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Medical Evaluation of Functional GI Disorders
Published in Kevin W. Olden, Handbook of Functional Gastrointestinal Disorders, 2020
Michael Camilleri, Jeffrey W. Frank
If all these tests are normal, we do not perform any more general investigations, but use the clinical history and examination to suggest a specific test or tests to demonstrate an altered function that would result in a specific treatment rather than the customary symptomatic treatment. For example, if the patient has intractable constipation despite increased dietary fiber, or if there are disturbances of defecation, we pursue further testing because this may lead to additional therapeutic approaches, such as osmotic laxative and prokinetic therapy in those with slow-transit constipation, or biofeedback for those with anismus or pub-orectalis spasm.
Motility disorders
Published in Michael JG Farthing, Anne B Ballinger, Drug Therapy for Gastrointestinal and Liver Diseases, 2019
Normal defaecation requires co-ordinated relaxation of the internal and external anal sphincters, with straightening of the anorectal angle secondary to relaxation of the puborectalis. Accurate diagnosis requires anorectal manometry, occasionally with defaecating proctography. Anorectal manometric studies measure rectal and anal sphincter pressures, and also the anorectal reflex. Anismus is the association of a high resting pressure in the anal canal with failure of relaxation during defaecation. The puborectalis syndrome describes the inability of the puborectalis sling to relax appropriately. There is considerable overlap between these features; they are now best described together as ‘functional outflow obstruction’.
The large intestine
Published in Paul Ong, Rachel Skittrall, Gastrointestinal Nursing, 2017
Constipation is associated with a number of pathophysiological diseases which can be grouped into two major types in the body. Constipation is therefore generally considered a symptom, rather than a disease in itself (Kamm, 2003; Duncan, 2004). The first pathophysiological type described is rectal outlet delay (also known as outlet obstruction or disordered defaecation) where the person has difficulty evacuating stool (Harari, 2002). Diseases and conditions that can lead to rectal outlet delay and chronic constipation include neurologic disorders such as Parkinson's disease or stroke (Wiesel and Bell, 2004). Also a condition called anismus which is characterised as a paradoxical (as opposed to a normal) contraction of the anal sphincter and pelvic floor (Preston and Lennard-Jones, 1985; Edwards et al., 1994). The second pathophysiological type described is slow colonic transit which occurs when colonic peristalsis is ineffective at facilitating the transport of stool to the rectum at a rate that prevents constipation (Müller-Lissner, 2002).
Botulinum toxin type-A infiltration of the external anal sphincter to treat outlet constipation in motor incomplete spinal cord injury: pilot cohort study
Published in Scandinavian Journal of Gastroenterology, 2021
Margarita Vallès, Sergiu Albu, Hatice Kumru, Fermín Mearin
Our findings are in line with previous reports of improved bowel function inpatients with obstructed defecation due to functional anismus, and with outlet constipation in Parkinson's disease patients [8,11,12,27–30]. Although BTX infiltration had variable effect on the basal anal canal pressure and the pressure of voluntary contraction of the EAS, most studies observed a reduction in anal canal pressure during the defecatory manoeuvre, which improves symptoms of obstructed constipation [8,11,12,27,29,30]. Moreover, in studies where defecography was performed, an increase in the anorectal angle during the defecatory maneuvers was observed following BTX infiltration [8,11,12,30]. However, these studies included patients with different neurological diseases, did not have a control group, infiltration was done in different target muscles (EAS or puborectalis muscle), applied different dose of BTX-A (30–100 UI), and used different monitoring techniques (clinically, electromyography or ultrasonography).
Physiotherapist management of a patient with spastic perineal syndrome and subsequent constipation: a case report
Published in Physiotherapy Theory and Practice, 2021
Shankar Ganesh, Mritunjay Kumar
Isolated defecatory dysfunction can occur in 25% of the persons suffering from constipation (Lembo and Camilleri, 2003). In the normal state, the anorectal angle is maintained by the tonic contraction of the puborectalis muscle and the anal sphincter is closed. During normal defecation smooth muscle relaxation of the anal canal (Sorensen, Lorentzen, Petersen, and Christiansen, 1991) occurs along with the relaxation of puborectalis muscle, straightening out the anorectal angle. In dyssynergic type of constipation, there is a paradoxical contraction of pelvic floor muscles (i.e. puborectalis muscle and external anal sphincter) leading to the significantly impaired ability to expel stool during attempts to defecate (Dailianas et al., 2000). These patients have a functional outlet obstruction related to the neuromuscular dysfunction of the defecation unit and are addressed by other names in the literature such as anismus, pelvic floor dyssynergia, obstructive defecation, paradoxical puborectalis contraction, pelvic outlet obstruction, and spastic pelvic floor or perineal syndrome. In this study, we have used the term dyssynergic defecation (DD) to refer to constipation that occurs as a result of pelvic floor dysfunction. The term functional constipation (FC) has been used where the cause of constipation could not be identified.