Using the Hinton technique for measuring colonic transit, the patient swallowed a capsule containing 24 radio-opaque markers. after 5 days, an abdominal X-ray obtained in the supine position (110 keV) showed three markers remaining in the sigmoid colon and rectum (normal <5 markers) (Box 3). Th us both anorectal manometry and the balloon expulsion test are abnormal (Boxes 3 and 7). On this basis a diagnosis of a functional defecation disorder is made (Box 8). This disorder is further characterized as functional defecation disorder with normal transit (Boxes 11 and 13).
On this basis the patient is referred to the laboratory for anorectal biofeedback therapy. She undergoes five biofeedback sessions during a 5-week period with a trained therapist. Other centers provide a more intensive program with 2–3 sessions daily over 2 weeks. Using biofeedback, she learns to normalize her defecation profile. She reports significant clinical improvement and is now able to expel the balloon within 20 s.
FECAL INCONTINENCE
Case history
A 60-year-old telephone operator is referred to a gastroenterologist because of FI, which has been present for 2 years. Her usual bowel habit is that she passes 1–2 soft but formed bowel movements daily, feeling satisfied thereafter. Approximately once a week, however, she is incontinent for a small amount of semi-formed stool, perhaps the size of a quarter, often while walking or standing (Box 1, Figure 2). She is aware of the incontinent episode approximately 50% of the time, and there is no associated urgency. She can usually differentiate between the sensation of gas and stool in her rectum, and is often incontinent for flatus. She wears a pantiliner throughout the day, everyday. These symptoms make it difficult for her to continue with her current work, and have significantly affected her quality of life. There is no blood or mucus in the stools and she has no other significant gastrointestinal symptoms. A review of other systems is negative; in particular she has no urinary or neurological symptoms (Box 2). Her dietary history does not reveal symptoms of carbohydrate intolerance. She has no other medical conditions and is taking multivitamins only. The obstetric history is notable for two vaginal deliveries accompanied by episiotomy but no forceps assistance or anal sphincter injury.
General physical examinations, including abdominal exam, are normal. Neurological examination is grossly normal. Digital rectal examination (Box 2) does not reveal any evidence of fecal impaction (Box 3), and there are no anorectal lesions detected. There is a reduced anal-resting tone, a reduced anal-squeeze response, a normal puborectalis lift to voluntary command, and normal perineal descent during simulated evacuation (Box 2). During the digital rectal examination, perineal descent is estimated by inspecting for perineal descent during simulated evacuation and normally should be <3 cm. Perianal pinprick sensation and anal wink reflex are normal.
The gastroenterologist confirmed that she did not have episodes of loose or frequent stools (Box 5), and obtained further history that she had tried loperamide (Box 7), but this did not produce any significant improvement (Box 8) and in fact caused constipation. She had also tried using a perianal cotton plug (Box 7), but was not satisfied with this (Box 8). Anal manometry is then arranged (Box 10). This reveals average anal-resting (35 mm Hg) and -squeeze (90 mm Hg) pressures at the lower limit of normal (for her age, normal values for resting and squeeze pressure are 29–85 mm Hg and 88–179 mm Hg, respectively) (Box 11). The anal cough reflex is present but weak. Although the rectal sensory threshold for first sensation is normal, her maximum tolerable capacity is reduced (i.e., 60 cc). She is able to expel a rectal balloon within 20 s. Endoanal magnetic resonance imaging of the sphincters (Box 13) discloses mild anterior focal thinning of the internal and external sphincters (Box 14). Puborectalis structure and function appear normal. Dynamic MRI reveals normal puborectalis function during squeeze and evacuation. Based on these findings, anal sphincter weakness and altered stool consistency likely contribute to FI. As the abnormality of sphincter structure is minor, a diagnosis of functional FI is made (Box 12).
CHRONIC ANORECTAL PAIN
Case history
A 52-year-old woman is referred to a gastroenterologist because of rectal discomfort of 8 months duration (Box 1, Figure 3). She describes the pain as a deep, dull aching discomfort, lasting for some hours, and often precipitated or worsened by sitting (Box 2). The pain is not associated with bowel movements or eating (Box 4). The pain occurs inconsistently but is present, at a moderate level of severity, for as many as 4–5 days each week, and there are no pain-free intervals (Box 6). She averages five bowel movements weekly, passed with minimal straining and, on some occasions, with a sense of incomplete evacuation; there has been no change in bowel habits and no rectal bleeding. There is no history of dyspareunia, dysuria, back pain, or trauma. She has had no pelvic surgery. A pelvic exam by her gynecologist was normal and a pelvic ultrasound was negative (Box 2). A colonoscopic screening 2 years ago was normal. She has no other significant medical illnesses.
General physical examination, including abdominal and neurological examination, is normal. Digital rectal examination discloses no perianal disease or tenderness (Box 2). Anal canal tone and squeeze are normal. Perianal pinprick sensation and anal wink reflex are normal. Palpation of the coccyx is not painful and no masses are felt. However, there is tenderness with posterior traction of the puborectalis muscle, greater on the left than right (Box 8).
The gastroenterologist arranges a complete blood count and ESR and recommends flexible sigmoidoscopy and perianal imaging (Box 2), to exclude inflammation and neoplasia. These tests are normal. A diagnosis of levator ani syndrome is made (Box 9).
Footnotes
CONFLICT OF INTEREST
Guarantors of the article: The Rome Foundation.
Specific author contributions: Equal contribution toward all aspects of the paper, Adil E. Bharucha and A. Wald.
Financial support: The expenses for a 1 day planning meeting were covered by The Rome Foundation and $1000 for working on the Rome algorithms.
Potential competing interests: No conflicts of interest exist.
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