Contracción paradojal del puborrectal como causa de defecación obstructiva: resultados a corto plazo del tratamiento con biofeedback y rehabilitación pelviperineal / Puborectal paradoxical contraction as a cause of obstructive defecation: short-term outcomes of treatment with biofeedback and pelviperineal rehabilitation

Resumen Introducción: En pacientes constipados crónicos por obstrucción de salida, la contracción paradojal del puborrectal (CPP) o "anismo" es frecuente. El tratamiento con Biofeedback y rehabilitación pelviperineal presenta resultados exitosos entre el 40-90%. Objetivo: Evaluar el resultado del tratamiento con Biofeedback y rehabilitación pelviperineal en pacientes con CPP a corto plazo. Materiales y Método: Serie de casos. Datos obtenidos prospectivamente de la Unidad de Piso Pelviano. Se incluyó pacientes entre 2008 y 2015 que cumplían criterios de constipación crónica secundaria a CPP, confirmado por manometría anorrectal y/o defeco-resonancia. Se analizaron datos demográficos, frecuencia de evacuaciones, uso de laxantes, enemas, pujo, Score de Altomare y Score de constipación de Wexner pre y post-tratamiento. Resultados: 43 pacientes, de los cuales 39 son mujeres. Edad media de 40 años (rango: 14-84). Duración de síntomas fue ≥ 5 años en el 72,5%. Mediana de sesiones de Biofeedback de 8 (6-10). El 62,8% presenta ≤ 2 evacuaciones semanales y disminuye a un 29,3% post-tratamiento (p < 0,001). El 76,2% requiere laxantes orales y el 42,9% enemas, disminuyendo a 35,1% (p < 0,001) y 5,4% (p < 0,001) respectivamente post-tratamiento. Sensación de evacuación incompleta/fragmentada en todos los intentos mejoró de 67,4% a 14,6% (p < 0,001) y el pujo excesivo en más de la mitad de intentos mejoró de 76,1% a 10,8% (p < 0,001). Score de Wexner para constipación y Altomare mejoró de 18 a 7 (p < 0,001) y de 16 a 5 (p < 0,001) respectivamente. Conclusión: El biofeedback y la rehabilitación pelviperineal son efectivas en el tratamiento de la CPP.

Introduction: In patients with chronic constipation by obstructive defecation syndrome Paradoxical Puborectalis Contraction or "anismus" is important. Successful results for Biofeedback treatment and Pelviperineal Rehabilitation it described between 40-90%. Aim: To evaluate the outcome of biofeedback and pelviperineal rehabilitation in patients with CPP in the short-term. Materials and Method: Case series. Data was obtained from the prospective database of Pelvic Floor Unit of Universidad Católica de Chile. Patients with anismus were included between 2008 and 2015. Diagnostic criteria were chronic constipation patients by anismus with anorectal manometry and/or defecoresonancy that confirms this disorder and discards other causes of obstruted defecation síndrome. Demographic variables, frequency of bowel movements, use of laxatives, enemas, pushing, Altomare Score and Wexner constipation Score were analyzed pre and post-treatment. Results: Series of 43 patients, 39 of whom where women. Median age: 40 years (range: 14-84). Duration of symptoms ≥ 5 years in 72.5%. Median of Biofeedback sessions: 8 (range 6-10). Pre-treatment, 62.8% had ≤ 2 evacuations weekly and 29.3% post-treatment (p < 0.001). Oral laxatives were required in 76.2% and 42.9% enemas, decreasing to 35.1% (p < 0.001) and 5.4% (p < 0.001) post-treatment respectively. Feeling of incomplete/evacuation fragmented all the time improved from 67.4% to 14.6% (p < 0.001) and excessive pushing in more than half of time improved from 76.1% to 10.8% (p < 0.001). Wexner Score for and Altomare Score improved from 18 to 7 (p < 0.001) and 16 to 5 (p < 0.001) respectively. Conclusion: Adult with chronic constipation by anismus can be treated effectively with Biofeedback and Pelviperineal Rehabilitation.

Biofeedback therapy combined with diet to treating ODS (Anismus): 2 years outcome / Terapia por biofeedback combinada com dieta no tratamento da SDO (Anismus): desfecho de 2 anos

ABSTRACT Object: The advantages of biofeedback therapy along with diet in patients with constipation are among the issues discussed nowadays. The aim of this study was to evaluate 2 years outcome of biofeedback therapy along with diet in patients with obstructed defecation syndrome (ODS) (Anismus). Methodology: The focus of this prospective study is a group of 129 patients with ODS constipation, who were referred to two tertiary-care referral academic centers from 2013 to 2016. Patients received biofeedback therapy combined with appropriate diet in cases group and received diet in controls group. Good response was defined as a subject with at least 50 percent improvement from before to after biofeedback therapy on a Cleveland Clinic Florida Constipation Scoring System (CCF). Factors associated with better outcome were analyzed using SPSS 20 software. Results: Out of the 129 patients, 112 patients (86.8%) were female. The mean age of patients was 42.44 ± 15.05 years. The mean CCF score of the patients before and after biofeedback therapy was 12.41 ± 4.39 and 6.00 ± 3.28 respectively in case group (p-value < 0.001). In addition, the mean CCF score of the patients before and after diet therapy was 12.82 ± 4.85 and 9.43 ± 3.79 respectively in control group (p-value < 0.001). While CCF score in both case and control groups reduced significantly after therapy, the rate of this reduction was higher in case group (p < 0.001). Conclusion: Our findings suggest that biofeedback therapy combined with diet will improve patients outcome in ODS constipation. Prospective clinical trials with larger sample sizes are recommend allowing for causal correlations.

RESUMO Objetivo: As vantagens da terapia por biofeedback, juntamente com a dieta, em pacientes com constipação se situam entre os tópicos atualmente em discussão. O objetvo desse estudo foi avaliar os resultados, após 2 anos, da terapia por biofeedback associada à dieta em pacientes com síndrome da defecação obstruída (SDO) (Anismus). Metodologia: O enfoque desse estudo prospectivo é um grupo de 129 pacientes com constipação por SDO, encaminhados a dois centros acadêmicos de referência para atendimento terciário entre os anos de 2013 e 2016. Os pacientes receberam terapia por biofeedback em combinação com dieta apropriada no grupo de estudo (casos), e apenas dieta no grupo de controle. Boa resposta foi deinida como o paciente com pelo menos 50% de melhora desde antes até após a terapia por biofeedback, com o uso de um Sistema de Pontuação para Constipação do Centro Médico Cleveland Clinic Florida (CCF). Os fatores associados a melhor desfecho foram analisados com o uso do programa SPSS 20. Resultados: Dos 129 pacientes, 112 (86,8%) eram mulheres. A média de idade dos pacientes era de 4244 ± 15,05 years. O escore CCF médio dos pacientes antes e depois da terapia por biofeedback foi 12,41 ± 4,39 e 6,00 ± 3,28 respectivamente no grupo de casos (P < 0,001). Além disso, o escore CCF médio dos pacientes antes e depois da dietoterapia foi 12,82 ± 4,85 e 9,43 ± 3,79 respectivamente no grupo de controle (P < 0,001). Embora o escore CCF tanto no grupo de casos como no grupo de controle tenha apresentado redução significativa após a terapia, o grau dessa redução foi mais elevado no grupo de casos (P < 0,001). Conclusão: Nossos achados sugerem que a terapia por biofeedback em combinação com a dieta melhora o resultado para os pacientes apresentando constipação por SDO. Recomendamos a realização de estudos clínicos prospectivos com amostras mais expressivas, que permitam o estabelecimento de correlações causais.

Anismus, Physiology, Radiology: Is It Time for Some Pragmatism? A Comparative Study of Radiological and Anorectal Physiology Findings in Patients With Anismus

PURPOSE: Anismus is a functional disorder featuring obstructive symptoms and paradoxical contractions of the pelvic floor. This study aims to establish diagnosis agreement between physiology and radiology, associate anismus with morphological outlet obstruction, and explore the role of sphincteric pressure and rectal volumes in the radiological diagnosis of anismus. METHODS: Consecutive patients were evaluated by using magnetic resonance imaging proctography/fluoroscopic defecography and anorectal physiology. Morphological radiological features were associated with physiology tests. A categorical analysis was performed using the chi-square test, and agreement was assessed via the kappa coefficient. A Mann-Whitney test was used to assess rectal volumes and sphincterial pressure distributions between groups of patients. A P-value of 0.05). The sphincterial straining pressure was 71 mmHg in the anismus group versus 12 mmHg. Radiology was likely to identify anismus when the straining pressure exceeded 50% of the resting pressure (P = 0.08). CONCLUSION: Radiological techniques detect pelvic morphological abnormalities, but lead to overdiagnoses of anismus. No proctographic pathological feature predicts anismus reliably. A stronger pelvic floor paradoxical contraction is associated with a greater likelihood of detection by proctography.

Correlation of anorectal electromanometry and anorectal three-dimensional ultrasound findings in patients with fecal incontinence / Correlação dos achados da eletromanometria anorretal e ultrassonografia anorretal tridimensional nos pacientes portadores de incontinência fecal

Objective: To show the correlation of anorectal electromanometry and three-dimensional anorectal ultrasonography in patients with fecal incontinence. Method: Prospective study involving 34 women (mean age: 55 years) with a diagnosis of fecal incontinence. The samples were submitted to three-dimensional anorectal ultrasonogra- phy/Echodefecography and anorectal electromanometry. Results: Based on anorectal electromanometry data, 70.5% of 34 patients had hypotonia at rest, 64.7% had hypotonic contraction, 52.9% had both hypotonia at rest and hypotonic contraction, and 44.1% had anismus. By three-dimensional anorectal ultrasonography, 32.3% had internal anal sphincter injury, 79.4% had external anal sphincter injures, and 26.4% had both internal and external anal sphincter injuries. In 38.2%, anismus was suggested and 50% showed rectocele. Overall, only 5.8% had normal results for anorectal electromanometry combined with three-dimensional anorectal ultrasonography. Kappa index was 0.297 and the presence of anismus through anorectal electromanometry and three-dimensional anorectal ultrasonography was compared by Student's t test application, with p<0.0001. Conclusion: We conclude that there was a reasonable agreement in the comparison of sphincter hypotonia by anorectal manometry and sphincter injury by anorectal three-dimensional ultrasonography in a group of patients with fecal incontinence. The incidence of anismus in patients with fecal incontinence is considerable, and the therapeutic approach in these patients should be modified. (AU)

RESUMO Objetivo: Demonstrar a correlação entre eletromanometria anorretal (EMAR) e ultrassonografia tridimensional anorretal (3D-US) em pacientes com incontinência fecal. Método: Estudo prospectivo envolvendo 34 mulheres (média de idade: 55 anos) com diagnóstico de incontinência fecal. As amostras foram submetidas à 3D-US/Ecodefecografia e EMAR. Resultados: Com base nos dados de EMAR, 70,5% das 34 pacientes exibiam hipotonia em repouso, 64,7% exibiam contração hipotônica, 52,9% hipotonia em repouso e contração hipotônica, e 44,1% exibiam anismus. Com base nos achados de 3D-US, 32,3% exibiam lesão no esfíncter anal interno, 79,4% exibiam lesão no esfíncter anal externo, e 26,4% em ambos os esfíncteres anais interno e externo. Pela 3D-US, em 38,2% das pacientes houve indício de anismus, e em 50%, retocele. No total, apenas 5,8% obtiveram resultados normais combina- dos para EMAR e 3D-US. Foi constatado um índice Kappa = 0,297 e, no teste t de Student, a comparação de anismus por EMAR e por 3D-US obteve significância de p<0,0001. Conclusão: Concluímos ter havido concordância razoável ao ser comparada a manomatria anorretal para hipotonia esfinctérica e a ultrassonografia tridimensional anorretal para lesão esfinctérica em um grupo de pacientes com incontinência fecal. A incidência de anismus em pacientes com incontinência fecal é considerável, e a abordagem terapêutica para esses pacientes deve ser modificada. (AU)

Effectiveness of treatment using fecal incontinence biofeedback isolated or associated with electrical stimulation / Eficácia do tratamento de incontinência fecal utilizando o biofeedback isolado ou associado a eletroestimulação

Introduction: The prevalence of fecal incontinence (FI) has increased in recent decades, due to an aging population; and result in negative impacts on quality of life. Therefore, it is essential to search for an effective treatment in order to minimize the morbidity caused by incontinence. Objective To evaluate the effect of perineal training in the treatment of patients with fecal incontinence by biofeedback. Method: This is a prospective study which evaluated 85 patients with FI from January 2009 to January 2014, at the Coloproctology outpatient clinic of the Hospital São Lucas/Cascavel, Paraná. Results: Mean age was 47 years and the duration of treatment ranged from 5 to 25 sessions (mean, 13 sessions). From the women involved in the study, 70% (50) had vaginal deliveries and 34 (40%) participants were submitted to some orificial surgery. The FI score at baseline was 10.79 (6-17) and post-treatment FI was 2 (0-14) (p < 0.001). In the population studied, 49.4% (42) of the patients had an associated pre-BFT UI; and only 8.2% (7) had post-BFT UI (p < 0.001). Conclusions: The data presented in this study confirm that perineal training through biofeedback was effective in the treatment of patients with fecal incontinence without immediate indication for surgery, still ensuring for this technique the advantages of being effective, painless and of low cost. (AU)

Introdução: A prevalência de incontinência fecal (IF) vem aumentando nas últimas décadas devido ao envelhecimento da população; e resulta em impactos negativos na qualidade de vida. Logo, torna-se fundamental a busca de um tratamento efetivo, a fim de minimizar a morbidade ocasionada pela incontinência. Objetivo: Avaliar o efeito do treinamento perineal no tratamento de pacientes portadores de incontinência fecal através do biofeedback. Método Estudo prospectivo, que avaliou 85 pacientes com IF no período de janeiro de 2009 a janeiro de 2014, no ambulatório de Coloproctologia do Hospital São Lucas/Cascavel, Paraná. Resultados: A média de idade foi de 47 anos e a duração do tratamento variou de 5 a 25 sessões (média de 13 sessões). Das mulheres envolvidas no estudo, 70% (50) tiveram partos vaginais e 34 (40%) indivíduos fizeram alguma cirurgia orificial. O escore de IF na avaliação inicial foi de 10,79 (6 a 17) e no pós-tratamento foi de 2 (0 a 14) (p < 0,001). Na população estudada, 49,4% (42) dos pacientes apresentaram IU associada no pré-TBF e apenas 8,2% (7) no pós-TBF (p < 0,001). Conclusões Os dados demonstrados neste estudo confirmam que o treinamento perineal através do biofeedback mostrou-se eficaz no tratamento de pacientes com incontinência fecal sem indicação imediata de cirurgia, assegurando ainda para essa técnica as vantagens de ser eficaz, indolor e de baixo custo. (AU)

Biofeedback Therapy for Patients with Rectocele

PURPOSE: The aim of this study was to determine the outcome and identify predictors of success of biofeedback therapy for rectocele. METHODS: Twenty four female patients (mean age 43.8 years) with rectal emptying difficulties and a rectocele greater than 2 cm at defecography were evaluated before hand with a standardized questionnaires, immediately after biofeedback therapy, and at follow up. Defecography, manometry, colon transit studies and electrophysiology were also analyzed. RESULTS: Follow up (mean 7.2; range 2~17 months) results were evaluated by an independent observer in 20 patients. At the end of biofeedback, 22 (92 percent) patients felt improvement in symptoms, including 13 (54 percent) with symptomatic relief. At follow-up, 14 (70 percent) patients felt improvement in symptoms, including 3 (15 percent) with complete relief of symptoms. There was a significant reduction in difficult defecation (from 79 to 29, 40 percent, from pre-biofeedback to post-biofeedback, at follow-up respectively; P<0.001, P<0.05), sensation of incomplete defecation (from 96 to 46, 60 percent; P<0.001, P<0.005), laxative use (from 54 to 25, 30 percent; P<0.05), enema use (from 21 to 0,0 percent; P<0.05), anal pain (from 21 to 0, 5 percent; P<0.05) and digitation (from 21 to 4, 5 percent). Normal spontaneous bowel movement was significantly increased from 50 percent pre-biofeedback to 83 post-biofeedback (P<0.05), 65 percent at follow-up. Abdominal pain (P<0.05) and digitation (P<0.05) related to poor results. High mean squeeze pressure (P<0.001) and high maximum squeeze pressure (P<0.05) on pre-biofeedback manometry were also related to a poor outcome. Age, duration of symptoms, parity, number of sessions of biofeedback, gynecologic surgery history, and rectocele size at defecography had no prognostic value. Anismus and colonic inertia did not influence the outcome of biofeedback. CONCLUSIONS: Biofeedback is an effective treatment option for patients with obstructed defecation due to rectocele.

Clinical Results of Subtotal Colectomy in Chronic Constipation Patients

PURPOSE: The aim of this study was to assess the outcome of subtotal colectomy on patients with a diagnosis of chronic constipation. METHODS: A retrospective review of 11 consecutive patients who underwent subtotal colectomy between January 1990 and July 1999 was undertaken. Preoperative testings included complete history and physical examination, anorectal manometry, videodefecography, and colonic transit studies. RESULTS: The 11 patients consisted of 5 men and 6 women, with a mean age of 44 (range, 25~62) years. The most common symptom was inability to defecation and mean duration of this symptom was 13.6 (range, 0.75~45) years. Ten patients had slow colon transit and one patient had normal colon transit with anismus. All patients were followed up for mean duration of 33 (range, 5~120) months. Mean bowel frequency was 4 times per day after colectomy. Nine patients were satisfied with the results of surgery and showed improvement in quality of life. One patient was less satisfied due to diarrhea even with several times bowel movement per day. One patient felt that the operation was not so effective due to incontinence for liquid stool and 7 bowel movement per day. Three patients frequently used antidiarrheal medication after surgery. Three patients had postoperative small bowel obstruction and were treated without surgery. CONCLUSION: Subtotal colectomy with ileorectal anastomosis produces a satisfactory functional outcome in the majority of patients with proven slow transit constipation.