Constipation

and defecation

dynamics

Alesha Sayner

Continence Physiotherapist

Western Health

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Acknowledgements

Western Continence Service

Western Health Library Service

Super awesome manager (You can pay me later)

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Outline

• Constipation

• Functional - Structural - Behavioural

• Differential diagnosis

• What physiotherapists can contribute

• The ins and outs of rectal balloon therapy

*Disclaimer: The pun in unintentional

*Further disclaimer: …Maybe the pun is intentional

• Bowels are evil and complex REALLY super fantastically interesting and

them team work can be really rewarding!

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What I WON’T be talking about

• In depth lifestyle changes

• Dietary contributors

• Pharmacy/medications

• The aging population

• Aperients

• Slow transit constipation

• Neurological/systemic/metabolic contributors

• Toilet position, bowel regimes, detailed defecation dynamics

• Internal therapies and informed consent

• Surgical or medical management (i.e. Botox)

• The importance of the multi-disciplinary team

Constipation is MASSIVE!!!!!!!!!!!!

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“Have you heard of the movie “Constipation”?”

“I can’t say I have”

“That’s because it hasn’t come out yet”

……. You’re welcome

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How do we define constipation?

Rome 3 Criteria for functional constipation

(http://www.theromefoundation.org/assets/pdf/19_RomeIII_apA_885-898.pdf)

Fewer than 3 bowel movements per week

Straining ≥ 25% of the time

Lumpy or hard stools ≥ 25% of the time

Sensation of anorectal obstruction/”blocking” ≥ 25% of the time

Sensation of incomplete emptying ≥ 25% of the time

Manual maneuvering required to defecate ≥ 25% of the time

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What else?Other symptoms to watch for –

Abdominal bloating or discomfort

Pain on defecation – anal or abdominal

Rectal bleeding

Spurious diarrhea

Low back pain

Feeling of incomplete emptying

Digitating stool

Tenesmus

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Prevalence and other interesting stuff

• Global prevalence 11-18% (Suares & Ford, 2011)

• Many studies incorporate standard measures such as fibre intake

adjustment, increasing fluids, increasing exercise +/- the use of

aperients prior to biofeedback modalities (McCrea, Miaskowski, Stotts, Macera, & Varma,

2008)

• Push effort during defecation should be no more than 50-70% of

maximum push effort (Rao & Patcharatrakul, 2016)

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Structure and function• Structural and functional issues can co-exist

• Proximal colonic activity - ? Volume and stool

consistency

• Rectum acts as a reservoir for storage of stool

• During rectal filling

• Requirement for rectal wall compliance

• Autonomic neurons for

sensation/perception of stool volume and

consistency

• Activation of rectoanal inhibitory reflex

• Voluntary EAS contraction until able to

reach toilet

• Intact IAS for continence

(McCrea, Miaskowski, Stotts, Macera, & Varma, 2008; Wald et al 2014)

Image adapted from https://medical-dictionary.thefreedictionary.com/Rectum

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Defecation

• Reach level of critical fill

• Squat position – straighten anorectal angle

• More obtuse to 15-20°

• Relaxation of EAS and puborectalis

• ↑ IAP coordinated with ↓ pelvic pressures

• Allows stool to enter lower rectum

•Mobile perineum to allow for descent

•Spontaneous rectosigmoid contraction

• Continuous until the rectum is perceived as empty

(Nikjooy et al., 2015; Bharucha, 2006)

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Constipation - Behaviour

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Constipation – behaviour and adaptation

• ? Maladaptive learning

• Painful defecation in childhood

• Painful defecation post surgically

• Pelvic trauma or sexual abuse

• Toilet aversion/social impact

• Stress/anxiety

• Dietary changes – elderly?

(Whitehead, di Lorenzo, Leroi, Porrett, & Rao, 2009; Leroi, Berkelmans, Denis, Hémond, & Devroede, 1995; McCrea, Miaskowski, Stotts, Macera, & Varma,

2008; Rao, Tuteja, Vellema, Kempf, & Stessman, 2004)

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Differential diagnosis in constipation

Assessment modalities

• Digital rectal examination (DRE)

• Anorectal Manometry (ARM)

• Defecography

• EMG of the pelvic floor

• Balloon expulsion test (BET)

• Magnetic Resonance Imaging (MRI)

Structural and functional issues can co-exist

• Lack of adequate specificity of tests

• Dx – No single test – combination required(Wald, Bharucha, Cosman, & Whitehead, 2014)

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Differential diagnosis

• DRE

• Accessible

• Sensation testing

• Good NPV(91%)

• Simulated defecation

• ↓ Anal canal pressure

• Palpate puborectalis

– ? Widening of anorectal angle

• Appropriate training?? Under utilized??

(Lawrentschuk and Bolton 2004; Wald, Bharucha, Cosman, & Whitehead, 2014)

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Differential diagnosis

DRE and BET (Caetano, Santa-Cruz, & Rolanda, 2016)

• BET

• Sensitivity 67% (Caetano, Danta-Cruz, & Rolanda, 2016)

• Sensitivity 50% (Rao, 2008)

• Specificity 80%

• NPV 72%

• Left lateral lie V’s seated (Ratuapli, Bharucha, Harvey, & Zinsmeister, 2013)

•DRE

• Sensitivity 80%

• Specificity 84%

• NPV 64%

Neither suitable for screening when used in isolation

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Differential diagnosis

ARM

• Contraction V’s relaxation

• Canal pressures/rectal pressure activity

• Rectal propulsive force

• > 20% reduction in canal pressures(Rao, 2008; Wald, Bharucha, Cosman, & Whitehead, 2014)

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Differential diagnosis

Defecography (Rafiei et al., 2017)

• Barium injection and radiographic analysis

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Dyssynergic Defecation DD

What is DD (Dyssynergic Defecation)?

• Reportedly present in 28%-33 of people presenting with constipation (Nyam et al 1996; Rao et al 2010)

• Inappropriate relaxation and coordination of the PFM complex at time of

emptying

• Impaired push effort due to:

• Inappropriate relaxation of the PFM complex

• Poorly coordinated rectal, anal and abdominal muscles(Lee, Jung & Myung, 2013; Rao 2008)

• < 20% reduction in anal canal pressure during simulated defecation

• Inadequate expulsion at defecation

• Consider balloon expulsion test(Bharucha, Wald, Enck, & Rao, 2006; Wald, Bharucha, Cosman, & Whitehead, 2014; McCrea, Miaskowski, Stotts,

Macera, & Varma, 2008))

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Anorectal angle – what we expect

(Nikjooy et al., 2015)

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(Nikjooy et al., 2015)

(Nikjooy et al., 2015)

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(Rao & Patcharatrakul, 2016)

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EMG patterns – what might we see with anal BFB EMG? (Lee, Jung, & Myung, 2013)

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DD Profiling….• Profiling (Rao et al., 2004)

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DD – Social impact (Rao et al., 2004)

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Physiotherapy

• Introduce role/Introduce the session

• Voluntary reporting – do we need to dig?

• The importance of the subjective assessment and measures

such as Bowel diary and Bristol stool chart

• Standard treatments for constipation will not impact dyssynergic

defecation – Psst…..Clinical hint!!!! (Pourmomeny et al, 2011)

• Biofeedback interventions superior to aperients, diet, exercise and

diazepam in DD (Chiaroni et al,. 2006; Heyman et al., 2007; Rao et al., 2010)

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“Standard treatment”

• Avoid constipating medications

• Stool softeners if required

• Increase fibre – 30g daily

• Increase fluids

• Increase general exercise

• Bowel regime

• Avoid manual manoeuvres such as digitating

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Recommended pathway for DD

• Education

• Simulated defecation training (+ pelvic floor relaxation)

• 15 minutes of diaphragmatic breathing 3 x daily

• ? Positioning ? Appropriate context (Nikjooy et al., 2015)

• ? Individualised

• +/- Internal therapy

•Practicing simulated defecation

• Internal therapy I.e. Balloon expulsion, endo anal biofeedback

(Wald, Bharucha, Cosman, & Whitehead, 2014)

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Rectal balloon therapy

Why

• Defecation training

• Improving abdominal push effort

• Ano-rectal coordination (EAS/levator ani coordination)

• Functional training

• Coordination training for FI

• EAS coordination

• Sensation testing and training

• Internal sphincter de-sensitisation/improve sensory threshold

• Impaired sensation

•Specificity

• 80-90%

•Sensitivity 50%

(Rao, 2008; Chiarioni, Kim, Vantini, & Whitehead, 2014; Rao, Ozturk, & Laine, 2005)

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Rectal Balloon Therapy• Why again…. (Staring to sound like my 3 year old)

• Inexpensive

• Bedside/community level

• Can identify patients with DD

• Validation and reproducibility

• Found to be reliable for assessment of DD

• High level of agreement with anorectal manometry and EMG

• 2 minute upper limit for evacuation = 100% reproducible

• 1 minutes upper limit = 98% reproducible

(Chiarioni, Kim, Vantini & Whitehead, 2014; Lee & Kim, 2014)

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Rectal balloon therapy

What - Equipment

• Rectal balloon – Consider latex V’s latex free

• 60mls syringe

• 3 way Luer lock

• Lubrication

• Gloves

• Tissues

• Bluey

• ? Commode

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Filling the balloon

To deflate balloon Maintains balloon

volume and allows

drawing of air to

syringe

Allows

addition/subtraction of

air

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What does the process look like?

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Getting to know the balloon

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Rectal Balloon Therapy

How

• No standard methodology

• General -

• Double glove – ?? Latex allergy

• Patient in side lie – Knees/hips flexed

• Insertion of deflated balloon – Lubricated++++

• Insert to above anal verge

• Filling

• 10mls increment filling with air or;

• Fill with water (50mls) to mimic full rectum/sensation to

defecate (Pourmomeny, Emami, Amooshahi & Adibi , 2010; Chiaroni, Kim, Vantini & Whitehead,

2014)

What are we looking for?

(Chiaroni, Kim, Vantini & Whitehead, 2014; Lee & Kim, 2014)

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Rectal balloon therapy for DD

• Muscular coordination at 1st sensation

• Diaphragmatic breathing/body scanning

• Increased IAP/Increased rectal pressure/Reduced EAS pressure

• X 10-15 reps

• Functional training

• May wish to use enema 1-2 hours prior to session

• Confidence and comfort

• Although not necessary (Lee & Kim 2014)

• 50mls air/water

• Seated on commode

• May increase if 1st sensation not yet met

• ??? Ability to expel (Rao, 2007)

• Aim for expulsion within 1-2 minutes

• Repeat

• Typically 4-6 sessions – reinforce at 3, 6 and 12 months (Lee, Jung, &

Myung, 2013)

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The literature - Consensus….

• Standard constipation measures are important

• Differential diagnosis is important

• High heterogeneity in methodology

• An adjunct to usual therapy

• BFB/Internal therapies are labour intensive

• One study demonstrated BFB to be superior to balloon therapy

• Importance of multi-disciplinary team - ?? Feasibility

• Minimal studies around home based training

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Biopsychosocial

• Bio – Check

• Psychosocial

• Psychological stressors may exacerbate symptoms (Rao et al., 2004)

• BFB therapy can assist with improving quality of life in patients

with DD

• Correlation between constipation severity and mental and

physical health QOL outcomes (Albiani, Hart et al. 2013)

• ↑ Prevalence of OCD, anxiety, depression, psychotocism and

somatization (Rao et al., 2007)

• Successful therapy goals = ↑ QOL and ↑ patients satisfaction (Lewicky-Gaupp, Morgan, Chey, Muellerleile, & Fenner, 2008)

Goals must be REALISTIC, FLEXIBLE, NEGOTIABLE!!!!!

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Conclusions

• Constipation requires a MDT approach

• Differential diagnosis is important

• Psychological impact across all domains

• Biofeedback techniques are accessible and inexpensive

• HOWEVER – more research needed

• Adjuncts only

• Rectal balloon therapy/BET can be a very useful and reliable way to

assess and manage DD – Practice!

• Goal setting – Talk to your patients and reassure!

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References

Albiani, J. J., Hart, S. L., Katz, L., Berian, J., Del Rosario, A., Lee, J., & Varma, M. (2013). Impact of Depression and Anxiety on the Quality of Life of Constipated Patients. Journal of Clinical Psychology in Medical Settings, 20(1), 123-132. doi:10.1007/s10880-012-9306-3

Bharucha, A. E. (2006). Pelvic floor: anatomy and function. Neurogastroenterology & Motility, 18(7), 507-519. doi:10.1111/j.1365-2982.2006.00803.x

Bharucha, A. E., Wald, A., Enck, P., & Rao, S. (2006). Functional anorectal disorders. Gastroenterology, 130(5), 1510.

Caetano, A. C., Santa-Cruz, A., & Rolanda, C. (2016). Digital Rectal Examination and Balloon Expulsion Test in the Study of Defecatory Disorders: Are They Suitable as Screening or Excluding Tests? The Canadian Journal of Gastroenterology & Hepatology, 2016. doi:10.1155/2016/8654314

Chiarioni, G., Kim, S. M., Vantini, I., & Whitehead, W. E. (2014). Validation of the Balloon Evacuation Test: Reproducibility and Agreement With Findings From Anorectal Manometry and Electromyography. Clinical Gastroenterology and Hepatology, 12(12), 2049-2054. doi:10.1016/j.cgh.2014.03.013

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References

Heymen, S., Scarlett, Y., Jones, K., Ringel, Y., Drossman, D., & Whitehead, W. E. (2007). Randomized, Controlled Trial Shows Biofeedback to be Superior to Alternative Treatments for Patients with Pelvic Floor Dyssynergia-Type Constipation. Diseases of the Colon & Rectum, 50(4), 428-441. doi:10.1007/s10350-006-0814-9

Kashyap, A. S., Kohli, D. R., Raizon, A., & Olden, K. W. (2013). A prospective study evaluating emotional disturbance in subjects undergoing defecating proctography. World journal of gastroenterology, 19(25), 3990.

Lawrentschuk, N., & Bolton, D. M. (2004). Experience and attitudes of final-year medical students to digital rectal examination. The Medical journal of Australia, 181(6), 323.

Lee, B. E., & Kim, G. H. (2014). How to perform and interpret balloon expulsion test. Journal of neurogastroenterology and motility, 20(3), 407.

Lee, H. J., Jung, K. W., & Myung, S.-J. (2013). Technique of functional and motility test: how to perform biofeedback for constipation and fecal incontinence. Journal of neurogastroenterology and motility, 19(4), 532.

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ReferencesLeroi, A. M., Berkelmans, I., Denis, P., Hémond, M., & Devroede, G. (1995). Anismus as a marker of sexual abuse. Consequences of abuse on anorectal motility. Digestive diseases and sciences, 40(7), 1411-1416. doi:10.1007/BF02285184

Lewicky-Gaupp, C., Morgan, D. M., Chey, W. D., Muellerleile, P., & Fenner, D. E. (2008). Successful Physical Therapy for Constipation Related to Puborectalis Dyssynergia Improves Symptom Severity and Quality of Life. Diseases of the Colon & Rectum, 51(11), 1686-1691. doi:10.1007/s10350-008-9392-3

McCrea, G. L., Miaskowski, C., Stotts, N. A., Macera, L., & Varma, M. G. (2008). Pathophysiology of constipation in the older adult. World journal of gastroenterology, 14(17), 2631. doi:10.3748/wjg.14.2631

Nikjooy, A., Maroufi, N., Ebrahimi Takamjani, I., Hadizdeh Kharazi, H., Mahjoubi, B., Azizi, R., & Haghani, H. (2015). MR defecography: a diagnostic test for the evaluation of pelvic floor motion in patients with dyssynergic defecation after biofeedback therapy. Medical journal of the Islamic Republic of Iran, 29, 188.

Pourmomeny, A. A., Emami, M. H., Amooshahi, M., & Adibi, P. (2011). Comparing the efficacy of biofeedback and balloon-assisted training in the treatment of dyssynergic defecation. Canadian journal of gastroenterology = Journal canadien de gastroenterologie, 25(2), 89-92. doi:10.1155/2011/268062

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References

Rafiei, R., Bayat, A., Taheri, M., Torabi, Z., Fooladi, L., & Husaini, S. (2017). Defecographic Findings in Patients with Severe Idiopathic Chronic Constipation. Korean J Gastroenterol, 70(1), 39-43.

Rao, S. S. C., & Patcharatrakul, T. (2016). Diagnosis and Treatment of Dyssynergic Defecation. Journal of neurogastroenterology and motility, 22(3), 423.

Rao, S. S. C., Seaton, K., Miller, M. J., Schulze, K., Brown, C. K., Paulson, J., & Zimmerman, B. (2007). Psychological profiles and quality of life differ between patients with dyssynergia and those with slow transit constipation. Journal of Psychosomatic Research, 63(4), 441-449. doi:10.1016/j.jpsychores.2007.05.016

Rao, S. S. C., Tuteja, A. K., Vellema, T., Kempf, J., & Stessman, M. (2004). Dyssynergic defecation: demographics, symptoms, stool patterns, and quality of life. Journal of clinical gastroenterology, 38(8), 680.

Rao, S. S. C. M. D. P. F. (2008). Dyssynergic Defecation and Biofeedback Therapy. Gastroenterology Clinics of North America, 37(3), 569-586. doi:10.1016/j.gtc.2008.06.011

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References

Ratuapli, S., Bharucha, A. E., Harvey, D., & Zinsmeister, A. R. (2013). Comparison of rectal balloon expulsion test in seated and left lateral positions. Neurogastroenterology & Motility, 25(12), e813-e820. doi:10.1111/nmo.12208

Wald, A., Bharucha, A. E., Cosman, B. C., & Whitehead, W. E. (2014). ACG clinical guideline: management of benign anorectal disorders. The American journal of gastroenterology, 109(8), 1141-1157. doi:10.1038/ajg.2014.190

Whitehead, W. E., di Lorenzo, C., Leroi, A. M., Porrett, T., & Rao, S. S. (2009). Conservative and behavioural management of constipation. Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society, 21 Suppl 2, 55-61. doi:10.1111/j.1365-2982.2009.01404.x

Woodward, S., Norton, C., & Chiarelli, P. (2014). Biofeedback for treatment of chronic idiopathic constipation in adults. The Cochrane database of systematic reviews , (3).