The Clinical Characteristics and Outcomes of Biofeedback Treatment for Patients with Nonrelaxing Puborectalis Syndrome

PURPOSE: Biofeedback treatment is thought to be appropriate for patients with nonrelaxing puborectalis syndrome (NRPR). The aim of this study is to analyze the physiologic characteristics and to assess the outcomes of biofeedback treatment for patients with NRPR. METHODS: Forty-six (46) patients with NRPR were evaluated with anorectal physiologic studies, including colonic transit time (n=26), anorectal manometry (n=41), defecography (n=46), anal sphincter EMG (n=28), and colonoscopy or barium enema (n=33). The treatment consisted of a training program with EMG-based biofeedback for 30 minutes once a week and routine supportive care, including Kegel practice. RESULTS: The mean age was 52.8 years, and the sex ratio was 1 male to 0.6 female. A delayed colonic transit time was noted in 5 patients (19.26%). In the NRPR group, the maximal voluntary contraction and the mean squeezing pressure were higher than they were for other patients with pelvic outlet obstructive disease. Also, the perineal descents and the dynamic change of anorectal angle were shorter. Polyps were observed in 6 patients (18.2%), melanosis coli in 4 patients (12.1%), and diverticula in 3 patients (9.1%). The rectoanal inhibitory reflex (RAIR) was negative in 3 patients (7.3%). The patients underwent a mean of 4.0 sessions, and the mean follow-up was 7.4 months. Twenty-three (23) patients (82.1%) experienced improved of symptoms or EMG findings. The patients (17.9%) who did not improve had several abnormal findings: neuro-psychologic disease with delayed colonic transit time in 2 cases, negative RAIR in 2 cases, and melanosis coli in one case. CONCLUSIONS: We think that biofeedback training is an effective treatment for patients with NRPR. In addition, several factors, such as neuro-psychologic diseases, delayed colonic transit time, negative RAIR, or melanosis coli may influence the prognosis for biofeedback treatment, so further large-scaled studies will be needed to confirm these findings.

The Clinical and Physiologic Characteristics of Patients with Pelvic Outlet Obstructive Disease

PURPOSE: With recent anorectal physiologic studies, functional etiologies of pelvic outlet obstructive disease were evaluated in detail. The current study was designed to assess the clinical and the physiologic characteristics of patients with pelvic outlet obstructive disease. METHODS: one hundred two (102) patients with pelvic outlet obstructive disease were evaluated with anorectal physiologic studies, including the colonic transit time (n=66), anorectal manometry (n=88), defecography (n=102), anal sphincter EMG (n=50), and colonoscopy or barium enema (n=77). The patients were categorized as group I (nonrelaxing puborectalis syndrome), group II (rectocele), group III (sigmoidocele), and group IV (rectoanal intussusception). The clinical and the physiologic characteristics were compared between the groups. RESULTS: The mean age was 51.9 years, and the sex ratio was 1:1.9. the populations of the groups were group I 45.1% (n=46), group II 36.3% (n=37), group III 5.9% (n=6), and group IV 9.8% (n=10). In group II and group III, co-existing etiologies were more, and the incidences of female patients was higher (P<0.05). Delayed colonic transit time was noted in 11 patients (17%). Diverticula was observed in 6 patients (8%), polyps in 12 patients (16%), and melanosis coli in 14 patients (18%). On anorectal manometry, group I showed higher maximal voluntary contraction and mean squeezing pressure than the other groups (P<0.05). On defecography, group I had a shorter perineal descent at rest and a smaller anorectal angle at push (P<0.05). CONCLUSIONS: The current study showed the clinical and the physiologic characteristics of the each functional etiology in patients with pelvic outlet obstructive disease. These results provide fundamental data for diagnosis of and tailored therapy for pelvic outlet obstructive disease.

Investigation of Defecographic Findings in Patients with Pelvic Outlet Obstructive Disease

PURPOSE: Defecography is a dynamic investigation which can influence clinical decision making in patients with pelvic outlet obstructive disease (POOD). The current study was designed to establish defecographic findings in patients with POOD. Specifically, we sought to assess the physiologic characteristics of categorized types by using anorectal physiologic tests. METHODS: One hundred seven patients (disease group; 45 men, 62 women) with POOD were retrospectively categorized as type I [non-relaxation of puborectalis (NRPR) only, n=19], type II [NRPR and rectocele, n=20], type III [NRPR, rectocele, and dynamic perineal descent (PD), n=17], type IV [deformed rectocele, mild-to-moderate fixed PD, and absence of NRPR, n=29], and type V [rectocele, severe fixed PD, and absence of NRPR, n=20] on the bases of defecographic findings. The ability to evacuate, the frequency/degree of intarectal intussusception (IRI), and the size of the rectocele were evaulated in these defecographic types of POOD. Age, duration of symptoms, and the physiologic findings of anal manometry and EMG/PNTML were compared for the five types. Eighteen healthy volunteers who had no defecation difficulty were used to estimate the normal findings of defecography. RESULTS: The age and the sex showed no significant differences among the types. The duration of symptoms was gradually lengthened from type I to V (P<0.01). The ability to evacuate in patients with POOD was significantly worse (failed to effectively evacuate) compared to that in the healthy volunteers (P<0.01). The frequency of IRI was increased more and more from type I to V (P<0.01). The size of the rectocele was significantly increased in types V compared to the other types (P<0.01). Manometric and neurologic findings, including EMG/PNTML, revealed no significant differences among the types. CONCLUSIONS: Even though there were no specific differences in the findings of the anal manometric and neurologic tests, the evacuation dynamics; were different in the five defecographic categories of patients with POOD. Specifically, these differences were relevants to the presence of NRPR, rectoceles, IRI, and perineal descent.

Psychiatric Investigation by Using the Minnesota Multiphasic Personality Inventory in Patients with Chronic Constipation

PURPOSE: Current study was designed to understand the personality and emotional composition of patients with chronic constipation. Specifically, the personality differences were evaluated in the ramified subgroups based on the physiologic characteristics. METHODS: Forty patients (31 females and 9 males) of a mean age of 48 (range, 16~86) years underwent the MMPI among 310 patients with chronic constipation. MMPI (Minnesota Multiphasic Personality Inventory) profiles were utilized for psychologic assessment for all patients prior to making diagnosis. Three validity scales of MMPI included L (Lie scale), F (Infrequency scale), K (Suppressor scale). Ten clinical scales included HS (hypochondriasis), DP (depression), HY (hysteria), PD (psychopathic deviant), MF (masculinity- feminity), PA (paranoia), PT (psychasthenia), SC (schizophrenia), MA (mania), SI (social introversion). On the basis of findings with use of anorectal physiologic studies, subgroups were categorized as patients with rectocele (A1, n=22), patient without rectocele (A2, n=18), patients with nonrelaxing puborectalis syndrome (B1, n=10), patients without nonrelaxing puborectalis syndrome (B2, n=30). The MMPI profiles were compared between subgroup patients. RESULTS: In overall patients, mean scores for scales HS, DP were elevated as compared with mean profiles (60~65 and 45~55, respectively). Male patients showed higher mean scores for scale SI than those of female patients (male vs. female; 63.5 vs. 53.9, P<0.05). A1 group showed higher mean scores for PD scale than those of A2 group (A1 vs. A2; 57.4 vs. 49.8, P=0.01). B1 group showed higher mean scores for DP scale than those of B2 group (B1 vs. B2; 67.5 vs. 59.8, P<0.05). CONCLUSIONS: Present series provided that the MMPI is a valuable tool for assessing the psychologic functioning of patients with chronic constipation. It has revealed a different personality and emotional composition in the subgroup patients based on the anorectal physiologic studies. An aspect of social introversion, psychopathic deviant and depression should be emphasized. These findings can provide the fundamental information for guideline of future diagnostic evaluation and therapy in the patients with chronic constipation.

Biofeedback Therapy in Patients with Nonrelaxing Puborectalis Syndrome: Are there differences of therapeutic effect according to methods of diagnosis?

PURPOSE: To evaluate therapeutic effect of biofeedback therapy according to methods of diagnosis in patients with norelaxing puborectalis syndrome. METHODS: From September, 1, 1998 to February, 30, 1999, the patients who were diagnosed with norelaxing puborectalis syndrome on anal electromyography (EMG) and/or cinedefecography (CD) underwent biofeedback therapy. The patients were divided into 3 groups according to the diagnostic method; CD group - only diagnosed on cinedefecography, EMG group - only diagnosed on anal electromyography, CD EMG group - diagnosed on both tests. RESULTS: Nineteen patients were diagnosed nonrelaxing puborectalis syndrome on CD and/or EMG. There were 14 females and 5 males with a mean age of 40.8+/-18.4 years. The patients were classified into CD group; five patients (26.3%); EMG group, eight patients (42.1%); CD EMG group, six patients (31.6%). The patients had 5.4 3.7 sessions of outpatient EMG-based biofeedback sessions. Subjective symptoms after biofeedback therapy improved in 4 (80.0%), 6 (75%), 5 (83%) patients in CD, EMG, CD EMG groups, respectively. There was a statistically significant increase in spontaneous bowel movements, and a reduction in assisted bowel movements after biofeedback therapy in patients in all three groups (p<0.05). However, no significant difference was found among the three groups. CONCLUSION: This study demonstrated that biofeedback therapy had a high therapeutic effect regardless to the diagnostic method. Therefore, biofeedbck therapy can be performed if one test results in the diagnosis of norelaxing puborectalis syndrome in patients with constipation.

Physiologic Characteristics and its Clinical Significances in the Patients with Pelvic Outlet Obstruction

Current study was designed to assess the functional etiology of patients with pelvic outlet obstruction. Moreover, physiologic characteristics and theirs clinical significances were evaluated in the patients with ramified diagnosis. METHODS: 172 patients with pelvic outlet obstruction were performed 328 numbers of physiologic studies. These included cinedefecography (n=172), anal manometry (n=87), colonic transit time study (n=38), and anal EMG/PNTML (n=31). On the basis of physiologic findings, patient groups were categorized as rectocele (group I), nonrelaxing puborectalis syndrome (group II), anal dyschezia (group III), and rectoanal intussusception (group IV). The physiologic findings were compared between subgroup patients. RESULTS: Incidence of categorized patients was 51.7% (group I, n=89), 22.7% (group II, n=39), 12.2% (group III, n=21), and 8.7% (group IV, n=15), respectively. The mean age of patients with group III were lower (p<0.05) than that of overall patients. The incidence of female patients was higher in group I and the incidence of male patients was higher in group II (p<0.0001). In cinedefecography, patients with group II showed smaller anorectal angle at strain (p<0.001), at dynamic change between rest and strain (p=0.002). In anal manometry, patients with group III showed higher mean resting pressures (p=0.001), higher maximum resting pressures (p<0.001), higher mean squeeze pressures, and higher maximal voluntary contraction (p=0.003) than those of patients with other group. In neurologic study, mean value of PNTML was 2.32 +/- 0.34 (range, 1.60~3.66) msec in overall patients. The size of rectocele was increased in proportion to patient's age (r=0.229, p<0.05), number of delivery (r=0.393, p=0.001), and degree of perineal descent (r=0.231, p<0.05). The degree of perineal descent was increased in proportion to patient's age (r=0.249, p<0.05). CONCLUSIONS: Present series provided the diagnostic ramification of pelvic outlet obstruction by using the anorectal physiologic investigations. In addition to the function of puborectalis muscle, evacuation dynamics of anorectum should be emphasized. These findings could provide the fundamental information for guideline of future therapy in the patients with obstructed defecation.