Consensus statement AIGO/SICCR: Diagnosis and treatment of chronic constipation and obstructed defecation (part I: Diagnosis)

Table 1 Levels of evidence[1]

Levels of evidence
I	Randomised clinical trials with P < 0.05, adequate sample size, and appropriate methodology
II	Randomised clinical trials with P < 0.05, inadequate sample size, and/or inappropriate methodology
III	Non-randomised trials with simultaneous controls
IV	Non-randomised trials with historical controls
V	Case series

Table 2 Grading of the recommendations[1]

Grading of the recommendations
A	Recommendation supported by two or more levelItrials, without conflicting evidence from other levelItrials
B	Recommendation based on evidence from a single levelItrial OR, evidence from two or more levelItrials with conflicting, evidence from another levelItrial OR, evidence from two or more level IItrials
C	Recommendations based on levels of evidence III-V

OR: Odds ratio.

Table 3 Areas defined by the committee for the consensus statement

Area
1	Clinical evaluation and scoring systems
2	Diagnostic techniques
3	Medical and rehabilitative treatment
4	Surgery for slow transit constipation
5	Surgery for obstructed defecation with or without associated pelvic diseases

Table 4 Interpretation of the manometric data

Test	Parameter evaluated	Interpretation
Resting pressure	IAS (70% of resting pressure) and EAS (30% of resting pressure)	P increased: Hypertonic sphincters (IAS and/or EAS). Oral nitroglycerin can identify the sphincter involved because it relaxes IAS, but not EAS
Squeeze pressure	EAS	The fatigue rate index can be calculated based on the pressure and duration of the contraction. However, the usefulness of the test in both constipated and incontinent patients is disputed[112,113]
Rectoanal inhibitory reflex	IAS relaxation during rectal inflation	Absent: Possible hirschsprung; If present with elevated volume inflation: Megarectum[57]
Rectal sensitivity	Rectal sensory function at different volumes	Elevated sensory thresholds may be linked to changes in rectal biomechanics (megarectum) or to afferent pathway dysfunction[114,115]
Rectal compliance	Mechanical rectal function	Increased compliance: megarectum[57]
Attempted defecation	Synchronisation between the increase in rectal pressure and the decrease in anal pressure during attempts to defecate	Three types of dysfunction may be detected[65]: Type 1: Adequate rectal P increase but associated with anal P increase; Type 2: Inadequate rectal P increase associated with anal P increase or inadequate anal P decrease; Type 3: Adequate rectal P increase but inadequate anal P decrease

IAS: Internal anal sphincter; EAS: External anal sphincter; P: Pressure. Modified from Azpiroz et al[57].