Pleasurable and problematic receptive anal intercourse and diseases of the colon, rectum and anus.

The ability to experience pleasurable sexual activity is important for human health. Receptive anal intercourse (RAI) is a common, though frequently stigmatized, pleasurable sexual activity. Little is known about how diseases of the colon, rectum, and anus and their treatments affect RAI. Engaging in RAI with gastrointestinal disease can be difficult due to the unpredictability of symptoms and treatment-related toxic effects. Patients might experience sphincter hypertonicity, gastrointestinal symptom-specific anxiety, altered pelvic blood flow from structural disorders, decreased sensation from cancer-directed therapies or body image issues from stoma creation. These can result in problematic RAI - encompassing anodyspareunia (painful RAI), arousal dysfunction, orgasm dysfunction and decreased sexual desire. Therapeutic strategies for problematic RAI in patients living with gastrointestinal diseases and/or treatment-related dysfunction include pelvic floor muscle strengthening and stretching, psychological interventions, and restorative devices. Providing health-care professionals with a framework to discuss pleasurable RAI and diagnose problematic RAI can help improve patient outcomes. Normalizing RAI, affirming pleasure from RAI and acknowledging that the gastrointestinal system is involved in sexual pleasure, sexual function and sexual health will help transform the scientific paradigm of sexual health to one that is more just and equitable.

Preclinical applications of high-definition manometry system to investigate pelvic floor muscle contribution to continence mechanisms in a rabbit model.

External anal sphincter (EAS), external urethral sphincters, and puborectalis muscle (PRM) have important roles in the genesis of anal and urethral closure pressures. In the present study, we defined the contribution of these muscles alone and in combination with the sphincter closure function using a rabbit model and a high-definition manometry (HDM) system. A total of 12 female rabbits were anesthetized and prepared to measure anal, urethral, and vaginal canal pressures using a HDM system. Pressure was recorded at rest and during electrical stimulation of the EAS and PRM. A few rabbits (n = 6) were subjected to EAS injury and the impact of EAS injury on the closure pressure profile was also evaluated. Anal, urethral, and vaginal canal pressures recorded at rest and during electrical stimulation of EAS and PRM demonstrated distinct pressure profiles. EAS stimulation induced anal canal pressure increase, whereas PRM stimulation increased the pressures in all the three orifices. Electrical stimulation of EAS after injury resulted in about 19% decrease in anal canal pressure. Simultaneous electrical stimulation of EAS and PRM resulted in an insignificant increase of individual anal canal pressures when compared with pressures recorded after EAS or PRM stimulations alone. Our data confirm that HDM is a viable system to measure dynamic pressure changes within the three orifices and to define the role of each muscle in the development of closure pressures within these orifices in preclinical studies.NEW & NOTEWORTHY We anticipate that with this new HDM technology, physiological changes within these orifices may be redefined using the extensive data that are generated from 96 sensors. When compared with conventional methods, HDM offers the advantages of an increased response rate, as well as the utilization of 96 circumferential sensors to simultaneously measure pressure along the three orifices. Our findings suggest a potential use of this technology to better define urinary leak point pressure.

The role of GSTM1 gene polymorphism in pathophysiology, evaluation, and management of constipation of anorectal outlet obstruction.

Constipation of anorectal outlet obstruction may be caused by mechanical or functional causes. This complication is a debilitating disease that needs proper and timely treatment. Many studies have shown that there is a direct link between constipation and intestinal cancer. One of the most effective ways to prevent or diagnose intestinal cancer is through genetic studies. Evaluation of people's polymorphism shows how much they are at risk for cancer. Therefore, in this study, the GSTM1 gene polymorphism was evaluated in patients with constipation of anorectal outlet obstruction to assess better and manage this disease and investigate the possibility of anorectal cancer in these people. In this regard, 40 people with constipation of anorectal outlet obstruction were compared with 40 healthy people. In the case group (patients), in addition to demographic and clinical evaluations, the anorectal manometric test was used to diagnose the pathology of the disease. Results showed that out of 40 patients with constipation of anorectal outlet obstruction, 5 cases (12.5%) had megarectum, 7 cases (17.5%) had anismus, 10 cases (25%) had Hirschsprung's disease, 5 cases (12.5%) had descending perineum syndrome, 6 cases (15%) had rectal prolapse, 4 cases (10%) had enterocele, and 3 cases (7.5%) were with rectocele. Also, the results of GSTM1 gene deletion polymorphism showed that patients with constipation of anorectal outlet obstruction were almost two times more exposed to the null genotype than the control group (P <0.04). Therefore, in people with both constipation of anorectal outlet obstruction and null genotype (i.e., deletion in the GSTM1 gene), because they do not have glutathione-S transferase, they appear to be at higher risk for anorectal cancer than healthy people with the same genotype.

[Consensus of Chinese experts on defecation management during perioperative period of benign anal diseases].

The significant increase in the incidence of benign anal diseases is related to the fast-paced life style, the change of dietary structure, the increase of work pressure and social psychological factors. Surgery is one of the most important treatments for benign anal diseases, while perioperative defecation management is closely related to the efficacy of surgery. In current clinical practice, there is no consensus on the management of perioperative defecation for benign anal diseases. Hence a discussion was held by the Professional Committee of Colorectal Diseases of Chinese Society of Integrated Chinese and Western Medicine, concerning the causes of perioperative defecation difficulties in perioperative anal benign diseases, the importance and specific strategy of defecation management. A consensus was consequently formed, aiming to provide a guideline for the clinical practice.

Ustekinumab for Perianal Crohn's Disease: The BioLAP Multicenter Study From the GETAID.

INTRODUCTION: New therapeutic options for patients with Crohn's disease (CD) with perianal lesions failing anti-tumor necrosis factor (TNF) agents are needed. We aimed to assess the effectiveness of ustekinumab in perianal CD (pCD) and predictors of clinical success in a real-life multicenter cohort. METHODS: We conducted a national multicenter retrospective cohort study in patients with either active or inactive pCD who received ustekinumab. In patients with active pCD at treatment initiation, the success of ustekinumab was defined by clinical success at 6 months assessed by the physician's judgment without additional medical or surgical treatment for pCD. Univariate and multivariable logistic regression analyses were performed to identify predictors of success. In patients with inactive pCD at ustekinumab initiation, the pCD recurrence-free survival was calculated using the Kaplan-Meier method. RESULTS: Two hundred seven patients were included, the mean age was 37.7 years, the mean duration of CD was 14.3 years, and the mean number of prior perianal surgeries was 2.8. Two hundred five (99%) patients had previously been exposed to at least 1 anti-TNF and 58 (28%) to vedolizumab. The median follow-up time was 48 weeks; 56/207 (27%) patients discontinued therapy after a median time of 43 weeks. In patients with active pCD, success was reached in 57/148 (38.5%) patients. Among patients with setons at initiation, 29/88 (33%) had a successful removal. The absence of optimization was associated with treatment success (P = 0.044, odds ratio 2.74; 95% confidence interval: 0.96-7.82). In multivariable analysis, the number of prior anti-TNF agents (≥3) was borderline significant (P = 0.056, odds ratio 0.4; 95% confidence interval: 0.15-1.08). In patients with inactive pCD at initiation, the probability of recurrence-free survival was 86.2% and 75.1% at weeks 26 and 52, respectively. DISCUSSION: Ustekinumab appears as a potential effective therapeutic option in perianal refractory CD. Further prospective studies are warranted.

The London Classification: Improving Characterization and Classification of Anorectal Function with Anorectal Manometry.

PURPOSE OF REVIEW: Objective measurement of anorectal sensorimotor function is a requisite component in the clinical evaluation of patients with intractable symptoms of anorectal dysfunction. Regrettably, the utility of the most established and widely employed investigations for such measurement (anorectal manometry (ARM), rectal sensory testing and the balloon expulsion test) has been limited by wide variations in clinical practice. RECENT FINDINGS: This article summarizes the recently published International Anorectal Physiology Working Group (IAPWG) consensus and London Classification of anorectal disorders, together with relevant allied literature, to provide guidance on the indications for, equipment, protocol, measurement definitions and results interpretation for ARM, rectal sensory testing and the balloon expulsion test. The London Classification is a standardized method and nomenclature for description of alterations in anorectal motor and sensory function using office-based investigations, adoption of which should bring much needed harmonization of practice.

Use of Botulinum Toxin A (BoNT-A) in Detrusor External Sphincter Dyssynergia (DESD): A Systematic Review and Meta-analysis.

We performed a systematic review to examine the efficacy and outcomes of Botulinum Toxin A (BoNT-A) as the primary intervention strategy for patients with detrusor external sphincter dyssynergia. Eleven studies were included in the analysis (n = 353; 16% female, 84% male). BoNT-A was effective in 60%-78% of patients for reducing postvoid residual, mean detrusor pressure, detrusor leak point pressure, and mean urethral pressure 1 month after injection. Most patients required reinjection after an average of 4-9 months. BoNT-A was not associated with any significant adverse events, and may improve quality of life, as well as urodynamic parameters for detrusor external sphincter dyssynergia.

Continuous vs stepwise anal acoustic reflectometry: An improved technique for physiological measurement of anal sphincter function?

BACKGROUND: Anal acoustic reflectometry (AAR) is a technique for measuring the physiological profile of the anal canal, primarily the internal anal sphincter. Evaluation of a new continuous method, recently developed for the urethra, would enable its future application for investigation of rectal reflexes. METHODS: Patients aged 18 and over with fecal incontinence (FI) were included. Stepwise AAR parameters were compared with continuous opening pressure (Op, cmH2 O), opening elastance (Oe, cmH2 O/mm2 ), closing pressure (Cp, cmH2 O), closing elastance (Ce, cmH2 O/mm2 ), hysteresis (Hys, [%]), squeeze opening pressure (SqOp, cmH2 O), and squeeze opening elastance (SqOe, cmH2 O/mm2 ). Vaizey incontinence and Manchester Health Questionnaire scores were also collected. RESULTS: Thirty-two patients, 26 females were analyzed. Median age: 60 (range, 32-75). Median AAR parameters of Op (37.50 vs 35.15, P = .031), Oe (1.31 vs 0.84, P < .0001), Ce (1.11 vs 0.88, P < .0001), Hys (37.75 vs 19.04, P < .0001), and SqOe (1.27 vs 1.06, P = .005) were significantly higher with the continuous method. Cp (22.70 vs 27.22, P = .003) is lower and SqOp (96.87 vs 59.47, P = .71) not significantly different. The continuous technique had superior repeatability between cycles for all AAR parameters except Oe, which was equivalent and continuous SqOp had a stronger negative correlation with Vaizey score than stepwise (-0.46, P = .009 vs -0.37, P = .038). CONCLUSIONS: The differences seen between the two techniques are likely to be related to the rate of stretch. The continuous technique appears to represent a more physiological measurement of anal sphincter function than the stepwise technique particularly in the assessment of voluntary squeeze function.

Early-stage Management of Complex Wounds Using Negative Pressure Wound Therapy With Instillation and a Dressing With Through Holes.

INTRODUCTION: An early-stage decision clinicians often make in the management of complex wounds is which method of wound preparation will be appropriate for the patient. This decision can be affected by numerous wound and patient risk factors that present challenges and may make surgical debridement difficult in patients with complex wounds. Recently, negative pressure wound therapy with instillation and dwell time (NPWTi-d) using a novel reticulated open-cell foam dressing with through holes (ROCF-CC) was shown to aid in the loosening and removal of thick exudate and nonviable tissue from wounds. OBJECTIVE: The authors present their experiences of using NPWTi-d with ROCF-CC, along with rationales for wound care decisions. MATERIALS AND METHODS: Patients received antibiotics and surgical debridement when appropriate. Therapy selection and parameters were based on a decision-tree model for wound care management that takes into consideration patient and wound information. Most patients received NPWTi-d with ROCF-CC for a duration of 5 to 8 days; however, 1 patient received NPWTi-d with ROCF-CC for more than 30 days due to the wound extent and severity. Therapy consisted of instilling saline or quarter-strength sodium hypochlorite solution with dwell times of 3 to 10 minutes, followed by 2 hours or 3.5 hours of NPWT either at -100 mm Hg or -125 mm Hg. RESULTS: There were 6 patients (3 men, 3 women; average age, 58.5 years) treated. Wound types included 3 pressure ulcers, 1 necrotizing soft tissue infection, 1 perianal abscess, and 1 large abdominal wound. Patient comorbidities included obesity, type 2 diabetes, and radiation therapy. In all cases, progression of wound healing was observed with no complications. This method produced viable granulation tissue and wound bed preparation; however, patients were not followed to closure or grafting. CONCLUSIONS: These cases help support the use of NPWTi-d with ROCF-CC as a viable option for wound care providers in the early-stage management of complex wounds.

Anal sphincter botulinum toxin injection in children with functional anorectal and colonic disorders: A large institutional study and review of the literature focusing on complications.

BACKGROUND AND AIM: Botulinum toxin (botox) is a commonly used treatment for functional anorectal and colonic disorders. Although generally regarded as safe, complications associated with botox injection into the anal sphincters in children with severe defecation disorders are not well described. We aimed to review our institutional experience and the existing literature to better understand the safety of this practice. METHODS: We performed a retrospective review of pediatric patients undergoing botox administration into the anal sphincter for treatment of a variety of defecation disorders between 2014 and 2018. Additionally, we performed a review of all published literature reporting complications from botox injection in this patient population. RESULTS: 881 patients ranging from 5 weeks to 19.7 years underwent a total of 1332 botox injections including our institution (332 patients/526 injections) and the reviewed series (549 patients/806 injections). Overall, complications were seen after 9 (0.7%) injections and included urinary incontinence (n = 5), pelvic muscle paresis (n = 2), perianal abscess (n = 1), pruritis ani (n = 1), and rectal prolapse (n = 1). Patient age, weight, and diagnosis were not associated with an increased rate of complication in our institutional experience. All complications were self-limited and did not require intervention. There were no episodes of systemic botulinum toxicity. CONCLUSION: Botox injection into the anal sphincters is accepted practice in children with Hirschsprung disease, severe functional constipation, and internal anal sphincter achalasia and appears to be safe from this review. The precise dosing and age at which complications are more likely to arise could not be ascertained and require further study. LEVEL OF EVIDENCE: IV TYPE OF STUDY: Retrospective cohort study.

A Practical Guide to Biofeedback Therapy for Pelvic Floor Disorders.

PURPOSE OF REVIEW: Biofeedback therapy (BFT) is effective for managing pelvic floor disorders (i.e., defecatory disorders and fecal incontinence). However, even in controlled clinical trials, only approximately 60% of patients with defecatory disorders experienced long-term improvement. The review serves to update practitioners on recent advances and to identify practical obstacles to providing biofeedback therapy. RECENT FINDINGS: The efficacy and safety of biofeedback therapy have been evaluated in defecatory disorders, fecal incontinence, and levator ani syndrome. Recent studies looked at outcomes in specific patient sub-populations and predictors of a response to biofeedback therapy. Biofeedback therapy is effective for managing defecatory disorders, fecal incontinence, and levator ani syndrome. Patients who have a lower bowel satisfaction score and use digital maneuvers fare better. Biofeedback therapy is recommended for patients with fecal incontinence who do not respond to conservative management. A subset of patients with levator ani syndrome who have dyssynergic defecation are more likely to respond to biofeedback therapy.

Three-dimensional high-resolution anorectal manometry in functional anorectal disorders: results from a large observational cohort study.

BACKGROUND: The aim of the study was to describe the results of 3D high-resolution anorectal manometry (3DHRAM) in a large cohort of patients with functional anorectal disorders. METHODS: In this single-center retrospective study, all consecutive patients referred for investigation of fecal incontinence (FI) or dyssynergic defecation (DD) underwent 3DHRAM. The parameters analyzed were usual manometric data, repartition of dyssynergic patterns, and the prevalence of a new "muscular subtype classification" underlying dyssynergia, anal sphincter defects, and pelvic floor disorders. RESULTS: Final analyses were performed in 1477 patients with a mean age 54 ± 16 years; 825 patients suffered from DD, and 652 patients suffered from FI. Among these patients, 86% met the diagnostic criteria for dyssynergia. Type II dyssynergia was the most frequently observed (56%) in women and men suffering from FI and in women with DD. Type I was the most frequently observed in men with DD (49%). Regarding the muscle type subgroups, combined puborectalis muscle involvement with an external anal sphincter profile was the most frequently observed. The global prevalence of rectal intussusception and excessive perineal descent were 12% and 21%, respectively. Type III dyssynergia was more frequently associated with pelvic floor disorders than were other types of dyssynergia (p < 0.001). CONCLUSION: This large cohort study provides reference values for 3DHRAM in patients with functional anorectal disorders. Further studies are necessary to assess the prevalence of pelvic floor disorders in healthy volunteers and to develop new scores and classifications including all of these new parameters.

Anal and rectal function after intensity-modulated prostate radiotherapy with endorectal balloon.

BACKGROUND AND PURPOSE: Late anorectal toxicity influences quality of life after external beam radiotherapy (EBRT) for prostate cancer. A daily inserted endorectal balloon (ERB) during EBRT aims to reduce anorectal toxicity. Our goal is to objectify anorectal function over time after prostate intensity-modulated radiotherapy (IMRT) with ERB. MATERIAL AND METHODS: Sixty men, irradiated with IMRT and an ERB, underwent barostat measurements and anorectal manometry prior to EBRT and 6 months, one year and 2 years after radiotherapy. Primary outcome measures were rectal distensibility and rectal sensibility in response to stepwise isobaric distensions and anal pressures. RESULTS: Forty-eight men completed all measurements. EBRT reduced maximal rectal capacity 2 years after EBRT (250 ±â€¯10 mL vs. 211 ±â€¯10 mL; p < 0.001), area under the pressure-volume curve (2878 ±â€¯270 mL mmHg vs. 2521 ±â€¯305 mL mmHg; p = 0.043) and rectal compliance (NS). Sensory pressure thresholds for first sense and first urge (both p < 0.01) increased. Anal maximum pressure diminished after IMRT (p = 0.006). CONCLUSIONS: Rectal capacity and sensory function are increasingly affected over time after radiotherapy. There is an indication that these reductions are affected less with IMRT + ERB compared to conventional radiation techniques.

Expert consensus document: Advances in the evaluation of anorectal function.

Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.

Incidence of new-onset benign anal disorders after bariatric surgery.

New-onset benign anal disorders (NBADs) represent a potential complication following bariatric surgery, although their incidence in this population is not well studied. The preoperative characteristics, weight loss, bowel habits and NBADs data of 196 patients with bariatric surgery were collected by telephone interviews and medical records review and evaluated retrospectively. Ninety-nine patients had undergone gastric bypass (GBP) and 97 had a modified biliopancreatic diversion (MBPD). Fifty-nine patients were excluded. The mean follow-up of the remaining 137 patients was 87.8 months, and 51 of them (37.2%) developed NBADs. Haemorrhoids were the most common diagnosis and 27.5% of the patients that developed NBADs were treated surgically. Patients who developed NBADs had a longer follow-up time (92.5 vs. 85.1 months, P = 0.003), and those with an abnormal bowel habit (diarrhoea or constipation) had a higher percentage of NBADs (54.5 vs. 28.3%, P = 0.003). NBADs were more frequent after MBPD (52.9%) than after GBP (21.7%) (P < 0.001). Multivariate analysis found that only an abnormal bowel habit was associated with NBADs, with an odds ratio of 3.2 (95% CI: 1.5-6.9, P = 0.003). As NBADs are a common complication after bariatric surgery, further studies should be performed to find the reasons for these complications.

In vivo magnetofection: a novel approach for targeted topical delivery of nucleic acids for rectoanal motility disorders.

In these studies, we developed a novel approach of in vivo magnetofection for localized delivery of nucleic acids such as micro-RNA-139-5p (miR-139-5p; which is known to target Rho kinase2) to the circular smooth muscle layer of the internal anal sphincter (IAS). The IAS tone is known to play a major role in the rectoanal continence via activation of RhoA-associated kinase (RhoA/ROCK2). These studies established an optimized protocol for efficient gene delivery using an assembly of equal volumes of in vivo PolyMag and miR139-5p or anti-miR-139-5p (100 nM each) injected in the circular smooth muscle layer in the pinpointed areas of the rat perianal region and then incubated for 20 min under magnetic field. Magnetofection efficiency was confirmed and analyzed by confocal microscopy of FITC-tagged siRNA. Using physiological and biochemical approaches, we investigated the effects of miR-139-5p and anti-miR-139-5p on basal intraluminal IAS pressure (IASP), fecal pellet count, IAS tone, agonist-induced contraction, contraction-relaxation kinetics, and RhoA/ROCK2 signaling. Present studies demonstrate that magnetofection-mediated miR-139-5p delivery significantly decreased RhoA/ROCK2, p-MYPT1, and p-MLC20 signaling, leading to decreases in the basal IASP and IAS tone and in rates of contraction and relaxation associated with increase in fecal pellet output. Interestingly, anti-miR-139-5p transfection had opposite effects on these parameters. Collectively, these data demonstrate that magnetofection is a promising novel method of in vivo gene delivery and of nucleotides to the internal anal sphincter for the site-directed and targeted therapy for rectoanal motility disorders. NEW & NOTEWORTHY These studies for the first time demonstrate the success of topical in vivo magnetofection (MF) of nucleic acids using perianal injections. To demonstrate its effectiveness, we used FITC-tagged siRNA via immunofluorescence microcopy and functional and biochemical evidence using miR-139-5p (which is known to target ROCK2). In conclusion, MF allows safe, convenient, efficient, and targeted delivery of oligonucleotides such as siRNAs and microRNAs. These studies have direct therapeutic implications in rectoanal motility disorders especially associated with IAS.