DOCSLIB.ORG

Obstructed Defecation Syndrome: Diagnosis and Therapeutic Options, with Special Focus on the STARR Procedure Ada Rosen MD

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Obstructed Defecation Syndrome: Diagnosis and Therapeutic Options, with Special Focus on the STARR Procedure Ada Rosen MD EDITORIALS IMAJ • VOL 12 • FEBRUARY 2010 Obstructed Defecation Syndrome: Diagnosis and Therapeutic Options, with Special Focus on the STARR Procedure Ada Rosen MD Department of Surgery A, Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel of constipation caused by obstructed nerves) [3]. Treatment can be conser- KEY WORDS: obstructed defecation syndrome, defecation: functional and mechanical. vative, such as the use of stool soft- STARR procedure, constipation, The functional type causes idiopathic eners, sphincter exercises and avoid- rectocele megarectum, anismus, descending ance of straining. Treatment may also IMAJ 2010; 12: 104–106 perineal syndrome, and solitary rectal be surgical, namely, post-anal repair, ulcer syndrome [3]. which corrects the anorectal angle. • Megarectum is an enlarged rectal • Solitary rectal ulcer 4–10 cm from diameter up to 6 cm at the level of the the anal verge usually occurs on the hronic constipation is a common pelvic brim, or total rectal capacity of anterior wall (68%). In these cases C self-reported bowel symptom that over 450 ml of air on manometry. In we often encounter a hyperactive affects 2–30% of people in the western special cases in children, megarec- puborectalis muscle with paradoxical world. It has a considerable impact on tum is due to a damaged mienteric contractions. It is frequently associ- health costs and quality of life. About plexus and abnormal motor func- ated with straining and prolapse (par- 30–50% of constipated patients have tion of the rectum [3]. Treatment is tial or complete). Treatment consists obstructed defecation [1,2]. surgical – anorectal myectomy or the of administration of local steroids The classical symptoms are pain at Duhamel procedure. and stool softeners (to prevent strain- defecation, extreme straining to def- • Anismus, also known as spastic pel- ing), as well as biofeedback [4,5]. If ecate, extended time on the toilet, long vic floor and pelvic floor dyssynergia, prolapse is present, it should be sur- interval between two evacuations (5–10 is a malfunction of the external anal gically repaired. days), perineal pain/discomfort when sphincter and puborectalis muscle standing, feeling of incomplete evacua- during defecation. This is a paradoxical Mechanical causes of obstructed defeca- tion, and fragmented defecation [1]. contraction: failure to relax the pelvic tion are stricture, neoplasm, enterocele, Once a patient with these com- floor and anal muscles during defeca- intussusception, rectal prolapse, and plaints enters a pelvic floor clinic, a very tion [3]. The treatment for anismus rectocele. detailed diagnostic workup is necessary is difficult since patients with func- • Stricture usually follows surgery or to assess the exact cause of obstruction tional defecation disorders are often trauma. Treatment can be conservative and to tailor the most appropriate treat- unresponsive to conservative medical (use of stool softeners and enemas), ment. The diagnostic workup starts with management such as stool softeners invasive (use of dilators, YAG laser, a general investigation that includes: and niphedipine. Biofeedback train- or diathermy), or surgical (resection, history of symptoms, physical exami- ing has a success rate of 70–78% [4,5]. sphincterotomy or anoplasty). nation (digital anal examination and Treatment with botulinum toxin in- • Neoplasm, which should be ruled anoscopy), blood tests, barium enema or jection may provide temporary im- out by colonoscopy. colonoscopy, and rectal biopsy if need- provement, but it remains an investi- • Enterocele is the herniation of small ed. This is followed by specific anorectal gational treatment. Surgical division bowel into the pouch of Douglas. tests, such as anorectal manometry, bal- of the puborectalis muscle can also be Treatment is laparoscopic closure of loon expulsion test, rectal compliance, offered to these patients [6]. the enlarged pouch of Douglas. [7]. electromyography, nerve stimulation, • Descending perineum syndrome • Rectal prolapse/intussusception is transit studies, defecography, and endo- is caused by excessive straining and a partial (mucosal) or complete pro- anal ultrasound. weakened perineal muscles (possible trusion of the entire thickness of the We distinguish between two types stretching damage to the pudendal rectal wall through the anal sphincter. 104 IMAJ • VOL 12 • FEBRUARY 2010 EDITORIALS It is classified as first degree when the ment option for obstructed defecation protrusion is invisible, second degree Figure 1. Stapled transanal rectal resection syndrome [14]. According to a Milan resection (STARR) [20] when it is visible on straining, and study reported in 2009, STARR is safe third degree when visible externally. and effective in the treatment of solitary It is caused by diastasis of the leva- rectal ulcer associated with internal rectal tors, deep Douglas pouch, redundant prolapse and has minimal complications rectosigmoid, patulous anus, or loss and no recurrence after 2 years [15]. of rectal horizontal position (due Recently, a new device – the CCS-30 to loose attachment to the sacrum). Contour Transtar – was developed by Treatment is surgical by the abdomi- the same Professor Longo. A multi- nal approach (Ribshtain procedure, STARR (stapled transanal rectal resec- center prospective study from Naples which is a fixation of the stretched tion) is a new surgical procedure that was confirms that the device is effective and rectum to the sacrum with or with- launched by Longo in 2001. It is a mini- safe and has functional results similar out a mesh), the perineal approach mally invasive transanal operation for rec- to those of the conventional STARR (Altemeier operation that involves a tocele and mucosal/rectal prolapse using [16]. This procedure (with both tech- sleeve resection of the prolapsed rec- a double circular stapler [Figure 1]. niques), according to most authors, tum and colon with a primary anas- In January 2006, the European is effective; the postoperative pain is tomosis performed transanally, or STARR registry was initiated. According mild, and the procedure is very much the Thiersch ring), or transanal (the to the results published in 2009 on 2838 accepted among colorectal surgeons for STARR procedure: namely, stapled patients, the improvement in rectal func- the treatment of rectocele as well as for transanal rectal resection). tion and quality of life was statistically internal rectal prolapse in patients with • Rectocele is defined as a herniation significant [13]. A multicenter study obstructed defecation. Yet, it should be of the rectal wall through a defect conducted in Spain between 2001 and emphasized that STARR is associated in the rectovaginal septum in the 2006 concluded that this procedure is with complications such as postop- direction of the vagina. It was tradi- associated with low morbidity and short erative bleeding, chronic proctalgia, tionally considered as a defect in the hospital stay and is an effective treat- rectovaginal fistula, stricture, and fecal rectovaginal septum, not the rectum. Possible causes are erect bipedal Figure 2. S.T.A.R.R. Written and agreed upon by the group of S.T.A.R.R. Pioneers Oct. 26-28, 2006 posture, vaginal childbirth, chronic increase in abdominal pressure (con- Diagnostic Approach Treatment Options after Dynamic Imaging stipation, straining), or congenital or Before the patient sees the surgeon Clinically & morphologically confirmed S.T.A.R.R. inherited weakness in the pelvic sup- Colonoscopy to rule out tumors + inflammatory Internal prolapse +/- rectocele only bowel disease (IBD), etc. port system. Classical symptoms are Patient was treated, but conservative treatment with incomplete rectal emptying or bulge laxatives/enemas/diet failed Clinically & morphologically confirmed Treatment of Internal prolapse +/- rectocele associated disorders in the vagina. Evacuation is often associated with other morphological as per local practice digitally supported. The definitive When the patient sees the surgeon disorders objective diagnosis of rectocele is Patient interview • Enterocele (low and stable) Reassessment of ODS • Patient history • Sigmoidocele (low and stable) symptoms, if positive most commonly made by defec- • ODS assessment (score assessment) • Urogenital prolapse • Incontinence assessment (score assessment) • External rectal prolapse S.T.A.R.R. ography. This also assesses the size • Urogenital symptoms of the rectocele and the emptying • Quality of life / patient motivation assessment Clinically & morphologically confirmed Biofeedback capacity. The surgical indications for Inernal prolapse +/- rectocele Clinical examination associated with pelvic dyssynergia rectocele repair are controversial, but Reassessment of ODS • Perineal examination symptoms, if positive most surgeons advocate operative • Proctoscopy (rest/ straining) repair when a symptomatic recto- • Urogenital exam S.T.A.R.R. cele is large (> 3 cm), or if it fails to empty sufficiently on defecography. Clinical evaluation Clinically & morphologically confirmed With sphincter defect • Defecography/ perineography or dynamic MRI Internal prolapse +/- rectocele The treatment of rectocele is sur- • Anal manometry and endo-anal ultrasound – associated with fecal incontinence gery, the surgical approach can be only if incontinence or suspicion of sphincter Tailored therapy S.T.A.R.R. based on leading transvaginal [8], transperineal [9], damage; otherwise not mandatory symptoms and
Load more

Recommended publications
  • No.9 September 2003
    Vol.46, No.9 September 2003 CONTENTS Defecatory Dysfunction Pathogenesis and Pathology of Defecatory Disturbances Masahiro TAKANO . 367 Diagnosis of Impaired Defecatory Function with Special Reference to Physiological Tests Masatoshi OYA et al. 373 Surgical Management for Defecation Dysfunction Tatsuo TERAMOTO . 378 Dysfunction in Defecation and Its Treatment after Rectal Excision Katsuyoshi HATAKEYAMA . 384 Infectious Diseases Changes in Measures against Infectious Diseases in Japan and Proposals for the Future Takashi NOMURA et al. 390 Extragenital Infection with Sexually Transmitted Pathogens Hiroyuki KOJIMA . 401 Nutritional Counseling Behavior Therapy for Nutritional Counseling —In cooperation with registered dietitians— Yoshiko ADACHI . 410 Ⅵ Defecatory Dysfunction Pathogenesis and Pathology of Defecatory Disturbances JMAJ 46(9): 367–372, 2003 Masahiro TAKANO Director, Coloproctology Center, Hidaka Hospital Abstract: In recent years the number of patients with defecatory disturbances has increased due to an aging population, stress, and other related factors. The medical community has failed to focus enough attention on this condition, which remains a sort of psychosocial taboo, enhancing patient anxiety. Defecatory distur- bance classified according to cause and location can fall into one of four groups: 1) Endocrine abnormalities; 2) Disturbances of colonic origin that result from the long-term use of antihypertensive drugs or antidepressants or from circadian rhythm disturbances that occur with skipping breakfast or lower dietary
    [Show full text]
  • The American Society of Colon and Rectal Surgeons' Clinical Practice
    CLINICAL PRACTICE GUIDELINES The American Society of Colon and Rectal Surgeons’ Clinical Practice Guideline for the Evaluation and Management of Constipation Ian M. Paquette, M.D. • Madhulika Varma, M.D. • Charles Ternent, M.D. Genevieve Melton-Meaux, M.D. • Janice F. Rafferty, M.D. • Daniel Feingold, M.D. Scott R. Steele, M.D. he American Society of Colon and Rectal Surgeons for functional constipation include at least 2 of the fol- is dedicated to assuring high-quality patient care lowing symptoms during ≥25% of defecations: straining, Tby advancing the science, prevention, and manage- lumpy or hard stools, sensation of incomplete evacuation, ment of disorders and diseases of the colon, rectum, and sensation of anorectal obstruction or blockage, relying on anus. The Clinical Practice Guidelines Committee is com- manual maneuvers to promote defecation, and having less posed of Society members who are chosen because they than 3 unassisted bowel movements per week.7,8 These cri- XXX have demonstrated expertise in the specialty of colon and teria include constipation related to the 3 common sub- rectal surgery. This committee was created to lead inter- types: colonic inertia or slow transit constipation, normal national efforts in defining quality care for conditions re- transit constipation, and pelvic floor or defecation dys- lated to the colon, rectum, and anus. This is accompanied function. However, in reality, many patients demonstrate by developing Clinical Practice Guidelines based on the symptoms attributable to more than 1 constipation sub- best available evidence. These guidelines are inclusive and type and to constipation-predominant IBS, as well. The not prescriptive.
    [Show full text]
  • Patient Information Leaflet
    9 Tighten your anal muscles once more when Not everyone is the same, a normal bowel you have finished opening your bowels. habit varies from between three times a day to three times a week. Your motion should be solid, but easy to pass. If after following the advice in this leaflet Patient Information you are still having problems with Leaflet constipation please seek further help from your Doctor, Nurse or Continence Advisor. Compliments, comments, concerns or complaints? If you have any compliments, comments, concerns or complaints and you would like to speak to somebody about them please telephone or email If you find that your anal muscles are 01773 525119 tightening instead of relaxing practising 4, 5 [email protected] and 6 will help to get these muscles working correctly. However if you are still unable to Are we accessible to you? This publication relax your anal muscles and are straining is available on request in other formats (for excessively for long periods you should seek example, large print, easy read, Braille or help from your Doctor or Continence Advisor. audio version) and languages. For free You may have a condition known as anismus translation and/or other format please call which simply means that the muscles in your 01246 515224, or email us anus contract when they should relax. This is [email protected] easily treated. Remember... Constipation Advice for ¨ Drink 1.5-2 litres of fluid a day Continence Advisory Service Patients ¨ Eat 5 portions of fruit / vegetables a day Alfreton Primary Care Centre ¨ Eat regularly ¨ Never ignore the sensation to go Church Street Not everyone has a bowel which works ¨ Allow yourself plenty of time and privacy Alfreton properly, but you may be able to improve ¨ Get into a routine Derbyshire your symptoms by following the advice - Exercise (within your capabilities) DE55 7AH offered in this leaflet - Do not strain.
    [Show full text]
  • The Efficacy of a Multidisciplinary Approach to the Management of Constipation: a Case Series
    Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2008, 102, 36–44 CLINICAL PAPER The efficacy of a multidisciplinary approach to the management of constipation: a case series R. W. C. Leung, B. K. Y. Fung & L. C. W. Fung Physiotherapy Department, Kwong Wah Hospital, Hong Kong W. C. S. Meng, P. Y. Y. Lau & A. W. C. Yip Department of Surgery, Kwong Wah Hospital, Hong Kong Abstract The aim of this study was to evaluate a rehabilitative programme including biofeedback training for the treatment of chronic constipation. A prospective series of patients with constipation, as defined by the Rome II diagnostic criteria, were assessed by a clinician, a dietitian and a physiotherapist. Anorectal physi- ology investigations and defecography were performed prior to and after the programme. The treatment involved consultation by the dietitian, postural re-education and pelvic floor re-education regarding the proper pattern of defecation. The subjects were followed up in alternate weeks for the first 3 months and then monthly for another 3 months. Twenty patients have been recruited into the programme since 2005. Ten subjects have completed the course of treatment and three have defaulted; the remaining seven were still undergoing treatment at the time of writing. On completion of the programme, there was a significant improvement in fibre intake (pre-treatment=12.9191.06 g; post-treatment= 20.2661.064 g; P=0.001), average straining effort (pre-treatment=6.360.391; post-treatment=3.720.391; P=0.001) and average straining time (pre- treatment=17.612.172 min; post-treatment=6.002.172 min; P=0.004).
    [Show full text]
  • Redalyc.Biofeedback Treatment in Chronically Constipated Patients
    Revista Latinoamericana de Psicología ISSN: 0120-0534 [email protected] Fundación Universitaria Konrad Lorenz Colombia Simón, Miguel A.; Bueno, Ana M.; Durán, Montserrat Biofeedback treatment in chronically constipated patients with dyssynergic defecation Revista Latinoamericana de Psicología, vol. 43, núm. 1, 2011, pp. 105-111 Fundación Universitaria Konrad Lorenz Bogotá, Colombia Available in: http://www.redalyc.org/articulo.oa?id=80520078010 How to cite Complete issue Scientific Information System More information about this article Network of Scientific Journals from Latin America, the Caribbean, Spain and Portugal Journal's homepage in redalyc.org Non-profit academic project, developed under the open access initiative Biofeedback on dyssynergic defecation Biofeedback treatment in chronically constipated patients with dyssynergic defecation Biofeedback aplicado al tratamiento de pacientes con estreñimiento crónico debido a defecación disinérgica Recibido: Marzo de 2009 Miguel A. Simón Aceptado: Agosto de 2010 Ana M. Bueno Montserrat Durán University of A Coruña, Department of Psychology, Research Group in Clinical and Health Psychology, Spain Correspondence: Miguel A. Simón, Full postal address: Research Group in Clinical and Health Psychology, Department of Psychology, University of A Coruña, Campus of Elviña, 15071 A Coruña, Spain Abstract Resumen The aim of this study was to evaluate the effects of El objetivo de este estudio fue evaluar los efectos del electromyographic biofeedback training in chronically entrenamiento
    [Show full text]
  • Irritable Bowel Syndrome
    Irritable Bowel Syndrome If you suffer from the following ongoing symptoms, you mostly because IBS is not limited to the large intestine (colon). might have IBS: Sometimes, IBS is confused with colitis or other inflammatory Abdominal Pain diseases of the intestinal tract, but the difference is clear – in Bloating IBS, inflammation does not seem to accompany symptoms. Constipation Diarrhea Symptoms IBS is a chronic, often debilitating, functional gastrointestinal Almost every person has experienced abdominal cramping, (GI) disorder with symptoms that include abdominal pain, bloating, constipation, or diarrhea at some point in his or her bloating, and altered bowel behaviours, such as constipation life. However, those who have IBS experience these multiple and/or diarrhea, or alternating between the two. In IBS, the symptoms more frequently and intensely, to the extent that they function, or movement, of the bowel is not quite right. There are interfere with day-to-day living. no medical tests to confirm or rule out a diagnosis and yet it is A person who has IBS likely has a sensitive digestive the most common GI condition worldwide and the most frequent system with heightened reactivity, so that the GI tract responds disorder presented by individuals consulting a gastrointestinal quite differently to normal gut stimuli, such as the passage of specialist (gastroenterologist). solids, gas, and fluid through the intestines. These unusual IBS can begin in childhood, adolescence, or adulthood and movements may result in difficulty passing stool, or sudden, can resolve unexpectedly for periods throughout an individual’s urgent elimination. Up to 20% of those who have IBS report lifespan, recurring at any age.
    [Show full text]
  • European Evidence Based Consensus on Surgery for Ulcerative Colitis Tom Øresland*, Willem A
    Journal of Crohn’s and Colitis, 2015, 4–25 doi:10.1016/j.crohns.2014.08.012 ECCO Guidelines/Consensus Paper ECCO Guidelines/Consensus Paper European evidence based consensus on surgery for ulcerative colitis Tom Øresland*, Willem A. Bemelman, Gianluca M. Sampietro, Antonino Spinelli, Alastair Windsor, Marc Ferrante, Philippe Marteau, Oded Zmora, Paulo Gustavo Kotze, Eloy Espin-Basany, Emmanuel Tiret, Giuseppe Sica, Yves Panis, Arne E. Faerden, Livia Biancone, Imerio Angriman, Zuzana Serclova, Anthony de Buck van Overstraeten, Paolo Gionchetti, Laurents Stassen, Janindra Warusavitarne Michel Adamina, Axel Dignass, Rami Eliakim, Fernando Magro, André D’Hoore, On behalf of the European Crohn's and Colitis Organisation (ECCO) Received July 14 2014; revised August 23 2014; accepted August 27 2014. ⁎Corresponding author at: Clinic for Surgical Sciences, Univ. of Oslo at Dept. of Digestive Surgery, Akershus Univ. Hospital, 1478 Lorenskog, Norway. Keywords: ulcerative colitis; surgery; ileal pouch-anal anastomosis; cancer 1. Introduction and also for all national representatives of ECCO for the second vot- ing procedure. The WGs finally met in Belgrade on September 25th The goal of this consensus initiated by the European Crohn's and 2013 for a final face-to-face discussion and to vote and consent on Colitis Organisation (ECCO) was to establish European consensus the statements. Technically this was done by projecting the statements guidelines for the surgical treatment of ulcerative colitis. The strategy and revising them on screen until a consensus was reached. Consensus to reach the consensus involved several steps and follows the standard was defined as agreement by more than 80% of participants, termed a operating procedures for consensus guidelines of ECCO.
    [Show full text]
  • Irritable Bowel-Anismus
    7-5 Irritable Bowel-Anismus Wael Solh and Eric G.Weiss The causes of constipation and altered defecation are mul- found in patients with solitary ulcer syndrome and idio- tifactorial, and the manifestations are varied. Etiologies of pathic perineal pain.3 Therefore, the diagnosis of NRPS must constipation or altered defecation can be divided into two be made based on the patient’s clinical findings, supported categories – slow transit constipation, and pelvic outlet by more than one physiologic investigation. obstruction. Pelvic outlet obstruction includes etiologies such as paradoxical or nonrelaxation of the puborectalis muscle or anismus (nonrelaxation of the “anal canal”), Treatment rectal prolapse or intussusception, and nonemptying rec- toceles. Associated findings may include perineal descent Because NRPS is a behavioral rather than an anatomic and solitary rectal ulcer syndrome. abnormality, biofeedback is the standard therapy. In In normal defecation, the pelvic floor muscles and exter- biofeedback training, patients are allowed to view their nal anal sphincter are voluntarily inhibited resulting in an own EMG or manometric tracings on a video monitor increase in the anorectal angle with increasing intraab- while attempting to relax the pelvic floor and sphincter dominal pressure. Patients with nonrelaxing puborectalis muscles. Numerous reports have demonstrated success syndrome (NRPS) or anismus are unable to voluntarily rates ranging from 37% to 100%.4 In the largest series to inhibit contraction of the pelvic floor. When inappropriate date, Gilliland and Wexner5 found only one variable to be function of the puborectalis muscle (inappropriate con- predictive of a successful outcome: patients who self- traction or failure to relax) results in the inability to evac- discharged from therapy had a success rate of only uate the rectum, the condition is termed anismus.
    [Show full text]
  • Management of Rectal Prolapse –The State of the Art
    Central JSM General Surgery: Cases and Images Bringing Excellence in Open Access Review Article *Corresponding author Adrian E. Ortega, Division of Colorectal Surgery, Keck School of Medicine at the University of Southern California, Los Angeles Clinic Tower, Room 6A231-A, Management of Rectal Prolapse LAC+USC Medical Center, 1200 N. State Street, Los Angeles, CA 90033, USA, Email: sccowboy78@gmail. – The State of the Art com Submitted: 22 November 2016 Ortega AE*, Cologne KG, and Lee SW Accepted: 20 December 2016 Division of Colorectal Surgery, Keck School of Medicine at the University of Southern Published: 04 January 2017 California, USA Copyright © 2017 Ortega et al. Abstract OPEN ACCESS This manuscript reviews the current understanding of the condition known as rectal prolapse. It highlights the underlying patho physiology, anatomic pathology Keywords and clinical evaluation. Past and present treatment options are discussed including • Rectal prolapsed important surgical anatomic concepts. Complications and outcomes are addressed. • Incarcerated rectal prolapse INTRODUCTION Rectal prolapse has existed in the human experience since the time of antiquities. References to falling down of the rectum are known to appear in the Ebers Papyrus as early as 1500 B.C., as well as in the Bible and in the writings of Hippocrates (Figure 1) [1]. Etiology • The precise causation of rectal prolapse is ill defined. Clearly, five anatomic pathologic elements may be observed in association with this condition:Diastasis of Figure 1 surrounded by circular folds of rectal mucosa. the levator ani A classic full-thickness rectal prolapse with the central “rosette” • A deep cul-de-sac • Ano-recto-colonic redundancy • A patulous anus • Loss of fixation of the rectum to its sacral attachments.
    [Show full text]
  • Biofeedback for Constipation Dawn E
    13 Biofeedback for Constipation Dawn E. Vickers Constipation, with its associated symptoms, is Biofeedback Defined the most common chronic gastrointestinal com- plaint, accounting for 2.5 million physician visits Schwartz et al9 define the biofeedback process as per year1 with a prevalence of 2% in the United “a group of therapeutic procedures which utilize States population.2 Rome II diagnostic criteria electronic instruments to accurately measure, for a diagnosis of constipation are specified in process, and feed back to persons and their ther- Table 13.1.3 After identification and exclusion of apists, meaningful physiological information extracolonic or anatomic causes, many patients with educational and reinforcing properties respond favorably to medical and dietary man- about their neuromuscular and autonomic activ- agement. However, patients unresponsive to ity, both normal and abnormal, in the form of simple treatment may require further physio- analog, binary, auditory and/or visual feedback logic investigation to evaluate the patho- signals.” This process helps patients develop a physiologic process underlying the symptoms. greater awareness of, confidence in, and an Physiologic investigation generally includes increase in voluntary control over physiologic colonic transit time study, cinedefecography, processes.This result is best achieved with a com- anorectal manometry, and electromyography petent biofeedback professional. Employing (EMG),4 which allows for definitive diagnosis of biofeedback instruments without proper cogni- treatable
    [Show full text]
  • Recent Advances in Understanding and Managing Chronic Constipation [Version 1; Peer Review: 2 Approved] David O
    F1000Research 2018, 7(F1000 Faculty Rev):1640 Last updated: 16 JAN 2020 REVIEW Recent advances in understanding and managing chronic constipation [version 1; peer review: 2 approved] David O. Prichard 1, Adil E. Bharucha 2 1Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA 2Clinical Enteric Neuroscience Translational and Epidemiological Research Program and Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA First published: 15 Oct 2018, 7(F1000 Faculty Rev):1640 ( Open Peer Review v1 https://doi.org/10.12688/f1000research.15900.1) Latest published: 15 Oct 2018, 7(F1000 Faculty Rev):1640 ( https://doi.org/10.12688/f1000research.15900.1) Reviewer Status Abstract Invited Reviewers Constipation, a condition characterized by heterogeneous symptoms, is 1 2 common in Western society. It is associated with reduced physical health, mental health, and social functioning. Because constipation is rarely due to version 1 a life-threatening disease (for example, colon cancer), current guidelines 15 Oct 2018 recommend empiric therapy. Limited surveys suggest that fewer than half of treated individuals are satisfied with treatment, perhaps because the efficacy of drugs is limited, they are associated with undesirable side effects, or they may not target the underlying pathophysiology. For F1000 Faculty Reviews are written by members of example, although a substantial proportion of constipated patients have a the prestigious F1000 Faculty. They are defecatory disorder that is more appropriately treated with pelvic floor commissioned and are peer reviewed before biofeedback therapy than with laxatives, virtually no pharmacological trials publication to ensure that the final, published version formally assessed for anorectal dysfunction.
    [Show full text]
  • Constipation Unplugged
    Constipation unplugged. Vikrant Tambe, MBBS No financial disclosures! Learning objectives Define and classify. Mechanisms. Evaluation. Management. Prevention. Self-reported constipation in older people is associated with anxiety, depression, and poor health perception, why clinical constipation in vulnerable individuals may lead to complications such as fecal impaction’s, overflow incontinence, sigmoid volvulus, and urinary retention. The challenges Constipation is an expensive condition, with high Council meeting from laxative expenditure to Nursing time. An estimated 80% of community nurses working with older people list managing constipation, particularly disimpaction, as a part of their case load. Physicians tend to have a dismissive attitude about constipation and tend not to take the problem seriously. Patients are keen to find a solution but often feel that useful and empathetic advice and information are generally unavailable. The challenges Majority of the patients have a strong imperative for self management including over-the-counter laxatives. Lifestyle modifications such as eating fruits and vegetables tend to be expensive, increased water intake can put them at risk for urinary incontinence and increasing physical activity can be challenging for those living alone or have disabilities. • 5 feet long and 3 times more volume. • 12 to 48 Hours. • 3X per day to 3X per week. • 1 liter of water each day. • 100 trillion microbes. 24-52% of your stool weight. Question • 68-year-old female with PMHx of HTN, type 2 DM, HLD, and hypothyroidism presents to the clinic with complaints of difficulty in passing bowel movements and hard lumpy stools since the past 4-5 weeks after she moved in with her son.
    [Show full text]