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Prevalence of sexual and physical abuse in patients with obstructed defecation: Impact on biofeedback treatment

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Abstract

obstructed defecation is one of the most common subtypes of constipation, and it is frequently responsive to biofeedback treatment.Aims: since a history of sexual and physical abuse may be present in patients with obstructed defecation, we assessed the incidence of abuse history in patients with obstructed defecation referred to a general gastroenterology practice, and whether such a history may lead to a different outcome of biofeedback training in these patients. one hundred and twenty-one patients (17 men, 104 women, age 53 +/- 15 years) with obstructed defecation were studied by retrospective chart review. Their history of sexual, physical and psychological abuse was obtained by a standard interview, and biofeedback training was carried out by means of a three-balloon technique. a history of sexual/physical or psychological abuse was present in 12.4% patients. Biofeedback training yielded a successful improvement of obstructed defecation in 93% patients without abuse and in 100% of patients with abuse; this difference was not statistically different (p = 0.53). the prevalence of sexual/physical or psychological abuse in a population of patients with obstructed defecation referred to a general gastroenterology practice is relatively low; such a history seems not to affect the outcome of biofeedback training in these patients.
ABSTRACT
Background: obstructed defecation is one of the most com-
mon subtypes of constipation, and it is frequently responsive to
biofeedback treatment.
Aims: since a history of sexual and physical abuse may be pre-
sent in patients with obstructed defecation, we assessed the inci-
dence of abuse history in patients with obstructed defecation re-
ferred to a general gastroenterology practice, and whether such a
history may lead to a different outcome of biofeedback training in
these patients.
Patients and methods: one hundred and twenty-one pa-
tients (17 men, 104 women, age 53 ± 15 years) with obstructed
defecation were studied by retrospective chart review. Their histo-
ry of sexual, physical and psychological abuse was obtained by a
standard interview, and biofeedback training was carried out by
means of a three-balloon technique.
Results: a history of sexual/physical or psychological abuse
was present in 12.4% patients. Biofeedback training yielded a
successful improvement of obstructed defecation in 93% patients
without abuse and in 100% of patients with abuse; this difference
was not statistically different (p = 0.53).
Conclusions: the prevalence of sexual/physical or psycholog-
ical abuse in a population of patients with obstructed defecation
referred to a general gastroenterology practice is relatively low;
such a history seems not to affect the outcome of biofeedback
training in these patients.
Key words: Abuse. Biofeedback. Constipation. Obstructed defe-
cation.
INTRODUCTION
Chronic constipation is a frequent complaint in clinical
practice, and affects 3 to 30% of the general population in
Western countries, particularly women (1). However, re-
cent studies have shown that similar figures are also pre-
sent in other countries, such as Latin America (2).
The pathophysiological basis of chronic idiopathic
constipation may basically be reconducted to two main
subtypes, slow-transit constipation (STC) and constipa-
tion due to obstructed defecation (OD) (3). The latter, af-
ter excluding anatomical or mechanical causes, may be
often due to paradoxical contraction or failure to relax of
the pelvic floor muscles during attempts to defecate,
which impedes the outflow of feces (4,5).
The prevalence of OD in different series varies be-
tween 25 and 70% (6,7). This probably reflects different
population samples, with a prevalence of 7% in the gen-
eral population (8). In many of these patients biofeedback
treatment is very effective (9,10).
Even though behavioral or psychological disturbances
are frequently encountered in OD, it is still controversial
whether these abnormalities are the cause or the conse-
quence of this often disabling symptom (11).
Physical and/or psychical abuse are described with rel-
ative frequency in some functional gastrointestinal disor-
ders, particularly in patients with irritable bowel syn-
drome (IBS) (12,13); less data are available for
constipated, non-IBS patients. Two recent studies report-
ed that more than 32% of patients with OD had a history
of physical and/or psychical abuse (14,15). However, no
data on the treatment of such patients are available.
The purpose of this study was: a) to establish the preva-
lence of sexual/physical or psychological abuse in a general
gastroenterology practice of a Latin American population;
and b) to assess whether patients with OD and a history of
abuse respond differently to biofeedback treatment when
compared to those without such a history of abuse.
Prevalence of sexual and physical abuse in patients with
obstructed defecation: impact on biofeedback treatment
L. I. Solé, M. C. Bolino, M. Lueso, L. Caro, C. Cerisoli, N. Castiglia1and G. Bassotti2
Diagnostic and Therapeutic Gastroenterology Practice (GEDYT). 1Methodology Institute. Buenos Aires, Argentina.
2Gastroenterology and Hepatology Section. Department of Clinical & Experimental Medicine. University of Perugia.
Italy
1130-0108/2009/101/7/464-467
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
Copyright © 2009 ARÁN EDICIONES,S. L. REV ESP ENFERM DIG (Madrid)
Vol. 101. N.° 7, pp. 464-467, 2009
Received: 03-02-09.
Accepted: 26-03-09.
Correspondence: Gabrio Bassotti. Clinica di Gastroenterologia ed Epatolo-
gia. Ospedale Santa Maria della Misericordia. Piazzale Menghini, 1. 06156
San Sisto (Perugia), Italy. e-mail: gabassot@tin.it
Solé LI, Bolino MC, Lueso M, Caro L, Cerisoli C, Pastiglia N,
G. Bassotti. Prevalence of sexual and physical abuse in pa-
tients with obstructed defecation: impact on biofeedback treat-
ment. Rev Esp Enferm Dig 2009; 101: 464-467.
06. OR 1507 SOLE:Maquetación 1 28/7/09 16:36 Página 464
PATIENTS
We retrospectively reviewed the charts of all patients
of a general gastroenterology practice – the Diagnostic
and Therapeutic Gastrointestinal practice, GastroEn-
terología Diagnóstica y Terapéutica (GEDYT) – evaluat-
ed for OD that underwent biofeedback training during the
period January 2004-January 2006. To be classified as
OD the patients had: a) to fulfill Rome II criteria for con-
stipation (16), i.e. two or more of six symptoms present
for at least 12 weeks of the preceding 12 months: strain-
ing, lumpy or hard stools, sensation of incomplete evacu-
ation, sensation of anorectal obstruction/blockage, or
manual maneuvers to facilitate defecation on more than
one fourth of bowel movements, or less than three evacu-
ations per week; and b) paradoxical contraction or failure
to relax pelvic floor muscles during attempts to defecate,
as shown by anorectal manometry and defecography. It is
worth noting that according to these criteria patients also
met the recently published Rome III criteria for function-
al defecation disorder (17). Secondary causes of consti-
pation were excluded by clinical and drug history taking,
physical examination, blood chemistry, and colonoscopy
or barium enema.
METHODS
Diagnostic criteria of sexual, physical, and
psychological abuse
All patients were evaluated for sexual and physical
abuse according to previously described criteria by
means of a standard, previously validated questionnaire
(18). This was done in a trustful clinical setting that en-
sured confidentiality and the patients’ right not to dis-
close such information if unable or unwilling.
Sexual abuse criteria
Sexual abuse was defined as any of three types of sex-
ual experiences: those involving attempts; those involv-
ing forced sexual touching with hand, mouth, or objects;
and lastly, those in which vaginal or anal intercourse
(rape) occurred (19,20). Briefly, the questionnaire includ-
ed the paraphrased items below. When you did not want
it, has anyone ever: threatened to have sex with you,
touched the sex organs of your body, made you touch the
sex organs of their body, forced you to have sex, or have
you had any other unwanted sexual experience?
Physical abuse criteria
Using the same interview for sexual abuse, we also in-
cluded questions concerning physical abuse. We counted
physical abuse only when it occurred as an event outside
the sexual abuse incident. Thus, physical abuse in this
study was counted only if the incident did not involve
sexual abuse. Physical abuse was divided into two cate-
gories: beaten, hit, or kicked, and life threat (19,20), and
was evaluated by a multiple-choice answer given to the
following question: when you were a child or nowadays,
have you ever been beaten, hit or kicked by someone old-
er than you or by other adult, respectively?: never; some-
times; occasionally; frequently. We considered physical
abuse when “frequently” was answered, or when a brutal
attack required medical aid or resulted in squeals.
Psychological abuse criteria
Psychological abuse was considered to be present
when at least one affirmative response was given to the
following questions: have you ever felt that someone in
your family or at work made you feel that you had no val-
ue on several occasions? Have you ever been accused un-
justifiably by a member of your family or at work on sev-
eral occasions? Have you ever been asked too much of
you by a member of your family or at work on several oc-
casions? Have you ever been forced to attend family
conflicts or difficult situations without being involved by
a member of your family or at work on several occa-
sions? For both sexual and physical abuse, yes/no re-
sponses were obtained.
Biofeedback technique
Biofeedback training (six weekly sessions of 30 min-
utes’ duration) was carried out by means of a three-bal-
loon manometric system (21). Biofeedback treatment in-
volved measuring internal anal sphincter (IAS) relaxation
and external anal sphincter (EAS) contraction by record-
ing pressure changes in two intra-anal balloons, and us-
ing a third balloon for rectal distension. By gradually and
progressively inflating the balloons located at the IAS
and EAS levels, while simultaneously asking the patient
to bear down, allowed the investigator and the patient to
visualize on a computer screen the effects of simulated
defecation. If during this maneuver a paradoxical con-
traction (i.e., increased pressure instead of relaxation dur-
ing straining) of the sphincter was observed, the patient
was instructed to relax in order to obtain a tracing similar
to that of a normal subject, also displayed on the screen.
Constant visual (by recording) and verbal reinforcements
were given to patients by the therapist when correct re-
sponses were made, and the patients were encouraged to
try harder or to modify their efforts in order to produce
normal tracings (i.e., avoiding paradoxical contraction of
the sphincter).
Patients were considered to have a successful biofeed-
back treatment if at the end of the training session they
Vol. 101. N.° 7, 2009 PREVALENCE OF SEXUAL AND PHYSICAL ABUSE IN PATIENTS WITH OBSTRUCTED 465
DEFECATION: IMPACT ON BIOFEEDBACK TREATMENT
REV ESP ENFERM DIG 2009; 101 (7): 464-467
06. OR 1507 SOLE:Maquetación 1 28/7/09 16:36 Página 465
were able to normalize paradoxical contraction at
manometry, to have at least two bowel movements per
week without (or with sporadic, i.e. once or less per
week) use of laxatives, and to refrain from the use of dig-
ital maneuvers to help defecation.
Ethical considerations
Since this was a retrospective study, no study-driven
clinical intervention was performed; therefore only a
simplified Institutional Review Board approval for retro-
spective studies was necessary.
Statistical analysis
Pre- and post-treatment data were compared by means
of Fisher’s exact test. p values < 0.05 were chosen for re-
jection of the null hypothesis.
RESULTS
Chart review showed that 121/131 (92%) patients (17
men, 104 women, age 53 ± 15 years) were eligible for the
study. The ten patients excluded were so for incomplete
data (5 patients), and inability to fulfill the entry criteria
(5 patients).
A history of abuse was found in 15/121 (12.4%) pa-
tients (5 sexual; 10 physical or psychological). Once OD
was diagnosed, all patients were treated with high-fiber
diet and/or laxatives, and this regimen did not resolve the
symptoms in 70 patients. These latter subjects were re-
ferred for biofeedback training.
Biofeedback treatment was thus carried out in 60 pa-
tients without a history of abuse and in 10 of those with a
history of abuse. At the end of the biofeedback training,
56/60 (93%) of the former and 10/10 (100%) of the latter
had a successful response, according to the criteria de-
scribed above: this difference was not significant (p =
0.53) between the two groups. No differences between
manometric or defecographic findings and between types
of abuse were found concerning the response to biofeed-
back treatment.
DISCUSSION
In this study we report that the prevalence of
sexual/physical or psychological abuse in patients re-
ferred to a general gastroenterology practice is slightly
higher than 10%, and lower than that reported by other
authors (14,15). However, the latter studies recruited pa-
tients referred to tertiary centers, more likely to be highly
selected and having more associated pathologies. Of
course, due to the peculiar, intimate, and difficult topic to
face, which requires some deep and trusty relationship
between patient and physician, there is the possibility that
a history of abuse could have not been reported or elicit-
ed in some of the patients during their evaluation. Studies
on patients with IBS, for instance, show different health
seeking behaviors in patients with and without a history
of abuse (22).
Biofeedback treatment is an effective option for pa-
tients with OD (5,6,23), as was also recently demonstrat-
ed by controlled trials (9,10,24), and the present study
confirmed this. In fact, 94% of our patients undergoing
this training had a successful response, al least in the
short term; however, there is evidence of a sustained re-
sponse of up to two years in up to 80% of patients (9).
The efficacy of biofeedback training for OD is influenced
by the skills of the biofeedback therapist and the tech-
nique used for training (9,10). We feel that the good re-
sults we obtained were due to the treatment being admin-
istered by the same physician with a long-standing
experience in such training, as shown in sexually abused
women with anismus (25). Of course, different results
may be obtained in different settings (26).
This study has limitations. We were unable to detect
differences in the response to biofeedback treatment be-
tween patients with and without a history of abuse; this
might be due to the small sample size of patients with
such a history that underwent this treatment, even though
it has been claimed that an abuse history has no relevant
role in the pathogenesis of either functional or organic
chronic gastrointestinal disorders, but it can affect their
clinical expression irrespective of functional or organic
diagnosis (27). Moreover, colonic transit was not evaluat-
ed; previous studies have shown reduced response rates
to biofeedback training in patients with coexistent OD
and slow transit compared to those with normal transit
(28). This potential confounding factor was not assessed
here. Finally, the period of observation of the results was
limited to the treatment period; long-term data are needed
to establish whether this treatment is effective in abused
patients even in the long term, as demonstrated in pa-
tients with OD without a history of abuse (9).
However, we feel that these results might be of inter-
est, since as far as we know there are no other such stud-
ies from South America evaluating the effect of biofeed-
back training in patients with OD and a history of abuse.
Since there is literature evidence of strong and consistent
relationships of sexual and physical abuse history with
functional GI symptoms and disorders (29), further stud-
ies in larger cohorts of patients are needed to establish the
proper effect of abuse on the effectiveness of biofeedback
training in OD patients.
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... Algunos estudios (Bouchoucha et al., 2004;Jovanović et al., 2015;Leung, Riutta, Kotecha, & Rosser, 2011;Solé et al., 2009) avalan la existencia de una alta asociación entre el abuso sexual y la presencia de contracción paradójica del puborrectal, indicando que esta última podría ser un indicador de que en algún momento de su vida la persona fue víctima de esta forma de abuso y que por ello es obligatoria la determinación de dichos antecedentes en los pacientes con este trastorno; sin embargo, los estudios no muestran un análisis de la posible relación causal entre ambos aspectos, sino que afirman la existencia de alta prevalencia y correlación entre ellos. Por esto se sugiere evaluar tanto las relaciones como el posible poder predictivo del antecedente de abuso sexual en el desarrollo, mantenimiento y eficacia de los tratamientos en esta y otras patologías anorrectales (Solé et al., 2009), con la finalidad de consolidar los algoritmos de evaluación e intervención establecidos para su tratamiento, ya que se ha comprobado que los pacientes con tales antecedentes suelen presentar exacerbación de síntomas y peor calidad de vida en relación con las patologías asociadas a la contracción paradójica del puborrectal, que aquellos que no los presentan (Imhoff, Liwanag, & Varma, 2012). ...
... Algunos estudios (Bouchoucha et al., 2004;Jovanović et al., 2015;Leung, Riutta, Kotecha, & Rosser, 2011;Solé et al., 2009) avalan la existencia de una alta asociación entre el abuso sexual y la presencia de contracción paradójica del puborrectal, indicando que esta última podría ser un indicador de que en algún momento de su vida la persona fue víctima de esta forma de abuso y que por ello es obligatoria la determinación de dichos antecedentes en los pacientes con este trastorno; sin embargo, los estudios no muestran un análisis de la posible relación causal entre ambos aspectos, sino que afirman la existencia de alta prevalencia y correlación entre ellos. Por esto se sugiere evaluar tanto las relaciones como el posible poder predictivo del antecedente de abuso sexual en el desarrollo, mantenimiento y eficacia de los tratamientos en esta y otras patologías anorrectales (Solé et al., 2009), con la finalidad de consolidar los algoritmos de evaluación e intervención establecidos para su tratamiento, ya que se ha comprobado que los pacientes con tales antecedentes suelen presentar exacerbación de síntomas y peor calidad de vida en relación con las patologías asociadas a la contracción paradójica del puborrectal, que aquellos que no los presentan (Imhoff, Liwanag, & Varma, 2012). ...
... Los índices de validez concurrente con constructos relacionados con la Escala de Sensibilidad Egocéntrica Negativa (sen), la Escala de Distanciamiento emocional (de; Guarino, & Roger, 2005) y la escala de Distrés Personal (dp) del iri (Davis, 1980) oscilan entre .71 y .28. (Solé et al., 2009). Explora el antecedente de abuso sexual y emocional. ...
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... 1 Multiple studies have shown that stressful life events, such as bullying, separation of parents or illness of a family member are associated with functional defecation problems such as FC and faecal incontinence in children. 2 3 In adults suffering from functional defecation disorders, such as slow-transit constipation and pelvic floor dyssynergia, a possible association with child abuse has been described. [4][5][6][7][8][9][10] In addition, abused adult patients reported more severe symptoms of constipation, 7 decreased quality of life 7 and more frequent use of surgical strategies 8 as compared with patients with no history of child abuse. Early detection of abuse is therefore important in the workup of both paediatric and adult patients with FC. ...
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Background A possible association between child abuse and neglect (CAN) and functional constipation (FC) has been described in adults, however, limited data are available in children. Our objective was to determine the prevalence of suspected CAN in children with FC as compared with their healthy peers. Methods A case–control study was carried out in children aged 3–10 years. Children with FC were recruited at a tertiary outpatient clinic, and healthy controls were recruited at schools. Parents were asked to fill out questionnaires about the history and behaviour of their child, children were inquired using a semistructured interview about experienced traumatic events and sexual knowledge. The interview was scored by two independent observers. The prevalence of suspected CAN was determined according to the questionnaires and interview. Results In total, 228 children with FC and 153 healthy controls were included. Both groups were age and gender comparable (50% females, median age 6 years (not significant)). No significant difference in the prevalence of suspected CAN was found between children with FC and healthy controls (23.3% vs 30.1%, 95% CI 0.44 to 1.12, p=0.14), including a suspicion of sexual, emotional and physical abuse. Conclusion Suspected CAN was detected in both children with FC as in healthy controls. The possible association between CAN and FC in children could not be confirmed.
... 2,3 In adults suffering from functional defecation disorders, such as slow-transit constipation and pelvic oor dyssynergia, a possible association with child abuse has been described, with 12%-44% of patients with constipation reporting a history of physical or sexual abuse. [4][5][6][7][8][9][10] In addition, abused adult patients reported more severe symptoms of constipation 7 , decreased quality of life 7 and more frequent use of surgical strategies 8 as compared to patients with no history of child abuse. Early detection of abuse is therefore important in the work-up of both pediatric and adult patients with FC. ...
Preprint
Full-text available
A possible association between child abuse and neglect (CAN) and functional constipation (FC) has been described in adults, however, limited data are available in children. Our objective was to determine the prevalence of suspected child abuse and neglect (CAN) in children with functional constipation (FC) as compared to their healthy peers. A case-control study was carried out in children aged 3-10 years. Children with FC were recruited at a tertiary outpatient clinic, and healthy controls were recruited at schools. Parents were asked to fill out questionnaires about the history and behavior of their child, children were inquired using a semi-structured interview about experienced traumatic events and sexual knowledge. The interview was scored by two independent observers. The prevalence of suspected CAN was determined according to the questionnaires and interview. In total, 228 children with FC and 153 healthy controls were included. Both groups were age and gender comparable (50% females, median age 6 years (NS)). Significantly more parents of children with FC had a low education level as compared to parents of healthy controls (66.2% vs. 32.7%, p<0.001). No significant difference in the prevalence of suspected CAN was found between children with FC and healthy controls (23.3% vs. 30.1%, 95% CI 0.44-1.12, p=0.14), including a suspicion of sexual, emotional and physical abuse. Conclusion: Suspected CAN was detected in both children with FC as in healthy controls. The possible association between CAN and FC in children could not be confirmed.
... First, identifying puborectalis tenderness may reflect an additional component of the rectal evacuation disorder that needs to be addressed in the management plan for patients presenting with chronic constipation. In patients with conditions of chronic pelvic pain, which includes levator ani syndrome, bladder pain syndrome/interstitial cystitis, and chronic prostatitis/chronic pelvic pain syndrome, biofeedback physical therapy has been shown to be an effective therapy.[10][11][12][13][14][15][16][17][18][19][20][21] Since rectal evacuation disorder is also best treated with biofeedback,22 the co-existence of pelvic floor tenderness constitutes an additional component that should be addressed in the biofeedback program. ...
Article
Background Patients with pelvic floor myofascial pain (PFMP) have puborectalis tenderness on digital rectal examination (DRE). Little is known about its significance to anorectal function in patients presenting with constipation. Aim To characterize demographics, clinical characteristics, findings on anorectal manometry (ARM), diagnosis of rectal evacuation disorder (RED), colonic transit [normal (NTC) or slow (STC)], and imaging in constipated patients with PFMP and compare these features to constipation without PFMP. Methods We performed an electronic medical records review of patients with constipation evaluated by a single gastroenterologist between January 2008 and February 2019. Patients with PFMP were compared to controls with constipation but without PFMP (1:2 ratio). Key Results A total of 98 PFMP cases and 196 controls were identified. Constipated patients with PFMP were more likely to have RED [OR 7.59 (3.82‐15.09), P < .01]; controls were more likely to have either NTC [OR 4.25 (1.45‐12.42), P < .01] or STC [OR 3.57 (1.45‐8.78), P < .01]. RED in patients with PFMP is supported by comparison to controls: On DRE, they had increased resting tone [OR 2.25 (1.33‐3.83), P < .01] and paradoxical contraction of the puborectalis upon simulated evacuation [OR 3.41 (1.94‐6.00), P < .01]; on ARM, they had higher maximum resting pressure (102.9 mmHg vs 90.7 mmHg, P < .01) and lower rectoanal pressure gradient (−39.4 mmHg vs −24.7 mmHg, P < .01). Conclusions/Inferences In constipated patients, PFMP is highly associated with RED. Its presence provides a valuable clue regarding the etiology of a patient's constipation; it should be assessed in all patients with constipation and should also be an additional target for management.
... Paradoxical contraction of or failure to relax pelvic floor muscles during attempts to defecate is observed on anorectal manometry and defecography [4]. It is worth noting that about one-third of the patients with OD have an altered mental pattern [5], and a story of physical or sexual abuse may be elicited from a subset of patients [6]. The importance of a psychological evaluation in at least a subset of constipated patients has been repeatedly highlighted [7, 8]. ...
Article
The psycho-neuroendocrine-immune approach relies on the concept of considering diseases from a holistic point of view: the various components (psyche, nervous system, endocrine system, and immune system) control the diseased organ/apparatus and in turn are influenced by a feedback mechanism. In this article, we will consider the psycho-neuroendocrine-immune approach to coloprocto-logical disorders, by providing clinical cases and discussing them in light of this approach.
... Paradoxical contraction of or failure to relax pelvic floor muscles during attempts to defecate is observed on anorectal manometry and defecography [4]. It is worth noting that about one-third of the patients with OD have an altered mental pattern [5], and a story of physical or sexual abuse may be elicited from a subset of patients [6]. The importance of a psychological evaluation in at least a subset of constipated patients has been repeatedly highlighted [7,8]. ...
Article
Full-text available
The psycho-neuroendocrine-immune approach relies on the concept of considering diseases from a holistic point of view: the various components (psyche, nervous system, endocrine system, and immune system) control the diseased organ/apparatus and in turn are influenced by a feedback mechanism. In this article, we will consider the psycho-neuroendocrine-immune approach to coloproctological disorders, by providing clinical cases and discussing them in light of this approach.
... This issue is of particular relevance since some forms of drug-induced constipation (e.g., that secondary to the use of opioid analgesics) can be managed by specific therapeutic approaches [13] , whereas other (e.g., that secondary to the use of antidepressants) can influence colonic motility to such a degree of severity [14,15] that they may require discontinuation of the offending drug or a switch to different drugs. Another sensitive and easy to miss condition, requiring a strong patient-physician relationship owing to the peculiarity of the issue, is a previous history (often only disclosed after several interviews) of physical or sexual abuse, found mainly in patients with symptoms of obstructed defecation (OD) [16] . ...
Article
Chronic constipation is a frequently encountered disorder in clinical practice. Most constipated patients benefit from standard medical approaches. However, current therapies may fail in a proportion of patients. These patients deserve better evaluation and thorough investigations before their labeling as refractory to treatment. Indeed, several cases of apparent refractoriness are actually due to misconceptions about constipation, poor basal evaluation (inability to recognize secondary causes of constipation, use of constipating drugs) or inadequate therapeutic regimens. After a careful re-evaluation that takes into account the above factors, a certain percentage of patients can be defined as being actually resistant to first-line medical treatments. These subjects should firstly undergo specific diagnostic examination to ascertain the subtype of constipation. The subsequent therapeutic approach should be then tailored according to their underlying dysfunction. Slow transit patients could benefit from a more robust medical treatment, based on stimulant laxatives (or their combination with osmotic laxatives, particularly over the short-term), enterokinetics (such as prucalopride) or secretagogues (such as lubiprostone or linaclotide). Patients complaining of obstructed defecation are less likely to show a response to medical treatment and might benefit from biofeedback, when available. When all medical treatments prove to be unsatisfactory, other approaches may be attempted in selected patients (sacral neuromodulation, local injection of botulinum toxin, anterograde continence enemas), although with largely unpredictable outcomes. A further although irreversible step is surgery (subtotal colectomy with ileorectal anastomosis or stapled transanal rectal resection), which may confer some benefit to a few patients with refractoriness to medical treatments.
Article
- Chronic constipation is a common disorder, particularly in women and the elderly.- Physical examination of patients with constipation should include rectal examination and in women also vaginal examination.- The patient is asked to relax, contract and bear down on the pelvic floor during inspection of the anal region as well as during the rectal examination. Patients can be considered to have a hypertonic pelvic floor when they have difficulty in relaxing or no relaxation at all during straining on three consecutive attempts.- Physical examination reveals potentially treatable conditions such as a rectocele or pelvic floor hypertonia in 40% of women with chronic constipation.- Anorectal manometry and anal endosonography provide little added value to physical examination in women with chronic constipation.- Anorectal function testing should be reserved for selected cases.
Article
Objective To examine the effect of previous sexual abuse or assault (SAA) on symptom severity, quality of life, and physiologic measures in women with fecal incontinence or constipation. Design A cross-sectional study of a prospectively maintained clinical database. Setting A tertiary referral center for evaluation and physiologic testing for pelvic floor disorders. Patients Women with fecal incontinence or constipation examined during a 6-year period. Main Outcome Measures Symptom severity and quality of life were measured with the Fecal Incontinence Severity Index (FISI), Fecal Incontinence Quality of Life Scale (FIQL), Constipation Severity Instrument (CSI), Constipation-Related Quality of Life measure (CR-QOL), and 12-Item Short Form Health Survey (SF-12). Physiologic variables were ascertained with anorectal manometry, electromyography, and endoanal ultrasonography. Results Of the 1781 women included, 213 (12.0%) reported SAA. These women were more likely to be white, to report a psychiatric illness, and to have a prior hysterectomy or episiotomy. On bivariate analysis, women with prior SAA had increased symptom severity on the FISI (P = .002) and CSI (P < .001) and diminished quality of life on the FIQL (P < .001), CR-QOL (P = .009), and SF-12 (P = .002 to P = .004). Physiologic variables did not differ significantly between patients with and without prior SAA. Conclusions A history of SAA significantly alters disease perception in fecal incontinence and constipation, but the disorders do not result from increased physiologic alterations. We must elicit a history of SAA in these patients, because the history may play a role in the discrepancy between symptom reporting and objective measurements and may modify treatment recommendations.
Article
There are no clear recommended imaging guidelines for the assessment of patients presenting primarily with obstructed defecation syndrome and defecation difficulty. The gold standard has always been the defecating proctogram which may require a rather poorly tolerated extended technique involving high-radiation exposure in young women which includes cystography, vaginography, small bowel opacification, and occasional peritoneography. The development of dynamic magnetic resonance imaging has obviated many of these extended techniques and may be supplemented by novel ultrasonographic methods including dynamic transperineal sonography, real-time 3D translabial ultrasound and 3D dynamic echodefecography. Patients potentially suitable for surgical treatment display a multiplicity of pelvic floor and perineal soft-tissue anomalies where one pathology (such as rectocele or enterocele) are considered dominant. Despite the introduction of recent stapled and robotic technologies, there is a dual dialog concerning the functional outcome of these procedures. Imaging and surgical algorithms for these patients are provided.
Article
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Irritable bowel syndrome (IBS) is a heterogeneous condition which is diagnosed according to specific bowel symptom clusters. The aim of the present study was to identify subgroups of IBS subjects using measures of rectal sensitivity and psychological symptoms, in addition to bowel symptoms. Such groupings, which cross conventional diagnostic approaches, may provide greater understanding of the pathogenesis of the condition and its treatment. A K means cluster analysis was used to group 107 clinic patients with IBS according to physiological, physical, and psychological parameters. All patients had severe IBS and had failed to respond to usual medical treatment. Twenty nine patients had diarrhoea predominant IBS, 26 constipation predominant, and 52 had an alternating bowel habit. The clusters were most clearly delineated by two variables: "rectal perceptual threshold (volume)" and "number of doctor visits". Three subgroups were formed. Group I comprised patients with low distension thresholds and high rates of psychiatric morbidity, doctor consultations, interpersonal problems, and sexual abuse. Group II also had low distension thresholds but low rates of childhood abuse and moderate levels of psychiatric disorders. Group III had high distension thresholds, constipation or alternating IBS, and low rates of medical consultations and sexual abuse. The marked differences across the three groups suggest that each may have a different pathogenesis and respond to different treatment approaches. Inclusion of psychosocial factors in the analysis enabled more clinically meaningful groups to be identified than those traditionally determined by bowel symptoms alone or rectal threshold.
Article
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To determine the prevalence of a history of sexual and physical abuse in women seen in a referral-based gastroenterology practice, to determine whether patients with functional gastrointestinal disorders report greater frequencies of abuse than do patients with organic gastrointestinal diseases, and to determine whether a history of abuse is associated with more symptom reporting and health care utilization. A consecutive sample of women seen in a university-based gastroenterology practice over a 2-month period was asked to complete a brief questionnaire. The self-administered questionnaire requested information about demographics, symptoms, health care utilization, and history of abuse. Physicians indicated the primary diagnosis for each patient and whether she had ever discussed having been sexually or physically abused. Of 206 patients, 89 (44%) reported a history of sexual or physical abuse in childhood or later in life; all but 1 of the physically abused patients had been sexually abused. Almost one third of the abused patients had never discussed their experiences with anyone; only 17% had informed their doctors. Patients with functional disorders were more likely than those with organic disease diagnoses to report a history of forced intercourse (odds ratio, 2.08; 95% CI, 1.03 to 4.21) and frequent physical abuse (odds ratio, 11.39; CI, 2.22 to 58.48), chronic or recurrent abdominal pain (odds ratio, 2.06; CI, 1.03 to 4.12), and more lifetime surgeries (2.7 compared with 2.0 surgeries; P less than 0.03). Abused patients were more likely than nonabused patients to report pelvic pain (odds ratio, 4.05; CI, 1.41 to 11.69), multiple somatic symptoms (7.1 compared with 5.8 symptoms; P less than 0.001), and more lifetime surgeries (2.8 compared with 2.0 surgeries; P less than 0.01). We found that a history of sexual and physical abuse is a frequent, yet hidden, experience in women seen in referral-based gastroenterology practice and is particularly common in those with functional gastrointestinal disorders. A history of abuse, regardless of diagnosis, is associated with greater risk for symptom reporting and lifetime surgeries.
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Chronic constipation is a prevalent condition that severely impacts the quality of life of those affected. Several types of primary chronic constipation, which show substantial overlap, have been described, including normal-transit constipation, rectal evacuation disorders and slow-transit constipation. Diagnosis of primary chronic constipation involves a multistep process initiated by the exclusion of ‘alarm’ features (for example, unintentional weight loss or rectal bleeding) that might indicate organic diseases (such as polyps or tumours) and a therapeutic trial with first-line treatments such as dietary changes, lifestyle modifications and over-the-counter laxatives. If symptoms do not improve, investigations to diagnose rectal evacuation disorders and slow-transit constipation are performed, such as digital rectal examination, anorectal structure and function testing (including the balloon expulsion test, anorectal manometry or defecography) or colonic transit tests (such as the radiopaque marker test, wireless motility capsule test, scintigraphy or colonic manometry). The mainstays of treatment are diet and lifestyle interventions, pharmacological therapy and, rarely, surgery. This Primer provides an introduction to the epidemiology, pathophysiological mechanisms, diagnosis, management and quality of life associated with the commonly encountered clinical problem of chronic constipation in adults unrelated to opioid abuse.
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This article focuses on the colonic and anorectal motility disturbances that are associated with chronic constipation and their management. Functional chronic constipation consists of three overlapping subtypes: slow transit constipation, dyssynergic defecation, and irritable bowel syndrome with constipation. The Rome criteria may serve as a useful guide for making a clinical diagnosis of functional constipation. Today, an evidence-based approach can be used to treat patients with chronic constipation. The availability of specific drugs for the treatment of chronic constipation, such as tegaserod and lubiprostone, has enhanced the therapeutic armamentarium for managing these patients. Randomized controlled trials have also established the efficacy of biofeedback therapy in the treatment of dyssynergic defecation.