Defecation symptoms in primary health care patients with irritable bowel syndrome.

BACKGROUND: The objectives of the present study were to (a) measure the prevalence of defecation symptoms in IBS, (b) investigate the relationship between stool consistency and defecation symptoms in IBS, and (c) investigate the association of defecation symptoms with health-related quality of life (HRQL) and self-reported stress in patients with IBS cared for in a primary health care setting. METHODS: Ten primary health care centres joined the study. 282 patients with IBS as well as 372 non-IBS controls filled in gastrointestinal symptom diaries prospectively for two weeks as well as the Perceived Stress Scale-14 (PSS14) and the EuroQol barometer to measure perceived stress and HRQL, respectively. RESULTS: Incomplete evacuation was present in 51% vs. 21% of the stools among the IBS patients and the non-IBS controls, respectively. The need to strain during defecation was existing in 41% vs. 33% of the stools for the IBS patients and the non-IBS controls, respectively. Urgency was experienced in 37% of the stools in the IBS patients compared with 18% of the stools in the non-IBS controls. Patients with IBS experienced in a significant higher degree of overlapping symptoms per stool (p < 0.001 to p = 0.007). The occurrence of all defecation symptoms in the same patient was related to decreased HRQL, and increased stress (p = 0.001 to p < 0.001). CONCLUSIONS: An overlap between IBS and symptoms from the anorectal region related to defecation was found in a primary health care population. Defecation symptoms are very common in primary care IBS-patients, it co-occurs with increased self-perceived stress, and decreased HRQL.

Defecation Symptoms in Relation to Stool Consistency Significantly Reflect the Dyssynergic Pattern in High-resolution Anorectal Manometry in Constipated Patients.

GOALS: To evaluate the usefulness of a 2-week patient-completed bowel habit and symptom diary as a screening tool for disordered rectoanal coordination (DRC). BACKGROUND: DRC is an important subgroup of chronic constipation that benefits from biofeedback treatment. Diagnosis of DRC requires a dyssynergic pattern (DP) of attempted defecation in high-resolution anorectal manometry (HRAM) and at least 1 other positive standardized examination, such as the balloon expulsion test or defecography. However, HRAM is generally limited to tertiary gastroenterology centres and finding tools for selecting patients for referral for further investigations would be of clinical value. STUDY: Retrospective data from HRAM and a 2-week patient-completed bowel habit and symptom diary from 99 chronically constipated patients were analyzed. RESULTS: Fifty-seven percent of the patients had a DP pattern during HRAM. In the DP group, 76% of bowel movements with loose or normal stool resulted in a sense of incomplete evacuation compared with 55% of the non-DP group ( P =0.004). Straining and sensation of incomplete evacuation with the loose stool were significantly more common in the DP group ( P =0.032). Hard stool was a discriminator for non-DP ( P =0.044). Multiple logistic regression including incomplete evacuation and normal stool predicted DP with a sensitivity of 82% and a specificity of 50%. CONCLUSIONS: The sensation of incomplete evacuation with loose or normal stool could be a potential discriminator in favor of DP in chronically constipated patients. The bowel habit and symptom diary may be a useful tool for stratifying constipated patients for further investigation of suspected DRC.

Symptoms and health experience in irritable bowel syndrome with focus on men.

BACKGROUND: Irritable bowel syndrome (IBS) is a disorder with a predominance in women; IBS in men is less studied. The present study evaluated symptoms as well as health and social experiences of men with IBS. METHODS: This cross-sectional study included 293 patients with IBS (64 men) and 363 non-IBS controls (62 men). Gastrointestinal symptom diaries were filled in prospectively, and data on comorbidities and healthcare-seeking behavior were assessed by questionnaires. Men with IBS were compared with men without IBS and women with IBS. KEY RESULTS: Compared with women with IBS, men with IBS had fewer contacts with the healthcare system, fewer psychiatric comorbidities, fewer sleeping problems, and less chronic pain. Urgency to defecate and nausea were less common, and stool frequency was higher in men with IBS. There was no difference between men with and without IBS in terms of educational level, satisfaction with household economy, or living with a partner. In contrast, women with IBS more often lived alone, were more often dissatisfied with household economy, and had a lower educational level than women without IBS. Men with IBS had the same proportion of full-time employment as men without IBS but in contrast, the proportion of women with IBS in full-time employment was only 34%, compared to 50% of the women without IBS. CONCLUSION AND INFERENCES: The present study improves the understanding of men's experiences of IBS and suggests that sex and gender may be integrated into the biopsychosocial model of IBS.

Measuring the impact of gastrointestinal inconvenience and symptoms on perceived health in the general population - validation of the Short Health Scale for gastrointestinal symptoms (SHS-GI).

OBJECTIVES: Gastrointestinal (GI) symptoms are intimately related to our wellbeing. The Short Health Scale for GI symptoms (SHS-GI) is a simple questionnaire to measure the impact of GI inconvenience and symptoms on quality of life. The aim was to validate the SHS-GI in a general population sample and to compare it with SHS-data across different patient groups. METHOD: A subsample of 170 participants from a population-based colonoscopy study completed the Rome II questionnaire, GI diaries, psychological questionnaire (hospital anxiety and depression scale) and SHS-GI at follow-up investigation. Psychometric properties of SHS-GI as an overall score were determined by performing a confirmatory factor analysis (CFA). Spearman correlation between SHS total score and symptoms was calculated in the general population sample. SHS-GI data was compared with SHS data from patients with inflammatory bowel disease (IBD) and fecal incontinence (FI). RESULTS: As expected, the general population rated their impact of GI inconvenience on quality of life as better than the patient populations in terms of all aspects of the SHS-GI. The CFA showed a good model fit meeting all fit criteria in the general population. Cronbach's alpha for the total scale was 0.80 in the general population sample and ranged from 0.72 in the FI sample to 0.88 and 0.89 in the IBD samples. CONCLUSIONS: SHS-GI demonstrated appropriate psychometric properties in a sample of the normal population. We suggest that SHS-GI is a valid simple questionnaire suitable for measuring the impact of GI symptoms and inconvenience on quality of life in both general and patient populations.

Response of the muscles in the pelvic floor and the lower lateral abdominal wall during the Active Straight Leg Raise in women with and without pelvic girdle pain: An experimental study.

BACKGROUND: The relationship between activation of the stabilizing muscles of the lumbopelvic region during the Active Straight Leg Raise test and pelvic girdle pain remains unknown. Therefore, the aim was to examine automatic contractions in relation to pre-activation in the muscles of the pelvic floor and the lower lateral abdominal wall during leg lifts, performed as the Active Straight Leg Raise test, in women with and without persistent postpartum pelvic girdle pain. METHODS: Sixteen women with pelvic girdle pain and eleven pain-free women performed contralateral and ipsilateral leg lifts, while surface electromyographic activity was recorded from the pelvic floor and unilaterally from the lower lateral abdominal wall. As participants performed leg lifts onset time was calculated as the time from increased muscle activity to leg lift initiation. FINDINGS: No significant differences were observed between the groups during the contralateral leg lift. During the subsequent ipsilateral leg lift, pre-activation in the pelvic floor muscles was observed in 36% of women with pelvic girdle pain and in 91% of pain-free women (P=0.01). Compared to pain-free women, women with pelvic girdle pain also showed significantly later onset time in both the pelvic floor muscles (P=0.01) and the muscles of the lower lateral abdominal wall (P<0.01). INTERPRETATION: We suggest that disturbed motor activation patterns influence women's ability to stabilize the pelvis during leg lifts. This could be linked to provocation of pain during repeated movements.

Combination therapy with biofeedback, loperamide, and stool-bulking agents is effective for the treatment of fecal incontinence in women - a randomized controlled trial.

OBJECTIVE: Biofeedback and medical treatments have been extensively used for moderate fecal incontinence (FI). There is limited data comparing and combining these two treatments. The objective of this study was to evaluate the effect of biofeedback and medical treatments, separately and in combination. MATERIAL AND METHODS: Sixty-four consecutive female patients, referred to a tertiary centre for FI, were included. The patients were randomized to start with either biofeedback (4-6 months) or medical treatment with loperamide and stool-bulking agents (2 months). Both groups continued with a combination of treatments, i.e. medical treatment was added to biofeedback and vice versa. A two-week prospective bowel symptom diary and anorectal physiology were evaluated at baseline, after single- and combination treatments. RESULTS: Fifty-seven patients completed the study. Median number of leakage episodes during two weeks decreased from 6 to 3 (p < 0.0001) from baseline to completion. The patients showed a significant (1) decrease in number of leakages without forewarning (p = 0.04); (2) decrease in number of stools with urgency (p = 0.001); (3) decrease in number of loose stool consistency; and (4) an increase in rectal sensory thresholds, both for maximum tolerable rectal pressure and first sensation (<0.01). The combination treatment was superior to both single treatments in terms of symptoms and functions. There was no significant difference between the two groups at any time point. CONCLUSIONS: The combination therapy with biofeedback and medical treatment is effective for symptom relief in FI. The symptom improvement was associated with improved fecal consistency, reduced urgency, and increased rectal sensory thresholds.

Predictors for long-term disability in women with persistent postpartum pelvic girdle pain.

PURPOSE: The majority of prognostic studies on postpartum lumbopelvic pain have investigated factors during pregnancy. Since the majority of women recover within the first few months of delivery, it is unknown if the same predictors are valid for long-term consequences. It is also important to investigate predictors within subgroups of patients with pregnancy-related lumbopelvic pain due to their different clinical courses. The aim of this study was to identify predictors for disability 15 months postpartum in women with persistent postpartum pelvic girdle pain (PGP). METHODS: Data were obtained by clinical tests and questionnaires 3 months postpartum. The outcome 15 months postpartum was disability measured with the Oswestry Disability Index. RESULTS: A multiple linear regression analysis identified two significant two-way interaction effects that were predictive of disability 15 months postpartum: (a) age + trunk flexor endurance, and (b) disability + hip extensor strength. CONCLUSIONS: Age, muscle function and disability seem to influence the long-term outcome on disability in women with persistent postpartum PGP. It may be important to consider the possibility of different variables impact on each other when predicting long-term disability. In addition, further studies are needed to investigate the impact of interaction effects on long-term consequences in women with persistent postpartum PGP.

Specific muscle stabilizing as home exercises for persistent pelvic girdle pain after pregnancy: a randomized, controlled clinical trial.

OBJECTIVE: To investigate the efficacy of home-based specific stabilizing exercises focusing on the local stabilizing muscles as the only intervention in the treatment of persistent postpartum pelvic girdle pain. DESIGN: A prospective, randomized, single-blinded, clinically controlled study. SUBJECTS: Eighty-eight women with pelvic girdle pain were recruited 3 months after delivery. METHODS: The treatment consisted of specific stabilizing exercises targeting the local trunk muscles. The reference group had a single telephone contact with a physiotherapist. Primary outcome was disability measured with Oswestry Disability Index. Secondary outcomes were pain, health-related quality of life (EQ-5D), symptom satisfaction, and muscle function. RESULTS: No significant differences between groups could be found at 3- or 6-month follow-up regarding primary outcome in disability. Within-group comparisons showed some improvement in both groups in terms of disability, pain, symptom satisfaction and muscle function compared with baseline, although the majority still experienced pelvic girdle pain. CONCLUSION: Treatment with this home-training concept of specific stabilizing exercises targeting the local muscles was no more effective in improving consequences of persistent postpartum pelvic girdle pain than the clinically natural course. Regardless of whether treatment with specific stabilizing exercises was carried out, the majority of women still experienced some back pain almost one year after pregnancy.

The postural response of the pelvic floor muscles during limb movements: a methodological electromyography study in parous women without lumbopelvic pain.

BACKGROUND: Pregnancy-related lumbopelvic pain is common. More than 30% of women have persistent pain 3 months after giving birth. There is no consensus regarding the pathology. However, coordination of muscle activity by appropriate timing and amplitude is necessary for maintaining adequate stability in the lumbopelvic area. The aim was to develop a method using surface electromyography to detect a feed-forward response in the pelvic floor muscles during limb movements performed at a comfortable speed applicable in future studies for women with lumbopelvic pain. METHODS: Ten parous women with no lumbopelvic pain in the past 12 months were included. Surface electromyographic activity was recorded from the pelvic floor muscles and unilaterally from transversus abdominis/internal oblique, rectus abdominis, erector spinae, hip adductors, rectus femoris and deltoid. The subjects performed leg lift in supine and arm lift from standing. The electromyographic onset was related to the initiation of the movement. FINDINGS: In the majority of the women the electromyographic onsets of the pelvic floor muscles occurred before the movement was initiated, regardless of whether it was a leg or an arm lift. In addition, electromyographic onsets for the other muscles, except the rectus abdominis during the arm lift, also occurred prior to the movements. INTERPRETATION: The findings suggest a feed-forward response in the pelvic floor muscles during leg and arm lifts in women who had previously given birth and were without lumbopelvic pain. Movements performed at a comfortable speed seem to be useful in order to detect such a response.