Proctalgia Syndromes: Update in Diagnosis and Management.

PURPOSE OF REVIEW: Functional anorectal pain syndromes are a neglected yet often disabling clinical entity resulting in significant economic and psychological burden to the patient. The aim of this review is to update the practicing gastroenterologist/coloproctologist on the diagnosis and management of these complicated disorders. RECENT FINDINGS: The updated Rome foundation diagnostic criteria (Rome IV) for functional anorectal pain subgroups chronic proctalgia (levator ani syndrome and unspecified functional anorectal pain) and acute proctalgia (proctalgia fugax) on the basis of symptom duration and digital rectal examination findings. Chronic proctalgia is thought to be secondary to paradoxical pelvic floor contraction in many patients and biofeedback to improve the defecation effort has proven effective for over 90% in the short term. Unfortunately, management of proctalgia fugax remains challenging and treatment outcomes modest at best. A number of therapies to relax the pelvic floor may be employed to improve symptoms in functional anorectal pain syndromes; however, only biofeedback to improve defaecatory dynamics in patients with levator ani syndrome has proven effectiveness in a randomized setting. Further investigation of treatment approaches in proctalgia fugax is required.

Frequency and clinical impact of Dolichocolon in women submitted to surgery for rectosigmoid endometriosis.

INTRODUCTION: Rectosigmoid endometriosis and Dolichocolon can both present with a triad of chronic abdominal pain, constipation and bloating. The relationship between these two pathologies is unknown. The present study aims to determine the frequency of DC in women with rectosigmoid endometriosis and its possible impact on pre- and post-operative symptoms. MATERIAL AND METHODS: We conducted a retrospective cohort study on 113 consecutive patients submitted to magnetic resonance imaging enema and subsequent complete surgical removal for symptomatic rectosigmoid endometriosis between June 2015 to June 2018. Dolichocolon is an anatomic variant characterized by redundancies and lengthening of the colon. We divided our study population according to its presence or absence. The two groups were compared in terms of demographic data, surgical findings and pre- and post-operative clinical variables. Pain symptoms were assessed through numerical rating scale from 0 to 10. Bowel complaints included constipation, bloating and diarrhea. RESULTS: Thirty-five patients (31 %) presented a dolichocolon at magnetic resonance imaging enema. The two groups were comparable in terms of demographic data, pre-operative clinical variables and surgical findings. At 6-month follow-up, there was a significant improvement of symptoms, except for constipation and bloating in dolichocolon group. In particular, we observed with a statistical difference (p < .05) the persistence of constipation and bloating in dolichocolon group compared to non-dolichocolon group. CONCLUSIONS: Dolichocolon was observed in one third patients with rectosigmoid endometriosis and could influence surgical outcomes for rectosigmoid endometriosis in terms of relief of bowel symptoms.

Effects of psychosensory stimulation on anal pressures: Effects of alfuzosin.

BACKGROUND: Our aim is to explain the lack of clarity in the ways in which anxiety and depression, which are common in defecatory disorders (DD), may contribute to the disorder. In this study, we evaluate the effects of mental stress and relaxation on anal pressures and the mechanisms thereof. METHODS: In 38 healthy women and 36 DD patients, rectoanal pressures were assessed at rest and during mental stressors (ie, word-color conflict [Stroop] and mental arithmetic tests) and mental relaxation, before and after randomization to placebo or the adrenergic α1 -antagonist alfuzosin. KEY RESULTS: During the baseline Stroop test, the anal pressure increased by 6 ± 13 mm Hg (mean ± SD, P = 0.004) in healthy women and 9 ± 10 mm Hg (P = 0.0001) in constipated women. During mental arithmetic, the anal pressure increased in healthy (4 ± 8 mm Hg, P = 0.002) and constipated women (5 ± 9 mm Hg, P = 0.004). After relaxation, anal pressure declined (P = 0.0004) by 3 ± 4 mm Hg in DD patients but not in controls. Alfuzosin reduced (P = 0.0001) anal resting pressure (by 31 ± 19 mm Hg) vs placebo (16 ± 18 mm Hg). However, during the postdrug Stroop test, anal pressure increased (P = 0.0001) in participants who received alfuzosin but not placebo. CONCLUSIONS & INFERENCES: In healthy controls and DD patients, mental stressors likely increased anal pressure by contracting the internal anal sphincter; relaxation reduced anal pressure in DD patients. Alfuzosin reduced anal resting pressure but did not block the Stroop-mediated contractile response, which suggests that this response is not entirely mediated by adrenergic α1 receptors.

Successful Treatment of Paradoxical Puborectalis Contraction and Intractable Anorectal Pain With Sacral Neuromodulation.

BACKGROUND: Paradoxical puborectalis contraction (PPC) is a syndrome of obstructed defecation associated with a cluster of complaints including rectal pain, incomplete evacuatory sensation, prolonged repetitive straining with bowel movements, and the need for digital manipulation. Traditional treatment has yielded mixed results. CASE: We present a case of PPC successfully treated with staged sacral neuromodulation and review her diagnostic features, medical regimen, and prior unsuccessful interventions tried. Symptoms were analyzed using a visual analog scale pain score (0-10). Criteria to progress to implantation of the pulse generator included a pain score less than 3 during test stimulation and/or greater than 50% decrease in the pain score compared to baseline.Our patient had a pain score of 0 (baseline 8) with stage 1 sacral neuromodulation. In addition, she had dramatic relief in her straining with bowel movements and need for digital manipulation. Her pulse generator was implanted after a 2-week trial, and she has experienced a lasting improvement at her follow-up of 2 years. CONCLUSIONS: Sacral neuromodulation is an established therapy for overactive bladder syndrome, urinary retention, and fecal incontinence. In urology, the use of sacral neuromodulation has been described to benefit some patients with pelvic floor pain. Sacral neuromodulation can be a successful treatment for PPC and functional anorectal pain with resulting improvement in quality of life without the sequelae of an invasive and irreversible surgery.

Functional outcomes after disc excision in deep endometriosis of the rectum using transanal staplers: a series of 111 consecutive patients.

OBJECTIVE: To assess the postoperative outcomes of patients with rectal endometriosis managed by disc excision using transanal staplers. DESIGN: Prospective study using data recorded in the CIRENDO database (NCT02294825). SETTING: University tertiary referral center. PATIENT(S): A total of 111 consecutive patients managed between June 2009 and June 2016. INTERVENTION(S): We performed rectal disc excision using two different transanal staplers: [1] the Contour Transtar stapler (the Rouen technique); and [2] the end to end anastomosis circular transanal stapler. MAIN OUTCOMES MEASURE(S): Pre- and postoperative digestive function was assessed using standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index and the Knowles-Eccersley-Scott Symptom Questionnaire. RESULT(S): The two staplers were used in 42 (37.8%) and 69 patients (62.2%), respectively. The largest diameter of specimens achieved was significantly higher using the Rouen technique (mean ± SD, 59 ± 11 mm vs. 36 ± 7 mm), which was used to remove nodules located lower in the rectum (5.5 ± 1.3 cm vs. 9.7 ± 2.5 cm) infiltrating more frequently the adjacent posterior vaginal wall (83.3% vs. 49.3%). Associated nodules involving sigmoid colon were managed by distinct procedures, either disc excision (2.7%) or segmental resection of sigmoid colon (9.9%). Postoperative values for the Gastrointestinal Quality of Life Index increased 1 and 3 years after the surgery, but improvement in constipation was not significant. The probability of pregnancy at 1 year after the arrest of medical treatment was 73.3% (95% confidence interval 54.9%-88.9%), with a majority of spontaneous conceptions. CONCLUSION(S): Disc excision using transanal staplers is a valuable alternative to colorectal resection in selected patients presenting with rectal endometriosis, allowing for good preservation of rectal function.

Electroneurostimulation for the management of bladder bowel dysfunction in childhood.

Both non-invasive and invasive electroneurostimulation (ENS) modalities for bladder bowel dysfunction have been studied and reported in children. A summary of the proposed mechanism of actions and the more commonly used and recently reported techniques and outcomes are described. This includes transcutaneous electrical nerve stimulation, functional electrical nerve stimulation, intravesical electrical nerve stimulation, percutaneous tibial nerve stimulation and sacral neuromodulation in conditions including overactive bladder, enuresis, dysfunctional voiding, constipation, combined bladder bowel dysfunction and neuropathic bladder and bowel dysfunction. There is a need for further high quality randomised trials as well as long-term outcomes to establish whether ENS is able to alter the long-term trajectory for an individual child with bladder bowel dysfunction.

Rectal Hyposensitivity Is Associated With a Defecatory Disorder But Not Delayed Colon Transit Time in a Functional Constipation Population.

The physiological mechanism of functional constipation (FC) includes defecatory disorders and delayed colon transit. About 18% to 68% constipated patients may have rectal hyposensitivity (RH). We performed this study to investigate the association between RH and functional defecatory disorder (FDD) as well as that between RH and delayed colon transit in FC patients.A total of 218 FC patients were enrolled. The constipation severity instrument (CSI) was used to assess constipation symptoms. High-resolution anorectal manometry (HR-ARM), defecography, balloon expulsion tests, and colon transit studies were performed for each patient. RH was defined as 1 or more sensory threshold pressures raised beyond the normal range based on HR-ARM. We investigated the association between RH and constipation symptoms, and the occurrence of FDD and delayed CTT. Ninety FDD patients completed the initial phase of biofeedback treatment (BFT). We investigated the association between RH and the effect of BFT.Totally 122 (56.0%) patients had RH. The total CSI (49.82 ±â€Š1.09 vs 41.25 ±â€Š1.55, P = 0.023) and obstructive defecation subscale scores (23.19 ±â€Š0.69 vs 17.07 ±â€Š0.90, P < 0.001) were significantly higher in RH than in non-RH patients. No significant difference was observed in slow transit symptoms (21.77 ±â€Š0.72 vs 19.90 ±â€Š0.85, P = 0.121) or abdominal pain (6.85 ±â€Š2.61 vs 5.00 ±â€Š1.04, P = 0.380). The frequency of prolonged CTT was not significantly different between RH and non-RH groups (54.1% vs 58.3%, P = 0.403). RH patients rated more occurrence of FDD (72.1% vs 53.1%, P = 0.014) and dysynergic defecation (79.8% vs 50.2%, P = 0.004) than non-RH patients, whereas no differences were seen for inadequate defecatory propulsion (59.2% vs 55.0%, P = 0.589). After BFT, the proportion of "no effect" was significantly higher in the RH group than in the non-RH group (22.4% vs 9.4%, P = 0.010).RH is associated with obstructive defecation symptoms and the occurrence of FDD. Further studies are needed to detect the mechanism of RH's effect on BFT and FC.

Effective treatment of dyssynergic defecation using sacral neuromodulation in a patient with cerebral palsy.

BACKGROUND: Dyssynergic defecation is a complex bowel problem that leads to chronic constipation and abdominal pain. Management is often challenging owing to the incoordination of multiple pelvic floor muscles involved in normal defecation. CASE: We report a case of dyssynergic defecatory dysfunction in a patient with cerebral palsy treated with sacral neuromodulation. At presentation, Sitz marker study and magnetic resonance defecography showed evidence of chronic functional constipation. Anorectal manometry, rectal anal inhibitory reflex, and rectal sensation study showed intact reflex and decreased first sensation of lower canal at 50 mL. After stage 2 of InterStim implant placement, bowel habits improved to once- to twice-daily soft solid bowel movements from no regular solid bowel movements. Fecal incontinence improved from daily liquid and small solid loss to no stool leakage. CONCLUSIONS: In patients with systemic medical problems contributing to defecatory dysfunction and bowel incontinence, such as cerebral palsy, sacral neuromodulation was found to provide significant relief of bowel symptoms in addition to associated abdominal pain. As a result of intervention, the patient reported significant improvement in quality of life and less limitations due to dyssynergic defecation.

[Descending perineum syndrome in children: Pathophysiology and diagnosis].

Objective: To propose a safer, simpler, and more exact method for the diagnosis of descending perineum syndrome (DPS). Material and Methods: A total of 194 patients aged 5 days to 15 years were examined and divided into 2 groups: Group 1 consisted of 65 patients without anorectal anomalies (AA); Group 2 comprised 129 patients, including 66 children with functional constipation, 55 with AA and visible fistulas, who were preoperatively examined, and 8 patients with anorectal angle (ARA), who were postoperatively examined. All the patients underwent irrigoscopy that was different from standard examination in the presence of X-ray CT contrast marker near the anus. Results and Conclusion: DPS is caused by puborectalis muscle dysfunction. A method was proposed to evaluate the status of the puborectalis muscle from the distance between the position of the ARA and the marker near the anus. This not only promotes an exacter estimate of DPS, but also allows refusal of defecography. The use of a barium enema with the minimum number of X-ray films decreases dose of ionizing radiation hazard and permits the use of this procedure not only in adults, but also in children with chronic constipation, fecal incontinence, and in AA for both pre- and postoperatively assessment of the causes of complications.

Prospective randomized double-blind study of temporary sacral nerve stimulation in patients with rectal evacuatory dysfunction and rectal hyposensitivity.

OBJECTIVE: Prospective randomized double-blind placebo-controlled crossover trial of 14 female patients (median age 52 [30-69] years) with proctographically defined evacuatory dysfunction (ED) and demonstrable rectal hyposensitivity (elevated thresholds to balloon distension in comparison with age- and sex-matched controls). BACKGROUND: Sacral nerve stimulation (SNS) is an evolving treatment for constipation. However, variable outcomes might be improved by better patient selection. Evidence that the effect of SNS may be mediated by modulation of afferent signaling promotes a role in patients with ED associated with rectal hyposensation. METHODS: SNS was performed by the standard 2-stage technique (temporary then permanent implantation). During a 4-week period of temporary stimulation, patients were randomized ON-OFF/OFF-ON for two 2-week periods. Before insertion (PRE), and during each crossover period, primary (rectal sensory thresholds) and secondary (bowel diaries, constipation, and GIQoL [gastrointestinal quality of life] scores) outcome variables were blindly assessed. RESULTS: Thirteen patients completed the trial. Following stimulation, defecatory desire volumes to rectal balloon distension were normalized in 10 of 13 patients (PRE: mean 277 mL [234-320] vs ON: 163 mL [133-193] vs OFF: 220 mL [183-257 mL]; P = 0.006) and maximum tolerable volume in 9 of 13 (PRE: mean 350 mL [323-377] vs ON: 262 mL [219-305] vs OFF: 298 mL [256-340 mL]; P = 0.012). There was a significant increase in the percentage of successful bowel movements (PRE: median 43% [0-100] vs ON: 89% [11-100] vs OFF: 83% [11-100]; P = 0.007) and Wexner constipation scores improved (PRE: median 19 [9-26] vs ON: 10 [6-27] vs OFF: 13 [5-29]; P = 0.01). There were no significant changes in disease-specific or generic quality of life measures. Eleven patients progressed to permanent stimulation (9/11 success at 19 months). CONCLUSIONS: Most patients with chronic constipation secondary to ED with rectal hyposensitivity responded to temporary SNS. The physiological results presented support a mechanistic role for rectal afferent modulation.

Patient experience and satisfaction with sacral neuromodulation: results of a single-center sample survey.

PURPOSE: Sacral neuromodulation is a well researched and successful treatment for functional bowel disorders. Indications have expanded throughout the years and various studies have been published on clinical efficacy or on technique improvement. The main goal of this retrospective study was to systematically evaluate daily experiences with this treatment and measure the long-term satisfaction of sacral neuromodulation therapy for functional bowel disorders. METHODS: After institutional review board approval a new, self-designed postal questionnaire was sent to all patients in our center who were being treated with sacral neuromodulation. Only patients with a minimal follow-up of 1 year were included in the survey. Implantation years range from 2000 to 2007. RESULTS: A total of 174 patients received the questionnaire regarding patient satisfaction and experience with sacral neuromodulation therapy. The response rate after reminder letter was 71.8% (n = 125) including 114 (91.2%) females. Patient satisfaction was high: 81 patients (65.3%) reported their results as very satisfying, 30 patients (24.2%) were moderately satisfied, and 13 patients (10.4%) were not satisfied. Analysis showed that patient satisfaction can be explained by both patient perception of present bowel function and their evaluation of the quality of daily life. No significant relationship was found with patient demographics, self-ascribed (co)morbidity, behavioral habits, or therapy duration. A total of 47 patients (38.2%) reported having some concerns regarding the future with sacral neuromodulation treatment. Twenty-eight patients (23.1%) reported a temporary loss of effect at any time during sacral neuromodulation therapy. Pain at the implantation site was reported by 65 patients (52.4%). CONCLUSIONS: This study shows that patients treated with sacral neuromodulation, in general, are very satisfied. The main problems mentioned by patients are pain, loss of efficacy, and general concerns.

Sacral neuromodulation for the treatment of chronic functional anorectal pain: a single center experience.

INTRODUCTION: Treatment of functional anorectal pain disorders remains a challenge. The purpose of this study is to describe a single center experience with sacral neuromodulation for the treatment of chronic functional anorectal pain. METHODS: This is a retrospective study based on prospectively collected data of patients treated with sacral neuromodulation for functional anorectal pain from April 2005 to August 2008. Symptoms were analyzed using a visual analog scale pain score (0 to 10). A 7-point Likert scale was used to rate global perceived effect. All patients had a percutaneous nerve evaluation and subsequent test stimulation to assess sacral neuromodulation outcome prior to permanent implantation. Patients were eligible for permanent sacral neuromodulation in case of a pain score <3 during test stimulation and/or >50% decrease in the pain score compared to baseline. RESULTS: Nine patients (2 males) were included in this study. Mean age was 53.8 years (27.6 to 74.0). Four patients (1 male) had successful test stimulation and were eligible for permanent implantation. Median pain score decreased from 8.0 (6.0 to 9.0) to 1.0 (0 to 2.0). All patients experienced a lasting improvement during the follow-up till 24 months. Global perceived effect in successful patient was 1 (completely recovered) in one patient and 2 (much improved) in three patients. CONCLUSION: This study showed that sacral neuromodulation can be a successful treatment for functional anorectal pain not responding to other treatments. Improvement obtained during test stimulation is a good predictor (diagnostic) for sustained success of permanent sacral neuromodulation.

Anorectal manometry with reference to operative rectal biopsy for the diagnosis/exclusion of Hirschprung's disease in children under 1 year of age.

AIMS: To establish the accuracy of anorectal manometry (ARM) with reference to operative rectal biopsy in the investigation of children under 1 year of age with defaecation difficulties. MATERIALS AND METHODS: The records of all infants who underwent ARM and operative rectal biopsy at our centre between 1994 and 2007 were reviewed. ARM was performed by a consultant paediatric surgeon in each and under ketamine anaesthesia, as operative rectal biopsy was taken. RESULTS: There were 81 patients (49 males, 32 females). The median age at investigation was 2 months (range 0.1-11 months). Thirty-three patients (41%) had Hirschprung's disease. No patient with a normal recto-anal inhibitory reflex (RAIR) had Hirschprung's disease (100% negative predictive value). No patient with Hirschprung's disease exhibited a reflex (100% sensitivity). The specificity and positive predictive value of ARM for Hirschprung's disease were 83% and 80%, respectively. Bowel habit normalised in 88% of patients with a reflex within 1 year. CONCLUSIONS: In children under 1 year of age, Hirschprung's disease is very unlikely in the presence of a RAIR. The specificity and positive predictive value of ARM for the diagnosis of Hirschprung's disease are inferior to those of rectal suction biopsy, and therefore, it cannot be recommended for use as a sole diagnostic tool for this disease. ARM may be a useful investigation in patients where the histologic specimen is inadequate and/or functional constipation is the most likely diagnosis. If RAIR is present, rectal biopsy may not be required.

Poor symptomatic relief and quality of life in patients treated for "solitary rectal ulcer syndrome without external rectal prolapse".

BACKGROUND: Solitary rectal ulcer syndrome (SRUS) is a chronic disabling condition. Several therapeutic options have been advocated including conservative approaches and surgery, bringing into question their functional outcomes. This study aimed to assess treatment procedures on both anorectal complaints and quality of life (QoL) using standardised self-administered questionnaires. MATERIALS AND METHODS: Forty-one patients who underwent treatments for SRUS in two referral centres were reviewed. A standardised self-administered questionnaire including incontinence (Cleveland Clinic), constipation (Knowles-Eccersley-Scott symptom, KESS) and gastrointestinal quality of life index validated scoring systems was mailed to each patient (median follow-up, 36 months). Correlation between treatment options, functional results and quality of life was analysed. RESULTS: The mean Cleveland Clinic and KESS scores were respectively 5.3+/-5.8 (normal 0) and 19.1+/-8 (normal<9). The mean QoL score reached 89+/-28.8 (normal 125). A linear correlation between the QoL score and functional results was observed. There was no influence of treatment options on QoL results. A multivariate analysis identified five parameters predictive of a better QoL: presence of paradoxical puborectalis contraction, absence of descending perineum, absence of procidentia, age<40 and treatment exclusively based on laxatives. CONCLUSION: Despite several therapeutic options including surgery, patients with SRUS still frequently complain of disturbed anorectal function and significant alteration of their QoL.

Stapled transanal rectal resection in solitary rectal ulcer associated with prolapse of the rectum: a prospective study.

PURPOSE: At present, none of the conventional surgical treatments of solitary rectal ulcer associated with internal rectal prolapse seems to be satisfactory because of the high incidence of recurrence. The stapled transanal rectal resection has been demonstrated to successfully cure patients with internal rectal prolapse associated with rectocele, or prolapsed hemorrhoids. This prospective study was designed to evaluate the short-term and long-term results of stapled transanal rectal resection in patients affected by solitary rectal ulcer associated with internal rectal prolapse and nonresponders to biofeedback therapy. METHODS: Fourteen patients were selected on the basis of validated constipation and continence scorings, clinical examination, anorectal manometry, defecography, and colonoscopy and were submitted to biofeedback therapy. Ten nonresponders were operated on and followed up with incidence of failure, defined as no improvement of symptoms and/or recurrence of rectal ulceration, as the primary outcome measure. Operative time, hospital stay, postoperative pain, time to return to normal activity, overall patient satisfaction index, and presence of residual rectal prolapse also were evaluated. RESULTS: At a mean follow-up of 27.2 (range, 24-34) months, symptoms significantly improved, with 80 percent of excellent/good results and none of the ten operated patients showed a recurrence of rectal ulcer. Operative time, hospital stay, and time to return to normal activity were similar to those reported after stapled transanal rectal resection for obstructed defecation, whereas postoperative pain was slightly higher. One patient complained of perineal abscess, requiring surgery. DISCUSSION: The stapled transanal rectal resection is safe and effective in the cure of solitary rectal ulcer associated with internal rectal prolapse, with minimal complications and no recurrences after two years. Randomized trials with sufficient number of patients are necessary to compare the efficacy of stapled transanal rectal resection with the traditional surgical treatments of this rare condition.

Manometric correlations of anorectal dysfunction and biofeedback outcome in patients with multiple sclerosis.

OBJECTIVE: To evaluate clinical and manometric characteristics of multiple sclerosis (MS) patients with anorectal dysfunction (ARD) and their influence on biofeedback outcome. PATIENTS AND METHODS: Patients were clinically and manometrically studied and compared with controls. Patients were subsequently offered to initiate biofeedback manoeuvres to improve ARD. RESULTS: Fifty-two patients with ARD, 39 women, mean age 44.96 +/- 9.26 years, mean Expanded Disability Status Scale 4.13 +/- 1.72, were evaluated. Thirty-one patients had relapsing-remitting (RR), 16 secondary progressive and five primary progressive MS. ARD complaints were constipation (67.3%), double ARD (23.1%) and isolated incontinence (9.6%). The manometric study showed significant differences in patients compared with controls in maximal contraction pressures (98.1 +/- 44.2 mm Hg versus 152.05 +/- 66.9 mm Hg, P < 0.001) and anal inhibitory reflex threshold (92.9 +/- 63.4 mL versus 40.45 +/- 11.3 mL, P < 0.001). Maximal pressure was lower in progressive forms compared with RR forms (83.1 +/- 36.2 mm Hg versus 108.2 +/- 46.7 mm Hg, P < 0.05) in relation to higher disability. Patients with paradoxical contraction (PC) (35 patients, 67.3%) showed more manometric disturbances. From a total of 18 patients performing biofeedback, those reporting some improvement (six complete, two partial) had milder manometric abnormalities. CONCLUSIONS: The most frequent manometric abnormalities in our MS patients with ARD were alterations of maximal pressures, anal inhibitory reflex and PC. Biofeedback could be more useful in patients with lower disability and manometric alterations.

Defecation disorders: an important subgroup of functional constipation, its pathophysiology, evaluation and treatment with biofeedback.

Functional defecation disorders are common and affect approximately 50% of patients with chronic constipation. The etiology of functional defecation disorders is not well known, but several pathophysiologic mechanisms have been described, including failure of rectoanal coordination, paradoxical anal contraction or insufficient relaxation of anal sphincter during defecation and impairment of rectal sensation as well as secondary slowing of colonic transit. Symptoms alone are inadequate to distinguish patients with defecation disorders from those with other types of constipation. Detailed clinical evaluation and anorectal physiologic tests are required for definitive diagnosis. There is also a pathophysiological association between functional defecation disorders and other anorectal conditions such as solitary rectal ulcer syndrome. Among the various treatment modalities, biofeedback therapy has emerged as an effective and specific treatment method for functional defecation disorders. The main goals of biofeedback therapy are to relax the pelvic floor and anal sphincter muscles during defecation and to improve rectoanal coordination and sensory perception. Today, it is possible to diagnose most functional disorders of defecation and either effectively treat or ameliorate symptoms in a majority of these patients.