Constipation

1. Constipation and pelvic flo
or disorders
Dr Naila Arebi
Consultant Gastroenterologist
Honorary Senior Lecturer

2. Normal Defaecation

3. Summary of muscular actions required for
defaecation

4. Normal Bowel Action
95% of UK population
3 bowel movements/week - 3 bowel movem
ents/day

5. Constipation is a symptom
Two or more of following x 12 weeks in
last 12 months:
straining
hard stools
incomplete evacuation
anorectal obstruction/blockage
manual assistance (digitation/perineal support)

6. Prevalence
General population 10%
Older patients 20%
Expenditure on laxatives £46 million/year

7. Classification of Constipation
Primary idiopathic constipation
Functional constipation
Slow transit constipation
Pelvic floor dysfunction
Secondary
Malignancy
Endocrine
Eating disorders
Neuro-muscular

8. Investigations for chronic constipati
on
• Colonic Transit Test
• Defaecating Proctogram
• Ano-rectal Physiology tests
• Balloon expulsion test
• Exclude secondary causes

12. Investigations for chronic constipati
on
• Colonic Transit Test
• Defaecating Proctogram
• Ano-rectal Physiology tests
• Balloon expulsion test
• Exclude secondary causes

13. Therapy
Lifestyle modification
Laxatives
Psychosocial assessment
Biofeedback
Gut stimulants: Prucalopride and Lincalotide
Colonic irrigation
Sacral nerve stimulation
Percutaneous endoscopic colostomy
Surgery

14. Faecal Incontinence
• Faecal urge incontinence
• Faecal passive incontinence
• Faecal urgency
• Flatus incontinence
• Leakage / soiling

15. Factors Affecting Faecal Continenc
e
• Stool consistency
• Colonic / rectal motility
• Rectal compliance
• Rectal sensation
• Anal sensation
• Higher cerebral control
The major physical barrier is provided
by the anal sphincters
• Internal anal sphincter (IAS) (smooth muscle)
• External anal sphincter (EAS) (striated muscle)

16. Investigations
• Ano-rectal physiology testing
• Endo-anal ultrasound
• Pelvic MRI

17. Therapies
• Primary Sphincter repair
• Biofeedback
• Sacral nerve stimulation
• Anal Plug
• Colostomy

18. Anorectal Physiology Tests
• Manometry
- functional anal canal length
- maximum anal canal resting pressure
- voluntary contraction
- involuntary contraction on coughing
• Rectal sensation to distension
• Anal and rectal sensitivity to electrical stimulation
Additional tests:
• Recto-anal inhibitory reflex (RAIR)
• Balloon expulsion
• Pudendal nerve terminal motor latencies (PNTML)

19. Anorectal Physiology Testing

20. Manometry
• Functional anal canal length
Important in maintaining continence
• Maximum resting pressure
Generated predominantly by the involuntary action of the internal a
nal sphincter
• Squeeze pressure
Generated during voluntary contraction of the external anal sphincte
r
• Cough pressure
Generated during involuntary contraction of external anal sphincter

21. Manometry Catheter
8 circumferential pre
ssure sensors

22. Anorectal Manometry
Normal Trace
VS VS IS IS ES
VS = voluntary squeeze
IS = involuntary squeeze
ES = endurance squeeze
IS

23. Sensory Function
Sensation to balloon distension.
Measures the following parameters:
• threshold volume (first sensation)
• urge to defaecate volume
• maximum tolerated volume

24. Rectal Balloon Distension

25. Sensation to Balloon Distension
Protocol
• balloon inserted into rectum
• patient asked to report threshold, urge and
maximum tolerated volumes

26. Sensory Function
Sensation to electrical stimulation
- anal sensitivity
- rectal sensitivity
Provides a quantitative guide to anorectal i
nnervation.

27. Bipolar Ring Electrode

28. Sensation to Electrical Stimulation
Anal mucosa
• Bi-polar ring electrode inserted 1cm in to anal canal
• Current increased until a change in sensation is perceive
d
Rectal mucosa
• Bi-polar ring electrode moved to 8cm above HPZ
• Stimulation parameters increased compared to anal muc
osa
• Current increased until a change in sensation is perceive
d

29. Abnormal Anorectal Manometry
Case Examples

30. Patient 1
• 25 yrs female
• 6 mths h/o passive + urge faecal incontine
nce since childbirth
• Forceps delivery, episiotomy

31. Patient 1
VS VS
V
S IS IS ES

32. Patient 1
Findings
• Low resting pressure
• Low voluntary + involun
tary squeeze pressures
Conclusion
• Impaired function of IAS
+ EAS

33. Patient 2
• 36 yrs old female
• Faecal urgency + urge incontinence since
first child
• Vaginal delivery – 3rd degree tear

34. Patient 2 – Manometry Trace
IS IS ES
VS VS VS VS VS

35. Patient 2
Findings
• Normal resting pressure
(IAS)
• Low squeeze pressures
• Poor endurance squeez
e
Conclusion
• Impaired function of EA
S

36. Rectal Irrigation