Management after obstetric anal sphincter injury: anorectal manometry and symptoms predict long-term fecal incontinence.

OBJECTIVES: Obstetric anal sphincter injury (OASI) is associated with serious morbidity and reduced quality of life. The role of anorectal manometry (ARM) to guide treatment is unclear. We aimed to define the role of ARM and symptom assessment post OASI in predicting anal incontinence at long-term follow-up. METHODS: Prospective evaluation of 205 consecutive post-OASI women who underwent baseline ARM and symptom assessment in a tertiary setting was undertaken. 99 were available for long term follow-up (median 6.6 years). Associations between post-OASI ARM testing and short- and long- term anal incontinence were examined in addition to clinical and obstetric factors. RESULTS: 4th degree tears and lower anal resting and squeeze pressures were associated with short-term anal incontinence. Females with anal incontinence at baseline, and females with lower anal resting pressure, were more likely to suffer from long-term fecal incontinence (FI). A best-fit cut-off value of 59 mmHg for baseline anal resting pressure predicted long-term FI, and none of the short-term asymptomatic females with an anal resting pressure of >59mmHg reported FI at long-term follow-up. CONCLUSIONS: Symptoms of anal incontinence and ARM in patients post OASI are both useful to predict subsequent long-term FI with a best-fit cut-off of 59mmHg for anal resting pressure. This provides rationale for routine ARM and accurate symptom assessment in all patients after OASI, to identify high risk groups to follow and treat, and it may assist decision-making regarding mode of subsequent obstetric deliveries.

Using a footstool does not aid simulated defecation in undifferentiated constipation: A randomized trial.

INTRODUCTION: The use of a footstool has been advocated to optimize posture when sitting on the toilet and thus facilitate bowel evacuation. We aimed to assess the alterations in defecatory posture, and the changes in simulated defecation with use of a footstool in patients with constipation. METHODS: Forty-one patients (female 93%, mean 52 year, SD 14 year) with constipation referred to a tertiary neurogastroenterology unit were enrolled. A bowel questionnaire, Hospital Anxiety and Depression Scale, and Rome questionnaire were administered prior to anorectal manometry. Each patient underwent three rectal balloon expulsion tests in randomized order with no footstool, a 7-inch, and a 9-inch footstool. Additional assessments included angle between spine and femur, and visual analogue scales assessing ease of evacuation, urge to defecate, and discomfort with expulsion. KEY RESULTS: Defecatory posture was significantly altered by footstool use, with progressive narrowing of the angle between the spine and femur as footstool height increased (p < 0.001 for all comparisons). Compared with no footstool, the use of a footstool was not associated with a change in balloon expulsion time and there was no difference between the two footstool heights. Subjectively, no significant change was identified in any of the three perceptions of balloon expulsion between no footstool and footstool use. CONCLUSIONS AND INFERENCES: Although the use of a footstool led to changes in defecatory posture, it did not improve subjective or objective measures of simulated defecation in patients with undifferentiated constipation. Therefore, the recommendation for its use during evacuation cannot be applied to all patients with constipation.

Volumetric Rectal Perception Testing: Is It Clinically Relevant? Results From a Large Patient Cohort.

INTRODUCTION: Rectal perception testing is a recommended component of anorectal physiology testing. Although recent consensus (London) guidelines suggested criteria for categorizing hyporectal and hyper-rectal sensitivity, these were based on scant evidence. Moreover, data regarding diagnostic capabilities and clinical utility of rectal perception testing are lacking. The aims of this study were to determine the association between rectal perception testing and both clinical and physiological variables to enhance the analysis and interpretation of real-life test results. METHODS: Prospectively documented data from 1,618 (92% female) patients referred for anorectal physiology testing were analyzed for 3 rectal perception thresholds (first, urge, and maximal tolerated). Normal values derived from healthy female subjects were used to categorize each threshold into hyposensitive and hypersensitive to examine the clinical relevance of this categorization. RESULTS: There was poor to moderate agreement between the 3 thresholds. Older age, male sex, and constipation were associated with higher perception thresholds, whereas irritable bowel syndrome, fecal incontinence, connective tissue disease, and pelvic radiation were associated with lower perception thresholds to some, but not all, thresholds (P < 0.01 on multivariate analysis for all). The clinical utility and limitations of categorizing thresholds into "hypersensitivity" and "hyposensitivity" were determined. DISCUSSION: Commonly practiced rectal perception testing is correlated with several disease states and thus has clinical relevance. However, most disease states were correlated with 2 or even only 1 abnormal threshold, and agreement between thresholds was limited. This may suggest each threshold measures different pathophysiological pathways. We suggest all 3 thresholds be measured and reported separately in routine clinical testing.