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Home , Anismus, Functional constipation, Proctalgia fugax, Rectal pain

Gut 1999;45(Suppl II):II55–II59 II55

Functional disorders of the and Gut: first published as 10.1136/gut.45.2008.ii55 on 1 September 1999. Downloaded from

W E Whitehead, A Wald, N E Diamant, P Enck, J H Pemberton, SSCRao

Abstract at which it is considered appropriate to initiate In this report the functional anorectal dis- treatment may be later. orders, the etiology of which is currently unknown or related to the abnormal func- EPIDEMIOLOGY tioning of normally innervated and struc- The prevalence of (includ- turally intact muscles, are discussed. ing organic causes) in US and European adults These disorders include functional fecal ranges from 2 to 7% and is about 0.7% for incontinence, functional anorectal , incontinence of solid stool.23Major risk factors including syndrome and proc- for functional fecal incontinence include reten- Chair, Committee on talgia fugax, and pelvic floor . tion of stool in the rectum, the irritable bowel Functional Anorectal The epidemiology of each disorder is syndrome, and . Among the elderly, Disorders, defined and discussed, their pathophysiol- cognitive and mobility impairment, certain Multinational Working ogy is summarized and diagnostic ap- medications, as well as diarrhea are significant Teams to Develop proaches and treatment are suggested. risk factors. Diagnostic Criteria for Some suggestions for the direction of Functional Functional fecal incontinence associated Gastrointestinal future research on these disorders are also with occurs in about 1.4% of Disorders (Rome II), given. children aged seven years. The incidence of Professor of Medicine, (Gut 1999;45(Suppl II):II55–II59) fecal incontinence from all causes in US and University of North Keywords: fecal incontinence; pelvic floor dyssynergia; British nursing home populations is estimated Carolina, to be 30%.4 Chapel Hill, NC, USA ; ; levator ani syndrome; W E Whitehead ; Rome II

Co-Chair, Committee DIAGNOSTIC CRITERIA on Functional A functional gastrointestinal disorder is de- Recurrent uncontrolled passage of fecal Anorectal Disorders, fined as “a variable combination of chronic or material for at least one month, in an Multinational Working recurrent gastrointestinal symptoms not ex- individual with a developmental age of at Teams to Develop least four years, associated with: Diagnostic Criteria for plained by structural or biochemical 1 (1) Fecal impaction; or Functional abnormalities.” In keeping with this definition, Gastrointestinal this report addresses anorectal symptoms, the (2) Diarrhea; or Disorders (Rome II), etiology of which is currently unknown or is (3) Non-structural anal sphincter dysfunc- University of related to the abnormal functioning of nor- tion. http://gut.bmj.com/ Pittsburgh Medical mally innervated and structurally intact mus- Center, It is recognized that functional causes of Pittsburgh, PA, USA cles, or is attributed to psychological causes. A Wald The functional anorectal disorders are de- fecal incontinence such as constipation and fined primarily on the basis of the symptoms diarrhea may overlap with structural abnor- The Toronto Hospital, (table 1). Retrospective reports are unreliable malities (e.g., sphincter muscle injury, nerve Western Division, but can be improved by interviewing the injury). Toronto, Ontario, patient and by prospective symptom diaries. RATIONALE FOR CHANGES IN DIAGNOSTIC CRITERIA on September 29, 2021 by guest. Protected copyright. Canada The lowest age for inferring that the uncon- N E Diamant This review and the associated recommen- + dations are based on an authoritative review of trolled passage of stool constitutes fecal Klinik für the world literature by experts. (See acknowl- incontinence has been increased from three Gastroenterologie and edgments for a list of expert reviewers whose to four years to bring these diagnostic crite- Infektiolagie, advice was sought by the authors.) The ria into line with the Diagnostic and Statisti- Heinrich Heine diagnostic criteria include minimum duration cal Manual of the American Psychiatric Universität, Association. Düsseldorf, Germany of symptoms, which were selected arbitrarily so P Enck as to exclude self-limiting conditions while + The criteria for functional fecal inconti- avoiding unnecessary delays in evaluation. nence have been broadened to include Mayo Clinic, incontinence associated with diarrhea as Rochester, MN, USA well as constipation. This acknowledges that J H Pemberton F1. Functional fecal incontinence about 25% of patients with diarrhea- Functional fecal incontinence is defined as predominant Department of recurrent uncontrolled passage of fecal mate- Internal Medicine, experience incontinence. rial in a person who has no evidence of neuro- + Previously, an elevated threshold for percep- University of Iowa, IA, logic or structural etiologies. This is distinct USA tion of rectal distension was included as a SSCRao from fecal incontinence due to neurological diagnostic criterion. Because elevated sen- injury, seepage from prolapsed rectal mucosa, sory thresholds are associated with organic Correspondence to: poor hygiene, and willful soiling. However, causes of fecal incontinence including spinal William E Whitehead, PhD, neurogenic and anatomic causes of fecal Division of Digestive cord injury, stroke, and diabetic peripheral Diseases, CB#7080, incontinence may coexist with functional neuropathy, this finding was felt to be too University of North Carolina causes of incontinence. at Chapel Hill, Chapel Hill, Fecal incontinence should not be considered NC 27599–7080, USA. Email: william_whitehead@ a medical problem earlier than age four years, Abbreviations used in this paper: EMG, med.unc.edu and depending on the cultural context, the age electromyography; CT, computed tomography. II56 Whitehead, Wald,Diamant, et al

Table 1 Functional gastrointestinal disorders Diagnostic tests used to identify anatomical and

neurological causes of fecal incontinence Gut: first published as 10.1136/gut.45.2008.ii55 on 1 September 1999. Downloaded from A. Esophageal disorders Anoscopy is recommended over flexible sig- A1. Globus A2. Rumination syndrome moidoscopy to examine the to A3. Functional chest pain of presumed esophageal origin determine whether fissures, inflammation, or A4. Functional heartburn A5. Functional dysphagia mechanical obstruction are contributing to A6. Unspecified functional esophageal disorder fecal soiling. B. Gastroduodenal disorders Manometry assesses continence mecha- B1. Functional dyspepsia B1a. Ulcer-like dyspepsia nisms by determining: (1) the threshold B1b. Dysmotility-like dyspepsia volume of rectal distension required to produce B1c. Unspecified (non-specific) dyspepsia the first sensation of distension and a sustained B2. Aerophagia B3. Functional vomiting feeling of urgency to defecate; (2) rectal C. Bowel disorders compliance as determined by the pressure:vol- C1. Irritable bowel syndrome ume ratio during stepwise distension and C2. Functional abdominal bloating C3. maximum tolerable volume; (3) amplitude and C4. Functional diarrhea duration of voluntary contractions of the exter- C5. Unspecified functional bowel disorder nal anal sphincter; and (4) resting pressure in D. Functional abdominal pain D1. Functional abdominal pain syndrome the anal canal. This can be done using perfused D2. Unspecified functional abdominal pain catheters, solid-state pressure transducers, E. Biliary disorders E1. Gall bladder dysfunction electromyography (EMG) electrodes in the E2. Sphincter of Oddi dysfunction anal canal, or balloons positioned in the anal F. Anorectal disorders canal.5 The use of EMG alone is not F1. Functional fecal incontinence F2. Functional anorectal pain recommended. F2a. Levator ani syndrome Anal endosonography allows imaging of F2b. Proctalgia fugax both anal sphincters to identify structural F3. Pelvic floor dyssynergia G. Functional pediatric disorders defects in either muscle. The procedure is G1. Vomiting rapid and less invasive than pelvic computed G1a. Infant regurgitation tomography (CT), magnetic resonance imag- G1b. Infant rumination syndrome G1c. ing, or EMG. However, interpretation is very G2. Abdominal pain operator dependent and requires some experi- G2a. Functional dyspepsia ence. G2b. Irritable bowel syndrome G2c. Functional abdominal pain Neurophysiological studies to evaluate the G2d. Abdominal migraine integrity of the pudendal nerve in patients with G2e. Aerophagia fecal incontinence include pudendal nerve ter- G3. Functional diarrhea G4. Disorders of minal motor latencies and concentric needle G4a. Infant dyschezia EMG recordings from the external anal G4b. Functional constipation G4c. Functional fecal retention sphincter or puborectalis muscle. These stud-

G4d. Non-retentive fecal soiling ies are usually not indicated. However, surface http://gut.bmj.com/ EMG recorded in the anal canal or from peri- non-specific to serve as a diagnostic crite- anal electrodes is useful as a signal rion for functional fecal incontinence. for pelvic floor retraining in patients with fecal incontinence or pelvic floor dyssynergia. CLINICAL EVALUATION The diagnosis of functional fecal incontinence PATHOPHYSIOLOGY AND PSYCHOLOGICAL due to constipation or diarrhea can often be FACTORS made by history and physical examination. Impaired perception of rectal distension has on September 29, 2021 by guest. Protected copyright. Three alternative causes of soiling must be been well documented in both children and excluded: (1) with mucus adults with functional fecal incontinence. Sen- secreted onto the underclothes, (2) mental sory changes may be a consequence of fecal incompetence, and (3) willful soiling. impaction, which alters the tone and viscoelas- tic properties of the bowel wall, or may alter Physical examination mechanoreceptors. Decreased anorectal sensi- The initial examination should be done tivity may contribute to incontinence by without prior or . A character- causing the threshold for reflex inhibition of istic finding in constipation-related fecal incon- the to occur before the tinence is a large mass of stool in the rectum on patient perceives the presence of stool in the digital examination and/or in the colon on rectum.6 abdominal palpation. If the patient is able to Two types of internal anal sphincter dysfunc- contract the , eVerent tion have been described in patients with idio- denervation is unlikely. Rectal prolapse can be pathic incontinence: (a) decreased resting evaluated by asking the patient to strain as if pressure in the internal anal sphincter and (b) defecating while seated on a commode chair. increased frequency of spontaneous internal The digital examination should assess for anal sphincter relaxation (sampling reflex).7 pelvic floor dyssynergia (decreased anal canal Adult patients with fecal incontinence show pressures reliably exclude the diagnosis of pel- elevated levels of psychological distress as well vic floor dyssynergia, but abnormal findings as elevations on scales measuring physical require confirmation). If the history and physi- functioning, mental health, and social func- cal examination do not support a diagnosis of tioning. It is believed that these reflect functional fecal incontinence, further examina- primarily the consequences of having fecal tion may be required. incontinence. Functional disorders of the anus and rectum II57

TREATMENT are met but the physical signs are absent.

For patients with constipation-related fecal Clinical evaluation will usually include sig- Gut: first published as 10.1136/gut.45.2008.ii55 on 1 September 1999. Downloaded from incontinence, habit training after bowel cleans- moidoscopy and appropriate imaging studies ing results in complete continence for roughly such as , ultrasound, or pelvic CT 60% of children and substantial reduction in to exclude alternative diseases. frequency of soiling for another 23%.8 For eld- erly incontinent patients, a daily osmotic laxa- PATHOPHYSIOLOGY tive (e.g., lactulose 10 ml twice daily) plus a Levator ani syndrome has been hypothesized to weekly enema was reported to be eVective in result from spastic or overly contracted pelvic more than 90% of patients.9 For patients with floor muscles.10 However, the etiology is diarrhea-related incontinence, loperamide is unknown. Some reports suggest that levator recommended. Biofeedback should be consid- ani syndrome is associated with psychological ered only in patients who do not respond to stress, tension, and anxiety.11 habit training or medication. TREATMENT F2. Functional anorectal pain A variety of treatments directed at reducing Two forms of functional anorectal pain have tension in the levator ani muscles have been been described: levator ani syndrome and described: digital massage of the levator ani proctalgia fugax. These two types of pain muscles; Sitz baths; muscle relaxants such as frequently coexist, but they can be dis- methocarbamol, , and cycloben- tinguished on the basis of duration, frequency zeprine; electrogalvanic stimulation; and bio- and characteristic quality of pain. It is neces- feedback training. None of the treatment stud- sary to exclude other causes of anorectal pain ies included a control group, and patient such as ischemia, fissures, inflammatory bowel selection criteria varied. Many patients fail to disease, and intramuscular abscess. respond to treatment. Surgery should be avoided. F2a. Levator ani syndrome The levator ani syndrome is also called levator spasm, puborectalis syndrome, chronic proc- F2b. Proctalgia fugax talgia, pyriformis syndrome, and pelvic tension Proctalgia fugax is defined as sudden, severe . The pain is often described as a vague, pain in the anal area lasting several seconds or dull ache or pressure sensation high in the rec- minutes, and then disappearing completely.12 tum, often worse with sitting or lying down, Attacks are infrequent, occurring less than five which lasts for hours to days. times a year in 51% of patients. The prevalence of symptoms compatible Community prevalence estimates range from with levator ani syndrome in the general popu- 8 to 18%. Only 17–20% of those aVected lation is 6.6%, and it is more common in report the symptoms to their physicians. 3 women. Only 29% consult a physician, but Prevalence rates in men and women vary. http://gut.bmj.com/ associated disability appears to be significant. More than half of aVected patients are aged DIAGNOSTIC CRITERIA 30–60 years, and prevalence tends to decline (1) Recurrent episodes of pain localized to after age 45. the anus or lower rectum; and (2) Episodes last from seconds to minutes; DIAGNOSTIC CRITERIA and

At least 12 weeks, which need not be (3) There is no anorectal pain between epi- on September 29, 2021 by guest. Protected copyright. consecutive, in the preceding 12 months of: sodes. (1) Chronic or recurrent or ach- ing; CLINICAL EVALUATION (2) Episodes last 20 minutes or longer; and Diagnosis is based on symptoms alone. There (3) Other causes of rectal pain such as are no physical examination findings or labora- ischemia, inflammatory bowel disease, tory tests that support the diagnosis. cryptitis, intramuscular abscess, fissure, , prostatitis, and solitary PATHOPHYSIOLOGY AND PSYCHOLOGICAL rectal ulcer have been excluded. FACTORS The short duration and sporadic, infrequent CLINICAL EVALUATION nature of this disorder has made the identifica- The diagnosis of levator ani syndrome is made tion of physiological mechanisms diYcult. on the basis of symptoms alone, However, con- Several studies suggest that smooth muscle fidence in the diagnosis is substantially in- spasm may be the cause of proctalgia fugax.13 14 creased if posterior traction on the puborecta- Psychological testing suggests that many pa- lis reveals tight levator ani muscles and tients are perfectionistic, anxious, and/or hypo- tenderness or pain. Tenderness may be pre- chondriacal. dominantly left-sided, and massage of this muscle will generally elicit the characteristic TREATMENT discomfort. Two levels of diagnostic classifi- For most patients, episodes of pain are so brief cation are proposed: a “highly likely” diagnosis that treatment consists only of reassurance and of levator ani syndrome if symptom criteria are explanation. However, a small group of pa- satisfied and these physical signs are present, or tients have proctalgia fugax on a frequent basis; a “possible” diagnosis if the symptom criteria a recent study shows that inhalation of salbuta- II58 Whitehead, Wald,Diamant, et al

mol (a beta adrenergic agonist) shortens the and more restrictive diagnostic criteria have 15 20 duration of episodes of proctalgia. Others been recommended. The working team Gut: first published as 10.1136/gut.45.2008.ii55 on 1 September 1999. Downloaded from have recommended or amylnitrate. therefore recommends augmenting the diag- nostic criteria by requiring evidence of ad- equate propulsive forces and evidence of F3. Pelvic floor dyssynergia incomplete evacuation in addition to evidence Pelvic floor dyssynergia is characterized by of paradoxical contraction. However, there is paradoxical contraction or failure to relax the insuYcient empirical evidence to justify rec- pelvic floor during attempts to defecate.16 17 It is ommending specific tests or specific cut-oV frequently associated with symptoms of diY- points on those tests. cult defecation including straining, feeling of In the previous working team report, a diag- incomplete evacuation after defecation, and nostic category existed for diYcult defecation digital facilitation of defecation. which was associated with manometric evi- The prevalence of pelvic floor dyssynergia in dence of internal anal sphincter dysfunction. the population is unknown, because the The working team recommends dropping this diagnosis requires physiological testing. How- category until it is confirmed by further ever, in patients referred for evaluation of studies. chronic constipation, pelvic floor dyssynergia is found in 25–50% of both children and adults.18 This may be an overestimation due to the high CLINICAL EVALUATION The physiological investigations considered false-positive rates seen in some studies.19 No useful for making a diagnosis of pelvic floor information is available on gender diVerences. dyssynergia are: (1) , (2) electromyography of the external anal sphinc- DIAGNOSTIC CRITERIA ter, (3) balloon defecation (simulated defeca- (1) The patient must satisfy diagnostic cri- tion), and (4) defecography. Finding, on physi- teria for functional constipation in cal examination, that the patient is able to Diagnostic Criteria C3; decrease anal canal pressure when straining is (2) There must be manometric, EMG, or useful for ruling out pelvic floor dyssynergia, radiologic evidence for inappropriate but an increase in anal canal pressure when contraction or failure to relax the pelvic straining during physical examination is not a floor muscles during repeated attempts reliable indication of the presence of pelvic to defecate; floor dyssynergia. (3) There must be evidence of adequate The measurement of anal canal pressure and propulsive forces during attempts to EMG activity from the external anal sphincter defecate; and during straining to defecate is especially helpful (4) There must be evidence of incomplete in identifying patients with pelvic floor dyssyn- evacuation. ergia. There should be evidence of adequate

propulsive forces during straining, measured as http://gut.bmj.com/ Diagnostic criteria for functional constipa- increased intra-rectal pressures and/or abdomi- tion are: at least 12 weeks (which need not be nal wall contraction. consecutive) in the preceding 12 months of two EVorts to measure defecation include intro- or more of: (1) straining in >1/4 ; ducing lubricated balloons attached to thin (2) lumpy or hard stools in >1/4 defecations; catheters into the rectum, filling them with 50 (3) sensation of incomplete evacuation in >1/4 ml water or air, and asking the patient to defecations; (4) sensation of anorectal defecate them. Latencies less than 60 seconds obstruction/blockage in >1/4 defecations; (5) are considered normal. However, additional on September 29, 2021 by guest. Protected copyright. manual maneuvers to facilitate >1/4 defeca- research is needed to standardize this test. tions (e.g., digital evacuation, support of the Many investigators use the balloon defecation pelvic floor); and/or (6) <3 defecations/week. test as a screening tool which, if positive, leads Loose stools are not present, and there is insuf- to further testing. ficient evidence for irritable bowel syndrome. Defecography is a radiological technique to evaluate the rectum and pelvic floor during an RATIONALE FOR CHANGES IN DIAGNOSTIC attempted defecation. This test provides infor- CRITERIA mation on the presence of structural abnor- In the previous working team report, symp- malities and functional parameters such as the toms of diYcult defecation were used to define anorectal angle at rest and during straining, an independent diagnostic entity, which was diameter of the anal canal, indentation of the called dyschezia. However, diVerentiation of puborectalis, and degree of rectal emptying. subtypes of constipation based on symptoms However, its value has been questioned be- alone is not reliable. Consequently, in the cause agreement between investigations on the revised working team reports, a diagnosis of interpretation of findings is low.5 Defecography pelvic floor dyssynergia depends primarily on is principally useful for identifying structural physiological findings. causes of and for quanti- The previous working team report recom- fying rectal emptying. mended diagnosing pelvic floor dyssynergia on The most frequently used technique for the basis of symptoms of diYcult defecation measuring colonic transit time involves having plus manometric, EMG, or radiologic evidence the patient swallow radio-opaque rings and of failure to relax the pelvic floor when taking abdominal radiographs on one or more attempting to defecate. However, one study19 days thereafter.21 22 Although of no value in suggests that these criteria are too non-specific, diagnosing pelvic floor dyssynergia, this test is Functional disorders of the anus and rectum II59

useful for determining whether the patient has feedback, and muscle relaxant drugs for the

colonic inertia as an alternative or comorbid treatment of levator ani syndrome should be Gut: first published as 10.1136/gut.45.2008.ii55 on 1 September 1999. Downloaded from cause of constipation. performed.

PATHOPHYSIOLOGY We thank the following reviewers for their critique of the manu- Pelvic floor dyssynergia is not attributable to a script and their suggestions: Enrico Corazziari, Michael Crow- neurological lesion as at least two-thirds of ell, James W Fleshman, Hans C Kuijpers, J E Lennard-Jones, Vera Loening-Baucke, Nick W Read, Robert Sandler, Marvin patients can learn to relax the external anal M Schuster, Steven D Wexner. sphincter and puborectalis muscles appropri- ately when provided with biofeedback 23 1 Drossman DA, Thompson WG, Talley NJ, et al. Identifica- training. Anxiety and/or psychological stress tion of sub-groups of functional gastrointestinal disorders. may contribute to the development of pelvic Gastroenterol Int 1990;3:159–72. floor dyssynergia by increasing skeletal muscle 2 Nelson R, Norton N, Cautley E, et al. Community-based prevalence of anal incontinence. JAMA 1995;274:559–61. tension. Adults with diYcult defecation have 3 Drossman DA, Li Z, Andruzzi E, et al. U.S. Householder exhibited significantly higher scores for anxiety, survey of functional gastrointestinal disorders: Prevalence, sociodemography, and health impact. Dig Dis Sci 1993;38: depression, interpersonal sensitivity, obsessive 1569–80. compulsive traits, phobic anxiety, and somati- 4 Barrett JA, Brocklehurst JC, KiV ES, et al. Anal function in geriatric patients with fecal incontinence. Gut 1989;30: zation. Pelvic floor dyssynergia is more com- 1244–51. mon in women with a history of sexual abuse.24 5 Diamant NE, Kamm MA, Wald A, et al. AGA technical review on anorectal testing techniques. 1999;116:735–60. PATHOPHYSIOLOGY 6HoVman BA, Timmcke AE, Gathright JB, et al. Fecal seep- age and soiling. A problem of rectal sensation. Dis Colon Two types of training have been described for Rectum 1995;38:746–8. pelvic floor dyssynergia: (1) biofeedback train- 7 Speakman CTM, Hoyle CHV, Kamm MM, et al. Abnor- ing in which sensors in the anal canal or adja- malities of innervation of internal anal sphincter in fecal incontinence. Dig Dis Sci 1993;38:1961–9. cent to the anus, monitor and provide feedback 8 Lowery SP, Srour JW, Whitehead WE, et al. Habit training to the patient on striated muscle activity or anal as treatment of secondary to chronic constipa- 23 tion. J Pediatr Gastroenterol Nutr 1985;4:397–401. canal pressures ; and (2) simulated defecation 9 Tobin GW, Brocklehurst JC. Faecal incontinence in in which the patient practices defecation of a residential homes for the elderly. Prevalence, aetiology and 25 management. Age Ageing 1986;15:41–6. simulated stool. Both seem to be eVective. A 10 Grimaud JC, Bouvier M, Naudy B, et al. Manometric and systematic review published in 1993 gives an radiologic investigations and biofeedback treatment of 26 chronic idiopathic anal pain. Dis Colon Rectum 1991;34: overall success rate of 67%. However, recent 690–5. but uncontrolled studies of large series of 11 Heymen S, Wexner SD, Gulledge AD. MMPI assessment of 27 28 patients with functional bowel disorders. Dis Colon Rectum patients report improvement in 48 to 62% of 1993;36:593–6. patients (intent-to-treat analyses). 12 Thompson WG. Proctalgia fugax. Dig Dis Sci 1981;26: 1121–4. 13 Rao SSC, Hatfield RA. Paroxysmal anal hyperkinesis: A Directions for future research characteristic feature of proctalgia fugax. Gut 1996;39: 609–12. + Multicenter studies of the normal physiol- 14 Eckardt VF, Dodt O, Kanzler G, et al. Anorectal function

ogy of defecation in large groups of subjects and morphology in patients with sporadic proctalgia fugax. http://gut.bmj.com/ stratified by age, gender, and (in women) by Dis Colon Rectum 1996;39:755–62 15 Eckardt VF, Dodt O, Kanzler G, et al. Treatment of proctal- parity. This would (a) help to define the gia fugax with inhalation. Am J Gastroenterol normal ranges for diagnostic tests of fecal 1996;91:686–9. 16 Preston DM, Lennard-Jones JE. Anismus in chronic consti- incontinence and pelvic floor dyssynergia, pation. Dig Dis Sci 1985;30:413–18. and (b) help establish standardized technol- 17 Kuijpers HC, Bleijenberg G. The spastic pelvic floor syndrome. A cause of constipation. Dis Colon Rectum 1985; ogy for assessment of these conditions. 28:669–72. + Diagnostic criteria for pelvic floor dyssyner- 18 Wald A, Caruana BJ, Freimanis MG, et al. Contributions of

evacuation proctography and anorectal manometry to the on September 29, 2021 by guest. Protected copyright. gia must be validated and should include evaluation of adults with constipation and defecatory diY- definite changes in anal canal pressure dur- culty. Dig Dis Sci 1990;35:481–7. 19 Duthie GS, Bartolo DCC. Anismus: the cause of constipa- ing straining, propulsive forces, and per cent tion? Results of investigation and treatment. World J Surg evacuation of the rectum. 1992;16:831–5. 20 Roberts JP, Womack NR, Hallan RI, et al. Evidence from + A randomized, blinded study of the eYcacy dynamic integrated protocography to redefine anismus. Br of biofeedback treatment for pelvic floor J Surg 1992;79:1213–15. 21 Metcalf AM, Phillips SF, Zinsmeister AR, et al. Simplified dyssynergia should be carried out. The assessment of segmental colonic transit. Gastroenterology study design should control for the placebo 1987;92:40–7. 22 Chaussade S, Roche H, Khyari A, et al. Mesure du temps de response. transit colique global et segmentaire. Description et valida- + Psychological characteristics of patients tion d’une nouvelle technique. Gastroenterol Clin Biol 1986; 10:385–9. with levator ani syndrome and proctalgia 23 Rao SSC, Welcher KD, Pelsang RE. EVects of biofeedback fugux may help to define the etiology of on anorectal function in obstructive defecation. Dig Dis Sci 1997;42:2197–205. these disorders. These studies should com- 24 Leroi AM, Berkelmans I, Denis P, et al. Anismus as a marker pare medical clinic patients to individuals in of sexual abuse. Consequences of abuse on anorectal motility. Dig Dis Sci 1995;40:1411–16. the community. 25 Bleijenberg G, Kuijpers HC. Treatment of the spastic pelvic + Studies are needed to determine whether floor syndrome with biofeedback. Dis Colon Rectum 1987;30:108–11. proctalgia fugax and levator ani syndrome 26 Enck P. Biofeedback training in disordered defecation. A are separate disorders. These should include critical review. Dig Dis Sci 1993;38:1953–60. 27 Gilliland R, Heymen JS, Altomare DF, et al. Outcome and detailed symptom reports supplemented by predictors of success of biofeedback for constipation. Br J symptom diaries in large groups of patients. Surg 1997;84:1123–6. 28 Patankar SK, Ferrara A, Levy JR, et al. Biofeedback in + A randomized, blinded multicenter study to colorectal practice. A multicenter, statewide, three-year compare electrogalvanic stimulation, bio- experience. Dis Colon Rectum 1997;40:827–31.