Gastrointestinal manifestations of diabetes include a variety of symptoms, including fecal incontinence (FI). We investigated the relationship between hemoglobin A1c and FI among US adults in a large, population-based survey.

We identified adults (≥ 20 years) who completed the bowel health questionnaire and had A1c data in the National Health and Nutrition Examination Survey from 2005 to 2010 (N = 13,787). FI was defined as any involuntary loss of mucus, liquid, or solid stool during the last 30 days. Adjusted odds ratios (aORs) for FI were estimated in a multivariable logistic model according to A1c. Subgroup analyses examined relevant characteristics.

We identified 1283 (9.3%) adults with FI. A1c was associated with a 26% increase in the odds of FI (crude OR 1.26, 95% CI 1.20-1.33), which persisted after stepwise adjustment for age, demographic factors, and comorbidities (aOR 1.09, 95% CI 1.01-1.17). In subgroup analyses, A1c was associated with FI in diabetes (aOR 1.13, 95% CI 1.01-1.26), women (aOR 1.15, 95% CI 1.02-1.3), those < 65 years of age (aOR 1.17, 95% CI 1.09-1.25), overweight/obesity (aOR 1.1, 95% CI 1.02-1.20), non-white (aOR 1.1, 95% CI 1.01-1.20), and those with solid stool FI (aOR 1.17, 95% CI 1.04-1.32).

Increasing A1c was associated with an increased odds of FI. Our study provides insights into subgroups of patients who may benefit from interventions aimed at glucose control to reduce this risk of FI.

MR-defecography plays a key role in imaging complex pelvic floor dysfunction. Simultaneous detection of multiple findings in a complex anatomical setting makes correct analysis and clinical interpretation challenging. Thorough understanding of this imaging technique is essential for pelvic floor surgeons in order to make proper use of its advantages in the diagnosis of pelvic floor pathologies. We have reviewed the scientific literature on MR-defecography from recent years to sum up the most important aspects concerning patients' selection and preparation, examination procedure, standardised reporting and the most important pathological findings for pelvic floor surgery. MR-defecography is performed using static as well as dynamic MR sequences of high spatial resolution with excellent soft tissue contrast. The detection of pathological findings (pelvic floor relaxation, pelvic floor descent, rectocele, enterocele, peritoneocele, intussusception, rectal prolapse, dyssynergistic defecation) must always be correlated with clinical symptoms. It can provide information that is missed by other imaging modalities and hence it can alter therapeutic strategies in the interdisciplinary cooperation of pelvic floor surgeons, urologists and gynaecologists.

Functional anorectal pain (FAP) is classified as one of the disorders of gut-brain interaction (DGBI). It involves the impairments of anorectal afferents and disrupted gut-brain communication. However, neuroimaging studies focused on FAP are lacking.

A total of 25 FAP patients and 18 healthy controls (HC) underwent structural magnetic resonance imaging (MRI), diffusion tensor imaging (DTI), resting-state functional MRI (rs-fMRI) scans, and collection of demographic data, mental health assessment scales and pain assessment questionnaires. Voxel-based morphometry (VBM), tract-based spatial statistics (TBSS), regional homogeneity (ReHo), and amplitude of low-frequency fluctuations (ALFF) were utilized to analyze the imaging data. Correlation analyses were conducted to explore the relationships between the neuroimaging findings and clinical symptoms.

Functional anorectal pain (FAP) patients exhibited higher levels of anxiety, depression scores and lower sleep quality compared to HC. VBM analysis revealed increased gray matter volume (GMV) in the bilateral fusiform, right parahippocampal, bilateral inferior temporal gyrus (ITG), and decreased GMV in the right superior frontal gyrus (SFG), left middle frontal gyrus (MFG), bilateral inferior frontal gyrus (IFG), left Calcarine, bilateral middle occipital gyrus (MOG), left middle temporal gyrus (MTG) in FAP patients. TBSS analysis showed decreased fractional anisotropy (FA) in the superior longitudinal fasciculus (SLF), anterior thalamic radiation (ATR), and forceps minor in the FAP patients. Additionally, increased ALFF in the right cerebellum and increased ReHo in the right MFG were observed in the FAP patients.

These findings showed a worse psychological condition and suggested neuroanatomical and neurofunctional alterations associated with pain processing, emotion regulation, and cognitive control in FAP patients.

Excisional hemorrhoidectomy and stapled hemorrhoidopexy are 2 common procedures for treating symptomatic hemorrhoids. However, concerns persist regarding the risk of postoperative complications and their unclear prevalence in the literature. This systematic review aims to evaluate and compare the prevalence of incontinence after stapled hemorrhoidopexy and excisional hemorrhoidectomy.

A systematic search of Medline, EMBASE, and CENTRAL identified studies published in the past 25 years that reported incontinence after excisional treatments for hemorrhoids. Primary outcomes included early (<3 months) and late (≥3 months) fecal incontinence. Secondary outcomes included postoperative bleeding, urinary retention, and recurrence. Single-arm meta-analyses of proportions were performed using R with meta-regression.

In total, 139 studies were included in the meta-analysis, including 68 randomized controlled trials with 8,445 participants and 71 observational studies with 22,687 participants. Early incontinence rates were 5.32% in randomized controlled trials (95% confidence interval, 2.74-8.51%) and 1.03% in nonrandomized controlled trials (95% confidence interval, 0.28-2.09%). Late incontinence rates were 2.48% in randomized controlled trials (95% confidence interval, 1.09-4.25%) and 1.44% in nonrandomized controlled trials (95% confidence interval, 0.71-2.37%). There was no significant difference in the risk of incontinence or other postoperative complications between stapled hemorrhoidopexy and excisional hemorrhoidectomy, both in randomized controlled trials and nonrandomized controlled trials.

Incontinence after stapled hemorrhoidopexy and excisional hemorrhoidectomy is uncommon, and there appears to be no significant difference in risk between the 2 procedures. However, considerable heterogeneity was observed, likely the result of differences in assessment and reporting methods across studies. Future research should standardize definitions and methods for assessing incontinence and include preoperative assessments to more accurately define the risks of complications associated with hemorrhoid surgery.

Bionic technology is gaining momentum in medical research. In gastroenterology, bionic technologies such as the PillCam and SmartPill assess intestinal mucosa morphology and function during the gastrointestinal passage of the devices. Oral drug delivery devices and intestinal robots are other bionic technologies under development. Recently, Fecobionics, a simulated feces, was developed for assessment of anorectal (defecatory) function. It is an anally insertable device with shape and consistency like feces. The integrated device measures anorectal pressures, orientation, bending (a proxy of the anorectal angle), and the shape of the device when located in rectum and when being evacuated by patients. It integrates most elements of the current technologies on the market (balloon expulsion technology, high-resolution anorectal manometry, defecography, and the functional luminal imaging probe). Multiple measurements in a single study by a bionic device have obvious advantages since novel functional parameters can be computed. Several Fecobionics prototypes have been developed and evaluated in normal human subjects and in patients with fecal incontinence and defecatory disorders such as obstructed defecation. This paper provides an overview of the Fecobionics platform for assessment of defecatory function and dysfunction with a focus on design, signal processing, data analysis, current clinical trials, and future applications in diagnostics, therapy assessment, and therapy.

Introduction Obstructed defecation syndrome (ODS) is a common disorder in developed countries. This study aims to compare the efficacy of bilateral percutaneous tibial nerve stimulation (Bi-PTNS) to biofeedback therapy (BFT) in adult patients with ODS. Methods A prospective randomised control study was conducted on patients aged ≥18 years, diagnosed with ODS, who were referred to the Colorectal Surgery Department at a main university hospital between 2018 and 2020. Computerized 1:1 block randomization allocated patients into two groups: the bi-PTNS group and the BFT group. The Constipation Scoring System and Patient Assessment of Constipation Quality of Life Score (PAC-QoL) were used to assess the severity of the patient's symptoms prior to and after treatment. The primary outcome was the improvement of the Constipation Scoring System. The secondary outcome was the PAC-QoL score. Results In total, 60 patients, with 38 females (mean of 43 years in the BFT group and 48 years in the Bi-PTNS group), were studied. Statistically significant differences were achieved in patients who underwent bi-PTNS compared to the BFT group (p < 0.001). The average improvement in the Constipation Scoring System score for the bi-PTNS group was 66.66% ± 8.44 compared to 47.36% ± 10.44 for the BFT group. The bi-PTNS group showed improvement in the PAC-QoL score (60.41% ± 4.03) compared with 42.59% ±6.25 in the BFT group. Conclusion The Bi-PTNS intervention was more effective than BFT in alleviating symptoms of OD compared to BFT, evidenced by improvements in both the Constipation Scoring System and PAC-QoL scores.

The diagnosis and treatment of puborectalis syndrome (PRS) and spastic pelvic floor syndrome (SPFS) are still up for debate. This study aims to investigate and examine the similarities and differences between PRS and SPFS.

This study recruited 13 PRS cases, 10 SPFS cases, and 16 controls. Pelvic magnetic resonance imaging (MRI), histology, and ultrastructural pathology were explored. Additionally, anorectal manometry was performed prior to surgery, and Wexner constipation scores and patient assessment of constipation quality of life (PAC-QOL) scores monitored before surgery and 6 and 12 months post-surgery.

The puborectalis thickness in the pelvic MRIs of the SPFS and control groups did not appear to differ (4.62 ± 0.38 vs 4.56 ± 0.47, p = 0.378); however, the puborectalis in the PRS group was substantially thicker than that of the SPFS (8.65 ± 1.17 vs 4.62 ± 0.38, p < 0.001). The SPFS group showing atrophy and degeneration of muscle fibers and the PRS group exhibiting necrosis of muscle fibers, both groups had distorted texture myofibrils, disorganized arrangement, and rough Z lines; however, in severe cases of PRS group, localized myofibrils fracture and myofilament dissolution presenting as vacuolation. Patients with normal preoperative rectal propulsion force had improvements in postoperative Wexner constipation scores and PAC-QOL scores.

Histological and ultrastructural pathological evidence suggests that SPFS and PRS are distinct phases of paradoxical puborectalis syndrome (PPS). Furthermore, one indication for PPS surgical treatment is normal rectal evacuation pressure.

Neurogastroenterology and motility disorders are complex gastrointestinal conditions that are prevalent worldwide, particularly affecting women and younger individuals. These conditions significantly impact the quality of life of people suffering from them. There is increasing evidence linking these disorders to cirrhosis, with a higher prevalence compared to the general population. However, the link between neurogastroenterology and motility disorders and cirrhosis remains unclear due to undefined mechanisms. In addition, managing these conditions in cirrhosis is often limited by the adverse effects of drugs commonly used for these disorders, presenting a significant clinical challenge in the routine management of patients with cirrhosis. This review delves into this connection, exploring potential pathophysiological links and clinical interventions between neurogastroenterology disorders and cirrhosis.

Functional defecation disorders (FDD) are a common etiology of refractory chronic constipation (CC). FDD diagnosis (dyssynergic defecation [DD] and inadequate defecatory propulsion [IDP]), requires diagnostic tests including anorectal manometry (ARM) and balloon expulsion test (BET). Biofeedback (BF) is the treatment of choice for DD. The aims of our study were to evaluate: the outcome of BF in a group of constipated patients with defecatory disorders of any etiology; the efficacy of two simple diagnostic tools in predicting BF outcome in the short-term.

One hundred and thirty-one refractory CC patients failing the BET underwent BF therapy. Before BF, all patients underwent the following: ARM. Straining questionnaire. The answers were: "belly muscles"; "anal muscles"; "both"; "Don't know/No answer." Digital rectal examination augmented by abdominal palpation on straining (augmented-DRE). The BF therapist was blinded to ARM, straining questionnaire, and augmented-DRE results.

Eighty-one patients responded to BF. Gender, age, and IBS-C showed no significant impact on BF response. Both DD and IDP responded equally to BF, while the rate of response in patients with isolated structural pelvic floor abnormalities was lower (p < 0.001). The answer "anal muscles" to straining questionnaire showed a strong association with BF response (p < 0.001). A lack in abdominal contraction and in anal relaxation on augmented-DRE were strongly associated with BF response (p < 0.01). Absence of manual maneuvers to facilitate defecation was associated with BF response (p < 0.001).

BF is the therapy of choice for refractory constipation due to FDD of any etiology, inducing both clinical and anorectal physiology improvement in the short term. Comorbid IBS-C did not affect outcome while symptomatic isolated pelvic floor abnormalities appeared refractory to behavior treatment. The straining questionnaire and augmented-DRE outcomes showed a strong correlation with BF response and can be implemented in clinical practice to improve the management of constipated patients by prompting early referral to BF.

Recent evidence shows that consensual anal penetrative intercourse has become more prevalent, not only limited to gay, bisexual, and other men who have sex with men but also for women who are in a sexual relationship with men. The aim of this review was to study the influence of consensual anal intercourse on pelvic floor function and the role of pelvic floor physical therapy treatment in preventing or treating consensual anal intercourse-induced anodyspareunia and/or fecal incontinence. We reviewed 68 references that showed that anal penetrative intercourse is a risk factor for anodyspareunia and fecal incontinence in both men and women. This risk of anal intercourse may increase with emotional discomfort, an overactive pelvic floor, lack of lubrication, frequency of anal penetrative intercourse, and hard practice (BDSM: bondage and discipline, dominance and submission, sadism, and masochism). It seems that pelvic floor physical therapists play an essential role in preventing and treating pelvic floor dysfunctions due to anal intercourse, which can lead to anodyspareunia and fecal incontinence; the treatment includes education, pelvic floor training with and without biofeedback, electric stimulation, manual therapy, and dilatators. Further studies are warranted to enhance our understanding of the causes and treatment efficacy of pelvic floor dysfunctions due to anal penetrative intercourse.

Biofeedback therapy is useful for treatment of functional defecation disorders but is not widely available and is labor intensive. We developed an Internet-of-Medical-Things (IoMT) device, enabling self-guided biofeedback therapy. This study assesses the safety and efficacy of self-guided biofeedback therapy using the IoMT device in comparison to standard operator-led therapy. Patients experiencing urge or seepage fecal incontinence (≥1 episode/week) were randomly assigned to either our IoMT system or to the conventional anorectal manometry-based therapy. Both interventions comprised six weekly sessions, focusing on enhancing anal strength, endurance, and coordination. The novel device facilitated self-guided therapy via visual instructions on a companion app. Primary outcomes included safety/tolerability, changes in Vaizey severity scores, and alterations in anorectal pressure profiles. Twenty-five patients (22 females, 3 males) participated, with 13 in the novel device group and 12 in the standard therapy group. Both groups showed significant reductions in symptom severity scores: IoMT device group -4.2 (95% CI: -4.06, -4.34, p = 0.018), and the standard therapy group -4.8 (95% CI: -4.31, -5.29, p = 0.028). Anal sphincter resting pressure and sustained squeeze time improved significantly in both groups, and the novel device group demonstrated an increase in maximum sphincter squeeze pressure. There were no significant differences between the therapy groups. Importantly, the experimental device was well-tolerated compared with standard therapy, with no serious adverse events observed. This study demonstrates the comparable efficacy of self-administered biofeedback using the IoMT device with traditional biofeedback therapy. The results demonstrates the potential of the IoMT device as a safe, self-guided method for FI therapy, offering convenience and effectiveness in fecal incontinence management.

Faecal incontinence is a common debilitating condition associated with poor quality of life that generates substantial economic strain on healthcare systems.

We aimed to evaluate, in a tertiary referral population presenting with faecal incontinence, the impact of suffering additional disorders of gut-brain interaction (DGBI) on symptom severity, anxiety, depression and quality of life.

Design: Retrospective cohort study.

Tertiary referral Neurogastroenterology centre.

All patients presenting with faecal incontinence from 2007 to 2020 were included.

The results from structured medical and surgical questionnaires including Rome III Integrative Questionnaire, Faecal Incontinence Severity Index, Hospital Anxiety and Depression Scale, SF-36, and anorectal physiology were analysed using Stata version 17. Patients were categorised into 3 groups: 0-1 additional DGBI, 2 DGBIs, and 3+ DGBI. Statistical significance was defined as p < 0.05 (two-tailed).

Faecal incontinence patients (n = 249; mean age 63.4 ± 12.6 years; 93.6% female, 48.1% urge subtype) met diagnostic criteria for mean 2.2 additional DGBI each, mostly affecting bowel (n = 231, 42.4%) and anorectal (n = 150, 27.5%) regions. A greater number of DGBIs was associated with higher faecal incontinence symptom severity (p < 0.001), higher anxiety (p = 0.002) and depression (p = 0.003), and worse quality of life in areas of mental health (p = 0.037) and social effect (p < 0.001). Patients with a greater number of concurrent DGBI demonstrated a greater family history of gastrointestinal problems (p = 0.004). There were no associations found between a greater amount of DGBIs and anorectal physiology.

A greater number of additional DGBIs in faecal incontinence patients was associated with worse faecal incontinence symptoms, higher anxiety and depression scores, and worse quality of life but was unrelated to physiology. This highlights the need to proactively search for comorbid DGBI in patients presenting with faecal incontinence.

Some Chinese scholars have initially explored the efficacy of electroacupuncture at Baliao acupoint in patients with functional anorectal pain (FAP). However, their studies are performed in a single center, or the sample size is small. Therefore, we aim to further explore the efficacy of electroacupuncture at Baliao acupoint on the treatment of FAP.

In this multicenter randomized controlled trial, 136 eligible FAP patients will be randomly allocated into an electroacupuncture group or sham electroacupuncture group at a 1:1 ratio. This trial will last for 34 weeks, with 2 weeks of baseline, 4 weeks and 8 weeks of treatment, and 1, 3, and 6 months of follow-up. Outcome assessors and statisticians will be blind. The primary outcome will be clinical treatment efficacy, and secondary outcomes will be pain days per month, quality of life, psychological state assessment, anorectal manometry, pelvic floor electromyography, and patient satisfaction.

Results of this trial will be contributed to further clarify the value of electroacupuncture at Baliao acupoint as a treatment for FAP in the clinic.

This trial has been registered in Chinese Clinical Trial Registry  https://www.chictr.org.cn/  (ChiCTR2300069757) on March 24, 2023.

Defecation Disorders (DD) are a frequent cause of refractory chronic constipation. DD diagnosis requires anorectal physiology testing. Our aim was to evaluate the accuracy and Odds Ratio (OR) of a straining question (SQ) and a digital rectal examination (DRE) augmented by abdomen palpation on predicting a DD diagnosis in refractory CC patients.

Two hundred and thirty-eight constipated patients were enrolled. Patients underwent SQ, augmented DRE and balloon evacuation test before entering the study and after a 30-day fiber/laxative trial. All patients underwent anorectal manometry. OR and accuracy were calculated for SQ and augmented DRE for both dyssynergic defecation and inadequate propulsion.

"Anal Muscles" response was associated to both dyssynergic defecation and inadequate propulsion, with an OR of 13.6 and 5.85 and an accuracy of 78.5% and 66.4%, respectively. "Failed anal relaxation" on augmented DRE was associated with dyssynergic defecation, with an OR of 21.4 and an accuracy of 73.1%. "Failed abdominal contraction" on augmented DRE was associated with inadequate propulsion with an OR >100 and an accuracy of 97.1%.

Our data support screening constipated patients for DD by SQ and augmented DRE to improve management and appropriateness of referral to biofeedback.

Over 90% of rectal cancer patients develop low anterior resection syndrome (LARS) after sphincter-preserving resection. The current globally recognized evaluation method has many drawbacks and its subjectivity is too strong, which hinders the research and treatment of LARS.

To evaluate the anorectal function after colorectal cancer surgery by quantifying the index of magnetic resonance imaging (MRI) defecography, and pathogenesis of LARS.

We evaluated 34 patients using the standard LARS score, and a new LARS evaluation index was established using the dynamic images of MRI defecography to verify the LARS score.

In the LARS score model, there were 10 (29.41%) mild and 24 (70.58%) severe cases of LARS. The comparison of defecation rate between the two groups was 29.36 ± 14.17% versus 46.83 ± 18.62% (P = 0.004); and MRI-rectal compliance (MRI-RC) score was 3.63 ± 1.96 versus 7.0 ± 3.21 (P = 0.001). Severe and mild LARS had significant differences using the two evaluation methods. There was a significant negative correlation between LARS and MRI-RC score (P < 0.001), and they had a negative correlation with defecation rate (P = 0.028).

MRI defecography and standard LARS score can both be used as an evaluation index to study the pathogenesis of LARS.

Defecation disorders (DD) can sometimes affect the outcomes of pelvic or colorectal surgery. The aim of the present study is to evaluate the role of sacral neuromodulation for the treatment of constipation and other evacuation disorders after surgery.

A retrospective analysis in all the consecutive patients that underwent sacral nerve modulation (SNM) for DD arisen or worsened after pelvic or colorectal surgery was performed from January 2010 to December 2020. DD were defined starting from Rome IV Criteria, and according to manometric results, all patients were further divided into the two subgroups: inadequate defecatory propulsion and dyssynergic defecation. Cleveland Clinic Constipations Score (CCCS) and SF-36 have been evaluated in the time.

Thirty-seven patients have been included in the study. Twenty-seven out of thirty-seven (73.3%) patients had experienced sufficient benefits to implant the definitive device, and 22 patients (59.4% of tested and 81.5% of permanently implanted) still had the device functioning after a mean follow-up of 6.3 years. The most represented manometric pattern was inadequate propulsive function (59% of patients). CCCS at preoperative assessment for all patients was 17.5 with a reduction to 10.4 at the first year of follow-up (p < 0.001).

SNM appears to be a feasible, safe, and well-tolerated procedure with durable benefit in the long-term treatment of defecatory dysfunction after pelvic or colorectal surgery for benign diseases.

Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. The simultaneous detection of multiple findings in a complex anatomic setting renders correct analysis and clinical interpretation challenging.

The most important aspects (anatomy of the pelvic floor, three compartment model, morphological and functional analysis, reporting) for a successful clinical use of dynamic MRI of the pelvic floor are summarized.

Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panel of ESUR/ESGAR in 2016.

The pelvic floor is a complex anatomic structure, mainly formed by the levator ani muscle, the urethral support system and the endopelvic fascia. Firstly, morphological changes of these structures are analysed on the static sequences. Secondly, the functional analysis using the three compartment model is performed on the dynamic sequences during squeezing, straining and defecation. Pelvic organ mobility, pelvic organ prolapse, the anorectal angle and pelvic floor relaxation are measured and graded. The diagnosis of cystoceles, enteroceles, rectoceles, the uterovaginal as well as anorectal decent, intussusceptions and dyssynergic defecation should be reported using a structured report form.

A comprehensive analysis of all morphological and functional findings during dynamic MRI of the pelvic floor can provide information missed by other imaging modalities and hence alter therapeutic strategies.

Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. High-quality examination is crucial for diagnostic benefit but can be technically challenging.

The most important technical aspects (patient selection, patient preparation, MRI technology, MRI scan protocol, success control) for obtaining a state-of-the-art dynamic MRI of the pelvic floor are summarized.

Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panels of European Society of Urogenital Radiology/European Society of Gastrointestinal and Abdominal Radiology (ESUR/ESGAR) in 2016 and Society of Abdominal Radiology (SAR) in 2019.

Examination with at least 1.5 T and a surface coil after rectal instillation of ultrasound gel is clinical standard. Dynamic MRI in a closed magnet with the patient in supine position is the most widespread technique. No clinically significant pathologies of the pelvic floor are missed compared to the sitting position in an open magnet. The minimum scan protocol should encompass static, high-resolution T2-imaging (i.e., T2-TSE) in three planes and dynamic sequences with high temporal resolution in sagittal (and possibly axial) plane (i.e., steady-state or balanced steady-state free precession) during squeezing, straining and evacuation. Detailed patient instruction and practicing prior to the scan improve patients' compliance and hence diagnostic quality.

A technically flawless dynamic MRI of the pelvic floor according to these standards can provide information missed by other imaging modalities and hence alter therapeutic strategies.

Faecal incontinence is common and of multifactorial aetiologies, yet current diagnostic tools are unable to assess nerve and sphincter function objectively. We developed an anorectal high-density electromyography (HD-EMG) probe to evaluate motor-evoked potentials induced via trans-sacral magnetic stimulation (TSMS).

Anorectal probes with an 8 × 8 array of electrodes spaced 1 cm apart were developed for recording HD-EMG of the external anal sphincter. These HD-EMG probes were used to map MEP amplitudes and latencies evoked via TSMS delivered through the Magstim Rapid2 (MagStim Company). Patients undergoing pelvic floor investigations were recruited for this IDEAL Stage 2a pilot study.

Eight participants (median age 49 years; five female) were recruited. Methodological viability, safety and diagnostic workflow were established. The test was well tolerated with median discomfort scores ≤2.5/10, median pain scores ≤1/10 and no adverse events. Higher Faecal Incontinence Severity Index scores correlated with longer MEP latencies (r = 0.58, p < 0.001) and lower MEP amplitudes (r = -0.32, p = 0.046), as did St. Mark's Incontinence Scores with both MEP latencies (r = 0.49, p = 0.001) and MEP amplitudes (r = -0.47, p = 0.002).

This HD-EMG probe in conjunction with TSMS presents a novel diagnostic tool for anorectal function assessment. Spatiotemporal assessment of magnetically stimulated MEPs correlated well with symptoms and offers a feasible, safe and patient-tolerable method of evaluating pudendal nerve and external anal sphincter function. Further clinical development and evaluation of these techniques is justified.

The aim of this study was to investigate the clinical characteristics, psychological status, sleep quality, and quality of life of patients with functional anorectal pain (FAP). The study also assessed the treatment efficacy of paroxetine in alleviating FAP symptoms. A retrospective comparative study of forty-three patients with FAP who were first treated with an anal plug compound glycolate suppository versus paroxetine combined with anal plug compound glycolate suppository between November 2021 and August 2022. Pain, quality of life, depression, anxiety and sleep quality were assessed before and after treatment by the Chinese version of the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2), Health-related quality of life scale (The 12-Item Short-Form Health Survey, SF-12), 17-item Hamilton Depression Rating Scale (HDRS), 14-item Hamilton Anxiety Scale (HAMA), and Pittsburgh Sleep Quality Index (PSQI). A total of 46.5% of patients with FAP were found to have anxiety symptoms (HAMA ≥ 7), 37.2% of patients with FAP were found to have depressive symptoms (HDRS ≥ 8). A total of 32.6% of patients with FAP had sleep disorders (PSQI > 10). Within 1 week after drug withdrawal, the short-term efficacy rate of oral paroxetine was 95.5%. After treatment, the symptom pain score (VAS) and sleep score were lower than those before treatment (P < 0.01). In the areas of vitality (VT), Social Functioning (SF), and Mental Health (MH), the difference between the pre-treatment and 8 weeks posttreatment scores of the study group and the control group was statistically significant (P < 0.05). FAP patients have obvious symptoms of anxiety and depression, and the incidence of sleep disturbance is prevalent. Paroxetine, a typical serotonin reuptake inhibitor (SSRI), was able to alleviate depression, anxiety, and pain symptoms in FAP, which might have clinical application prospects.

Fecal incontinence is the involuntary passage or the incapacity to control the release of fecal matter through the anus. It is a condition that significantly impairs quality of life in those that suffer from it, given that it affects body image, self-esteem, and interferes with everyday activities, in turn, favoring social isolation. There are no guidelines or consensus in Mexico on the topic, and so the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, neurogastroenterologists, and surgeons) to carry out the «Mexican consensus on fecal incontinence» and establish useful recommendations for the medical community. The present document presents the formulated recommendations in 35 statements. Fecal incontinence is known to be a frequent entity whose incidence increases as individuals age, but one that is under-recognized. The pathophysiology of incontinence is complex and multifactorial, and in most cases, there is more than one associated risk factor. Even though there is no diagnostic gold standard, the combination of tests that evaluate structure (endoanal ultrasound) and function (anorectal manometry) should be recommended in all cases. Treatment should also be multidisciplinary and general measures and drugs (lidamidine, loperamide) are recommended, as well as non-pharmacologic interventions, such as biofeedback therapy, in selected cases. Likewise, surgical treatment should be offered to selected patients and performed by experts.

Faecal incontinence is an important complaint reported by patients with Crohn's disease [CD] and it is associated with several disease-related mechanisms, including anorectal functional disorders. This study aimed to assess the anorectal function and clinical characteristics to identify parameters associated with faecal incontinence in CD patients.

This is a cross-sectional study of 104 patients with CD, aged 18 years or older, from a referral centre between August 2019 and May 2021. Patients responded to a specific questionnaire, and underwent medical record review, proctological examination and anorectal functional assessment with anorectal manometry.

Of the 104 patients, 49% were incontinent. Patients with incontinence had a lower mean resting pressure [43.5 vs 53.1 mmHg; p = 0.038], lower mean squeeze pressure [62.1 vs 94.1 mmHg; p = 0.036] and lower maximum rectal capacity [140 vs 180 mL; p < 0.001]. Faecal incontinence was also associated with disease activity [p < 0.001], loose stools [p = 0.02], perianal disease [p = 0.006], previous anoperineal surgery [p = 0.048] and number of anorectal surgeries [p = 0.036].

This is the largest reported study describing manometric findings of Crohn's disease patients with and without faecal incontinence. Our results identified an association between faecal incontinence and functional disorders, in addition to clinical features in these patients. Functional assessment with anorectal manometry may help choose the best treatment for faecal incontinence in patients with CD.

Men with functional anorectal pain (FARP) report having erectile dysfunction (ED) and significant changes in psychological status.

The study sought to investigate the risk factors associated with FARP among male Chinese outpatients, alongside the impact of FARP on patients' ED, depression, and anxiety.

This case-control study included 406 male participants, divided into FARP (n = 323) and healthy control (n = 73) groups. Demographic and disease characteristics were collected from the patients, and the 5-item International Index of Erectile Function, Patient Health Questionnaire-9, and Generalized Anxiety Disorder 7 were used to assess erectile function, depression, and anxiety symptoms. Baseline characteristics were described using descriptive statistics, logistic regression analysis identified factors influencing FARP, and its association with ED, depression, and anxiety were analyzed using linear and ordinal logistic regression analyses. Validity was ensured through subgroup and sensitivity analyses.

The primary outcome was the association between FARP and ED, depression, and anxiety; the secondary outcome was the influencing factors of FARP such as lifestyle and work habits.

Men with FARP were likely to have more serious ED (59.8% vs 32.9%), depression (20.7% vs 4.1%), and anxiety(31.5% vs 12.3%); have lower 5-item International Index of Erectile Function scores; or have higher Patient Health Questionnaire-9 and Generalized Anxiety Disorder 7 scores compared with unaffected participants. Alcohol intake, family relationship, high work pressure, and prolonged bowel movements were significantly associated with FARP severity. The association between FARP with ED, depression, and anxiety was statistically significant in both crude and adjusted models. FARP was associated with 2.47, 2.73, and 2.67 times higher risk for ED, depression, and anxiety, respectively. An increase pain severity increased the incidence of ED (moderate pain: 4.80 times, P < .000; severe pain: 3.49 times, P < .004), depression (moderate pain: 1.85 times, P < .017; severe pain: 2.04 times, P < .037), and anxiety (moderate pain: 1.86 times, P < .014).Clinical Implications: Changes in lifestyle and work habits can help prevent pain symptom exacerbation. Attention to erection and psychological issues in patients with FARP and interdisciplinary comprehensive treatment may improve the efficacy.

The study highlights a correlation between FARP and ED, depression, and anxiety, with pain severity being a contributing factor. However, the study's limitations include a small sample size and potential recall bias, and other sexual functions were not thoroughly explored.

Patients with FARP have a higher prevalence of ED, depression, and anxiety, which increase with pain severity. Factors such as alcohol intake, work pressure, prolonged sitting, and longer defecation times are significantly correlated with FARP pain severity.

Functional constipation (FC) affects up to 32% of the pediatric population, and some of these patients are referred to pediatric surgery units to manage their constipation and/or fecal incontinence. The aim of the current paper is to report the recent updates on the evaluation and management of children with FC as a part of a manuscript series on bowel management in patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and FC.

A literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published within the last 5-10 years.

The first step of management of children with FC is to exclude Hirschsprung disease with a contrast study, examination under anesthesia, anorectal manometry (AMAN). If AMAN shows absent rectoanal inhibitory reflex, a rectal biopsy is performed. Internal sphincter achalasia or high resting pressures indicate botulinum toxin injection. Medical management options include laxatives, rectal enemas, transanal irrigations, and antegrade flushes. Those who fail conservative treatment require further assessment of colonic motility and can be candidates for colonic resection. The type of resection (subtotal colonic resection vs. Deloyer's procedure) can be guided with a balloon expulsion test.

Most of the patients with FC referred for surgical evaluation can be managed conservatively. Further studies are required to determine an optimal strategy of surgical resection in children unresponsive to medical treatment.

The effect of age and gender differences on anorectal function, symptoms severity, and quality of life (QoL) in patients with chronic constipation (CC) is not well studied. This study examines the impact of age and gender on anorectal function testing (AFT) characteristics, symptoms burden, and QoL in patients with CC.

This is a retrospective analysis of prospectively collected data from 2550 adults with CC who completed AFT. Collected data include demographics, sphincter response to simulated defecation during anorectal manometry (ARM), balloon expulsion testing (BET), and validated surveys assessing constipation symptoms and QoL. DD was defined as both the inability to relax the anal sphincter during simulated defecation and an abnormal BET.

2550 subjects were included in the analysis (mean age = 48.6 years). Most patients were female (81.6%) and Caucasian (82%). 73% were < 60 years old (mean = 41) vs. 27% ≥ 60 years old (mean = 69). The prevalence of impaired anal sphincter relaxation on ARM, abnormal BET, and DD in patients with CC was 48%, 42.1%, and 22.9%, respectively. Patients who were older and male were significantly more frequently diagnosed with DD and more frequently had impaired anal sphincter relaxation on ARM, compared to patients who were younger and female (p < 0.05). Conversely, CC patients who were younger and female reported greater constipation symptoms severity and more impaired QoL (p ≤ 0.004).

Among patients with CC referred for anorectal function testing, men and those older than 60 are more likely to have dyssynergic defecation, but women and patients younger than 60 experience worse constipation symptoms and QoL.

obstructed defecation syndrome (ODS) is a common but underestimated condition that may affect the outcomes after hemorrhoidectomy. Therefore, the aim of this study was to determine the prevalence of obstructed defecation syndrome (ODS) among patients who underwent hemorrhoidectomy and to assess the correlation between preoperative constipation score and postoperative patients' satisfaction.

This prospective study included adult patients who underwent hemorrhoidectomy for 3rd and 4th-grade hemorrhoidal diseases. All participant patients underwent an assessment of functional OD severity by the Agachan-Wexner Constipation Scoring System. All patients were subjected to conventional hemorrhoidectomy. At 6 months postoperatively, patients were assessed again for their constipation score and postoperative patients' satisfaction.

The study included 120 patients (62 males and 58 females) with a mean age of 38.7 ± 12.1 years. About one-quarter of patients (24.2%) had obstructed defecation (constipation score ≥12). ODS (constipation score ≥12) was found to be significantly more among older patients, female patients, especially those with multiple pregnancies and multiple labors, and those with perineal descent. The postoperative constipation score (5.6 ± 3.3 mean ± SD) showed significant improvement (p = 0.001) compared to (9.3 ± 3.9 mean ± SD) preoperatively. Postoperative patients' satisfaction (mean 12.3 ± 3.0) at 6 months had a negative correlation with preoperative total constipation score (r = -0.035, p = 0.702).

The prevalence of obstructed defecation among patients with hemorrhoids was higher than reported among the general population. High preoperative constipation scores had a negative correlation with postoperative patients' satisfaction. Routine preoperative measurement of ODS can allow the detection of this particular group of patients who require a more physical and psychological evaluation, in addition to special preoperative counseling.

About one-third of chronically constipated patients have an evacuation disorder, and dyssynergic defecation is a common cause of the evacuation disorder. In dyssynergic defecation, the coordination between abdominal and pelvic floor muscles during defecation is disrupted and patients cannot produce a normal bowel movement. The etiology of dyssynergic defecation is still unknown. Although a detailed history taking and a careful examination including digital rectal examination could be useful, other modalities such as anorectal manometry and balloon expulsion test are necessary for the diagnosis. Biofeedback therapy is one of the most effective and safe treatments. Here, we provide an overview of dyssynergic defecation as well as how to diagnose and manage this condition.

Patients with functional anorectal pain (FAP) often experience psychological distress, impaired quality of life, increased healthcare utilisation, and even suicidal tendencies. However, limited data exists on the psychological correlates of FAP in Chinese patients. Therefore, this study aimed to examine the prevalence of depression, anxiety, and related psychosocial factors in Chinese patients with FAP.

We used a cross-sectional research design and recruited 100 patients with FAP from SuBei Hospital's multidisciplinary clinic for pelvic floor disorders between January and December 2021. Information on patients' demographic and disease characteristics was also collected. Depressive and anxiety symptoms were assessed using the Patient Health Questionnaire Depression (PHQ-9) and the Generalised Anxiety Disorder Questionnaire (GAD-7). Multiple logistic regression analysis was used to examine factors associated with depression and anxiety.

The prevalence of depressive and anxiety symptoms among patients with FAP was 55% and 46%, respectively. Being a woman, specific marital status (single, divorced, separated, or widowed), longer FAP duration, and sleep disturbance were significantly associated with an increased risk of depressive symptoms. Additionally, specific marital status (single, divorced, separated, or widowed), sleep disturbance, and high Visual Analogue Scale scores were associated with anxiety symptoms.

Depressive and anxiety symptoms are prevalent in patients with FAP. Several socio-demographic and clinical predictors have been identified. There is a need for psychologists to be involved in the treatment of patients with FAP. Thus, multidisciplinary treatment may be the optimal treatment strategy.

Evaluation of chronic constipation is important, although it is often difficult to satisfactorily treat due to the complex interplay of factors. This study aimed to determine whether the volume of intraluminal contents and lateral diameter of the colon measured from computed tomography (CT) images were correlated with the symptoms of chronic constipation and stool consistency. Consecutive patients who underwent the Constipation Scoring System (CSS), Bristol Stool Form Scale (BSFS) questionnaires and simple abdominal CT were selected retrospectively. The intestinal tract diameter at each site was measured, and the amounts of stool and gas in the intestinal tract were evaluated at five levels. Of the 149 study participants, 54 were males and 95 were females and their mean age was 72.1 years. In the right hemi-colon, CSS5 (Time) correlated significantly with gas volume (p < 0.01). In the left hemi-colon, stool volume correlated significantly with CSS2 (Difficulty), CSS3 (Completeness), CSS5 (Time) and CSS total (p < 0.05). The BSFS negatively correlated with gas volume and diameter in the right hemi-colon and with gas volume in the rectum (p < 0.05). CT findings including stool volume, gas volume and diameter correlated with some constipation symptoms and stool consistency. These findings may be useful in evaluating and treating constipation.

Opioids prescribed to address postoperative pain drive opioid-related deaths in the United States. Prescribing guidelines have been developed for many general surgical procedures, which have decreased opioid prescription and consumption. The literature on opioids after anorectal surgery is lacking.

We analyzed our data on opioid prescription and consumption to create opioid-prescribing guidelines for anorectal procedures.

We designed a prospectively collected postoperative survey given to consecutive patients undergoing anorectal surgery by colorectal surgeons.

Patients had surgery at 2 academic, university-affiliated hospitals.

Patients undergoing anorectal surgery from May 3, 2018, to December 18, 2019, were included in the study. Patients were excluded if they were <18 years of age, had a concurrent abdominopelvic surgery, consumed opioids in the week before their operation, or were without follow-up at 3 months postoperatively.

The primary outcome of this study was the number of opioid pills needed to fulfill consumption of 80% of patients. Secondary outcome measures were patient, operative, and postoperative factors associated with increasing pill consumption.

Eighteen 5-mg oxycodone tablets were needed to fulfill the needs of 80% of patients. An overall median of 8 pills was consumed. Pill prescription was independently predictive of increased consumption. The only patient factor associated with increased consumption was race; no other patient or operative factors were predictive of consumption.

Limitations of this study include its partially retrospective nature, use of self-reported data, and lack of racial diversity among our cohort.

Without any clinical factors predictive of increased consumption, prescription guidelines can be standardized to ≤18 5-mg oxycodone tablets across anorectal surgery patients. As prescription is correlated with consumption, further work is needed to determine whether lesser quantities of opioids prescribed offer similar postoperative pain relief for patients undergoing anorectal surgery. See Video Abstract at http://links.lww.com/DCR/B821 .DESARROLLO DE PAUTAS PARA LA PRESCRIPCIÓN DE OPIOIDES DESPUÉS DE CIRUGÍA ANORRECTAL: ¿INFLUYEN EN EL CONSUMO LOS RESULTADOS INFORMADOS POR EL PACIENTE Y LOS FACTORES DE RIESGO?

Los opioides recetados para tratar el dolor posoperatorio provocan muertes relacionadas con los opioides en los Estados Unidos. Se han desarrollado pautas de prescripción para muchos procedimientos quirúrgicos generales y estas han conducido a una disminución de la prescripción y el consumo de opioides. Hay una carencia de literatura sobre el uso de opioides después de cirugía anorrectal.

Analizamos nuestros datos sobre prescripción y consumo de opioides para crear pautas de prescripción de opioides para procedimientos anorrectales.

Diseñamos una encuesta postoperatoria recopilada prospectivamente que se administró a pacientes consecutivos sometidos a cirugía anorrectal por cirujanos colorrectales.

Los pacientes fueron operados en dos hospitales académicos afiliados a la universidad.

Se incluyeron en el estudio pacientes sometidos a cirugía anorrectal desde el 3/05/2018 hasta el 18/12/2019. Se excluyó a los pacientes que tenían menos de 18 años, a los que se sometieron a cirugía abdominopélvica concurrente, a los que consumieron opioides en la semana anterior a la operación, o si no tenían seguimiento a los 3 meses del postoperatorio.

El desenlace principal de este estudio fue el número de píldoras de opioides necesarias para satisfacer el consumo del 80% de los pacientes. Las medidas de desenlace secundarias fueron los factores del paciente, operatorios y posoperatorios asociados con el aumento del consumo de píldoras.

Fueron necesarios dieciocho comprimidos de oxicodona de 5 mg para cubrir las necesidades del 80% de los pacientes. Se consumió una mediana general de 8 píldoras. La prescripción de la píldora fue un predictor independiente de un mayor consumo. El único factor del paciente asociado con un mayor consumo fue la raza; ningún otro paciente o factores operativos fueron predictivos del consumo.

Las limitaciones de este estudio incluyen su naturaleza parcialmente retrospectiva, el uso de datos autoinformados y la falta de diversidad racial entre nuestra cohorte.

Sin ningún factor clínico que prediga un aumento del consumo, las pautas de prescripción se pueden estandarizar a dieciocho o menos comprimidos de oxicodona de 5 mg en pacientes sometidos a cirugía anorrectal. Como la prescripción se correlaciona con el consumo, se necesita más trabajo para determinar si cantidades menores de opioides prescritos ofrecen un alivio del dolor posoperatorio similar para los pacientes sometidos a cirugía anorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B821 . (Traducción-Juan Carlos Reyes ).

During high-resolution anorectal manometry (HR_ARM), the raw data are converted into software-derived summary variables (e.g., rectoanal gradient during evacuation) that capture only a snapshot of the data collected during HR_ARM and are less useful than newer indices, which are also derived from the raw data, for diagnosing defecatory disorders (DD). However, it is cumbersome and time-consuming to extract raw data from the program and calculate such indices. This study aimed to devise a user-friendly approach to extract anorectal pressures measured with HR_ARM.

Anorectal pressures at rest, during anal squeeze, and evacuation were measured with HR_ARM in 180 women, among whom 60 each were healthy, had DD, or fecal incontinence. A reverse engineering approach extracted pressure values from color images in HR_ARM reports. The summary variables generated by the software and a reverse engineering approach were compared with Lin's concordance correlation coefficient (CCC), paired t-tests, and Bland-Altman's tests.

Anorectal pressures summarized by the software and a reverse engineering method were highly concordant for anal resting (CCC [95% CI], 0.98 [0.97, 0.99]) and squeeze pressures (0.99 [0.99, 0.99) and the rectoanal gradient during evacuation with an empty (0.98 [0.97, 0.98]) and a filled balloon (0.99 [0.99, 0.99]). For most variables, the paired t and Bland-Altman comparisons were not significant.

Anorectal pressures can be accurately determined from pressure topography images in HR_ARM reports. In future, this reverse engineering approach can be harnessed to compile large HR_ARM datasets across centers and to uncover newer, potentially more useful summary rectoanal pressure variables.

Obstructive defecation syndrome (ODS) is a common urogynaecology presentation. This study compares two questionnaires, the electronic Personal Assessment Questionnaire (e-PAQ), used in urogynaecology clinics, with the ODS-Score (ODS-S), a simple validated scoring system used in colorectal clinics for diagnosing ODS, to identify patients with an ODS-S cut-off ≥9.

A total of 221 paired ODS-S and e-PAQ questionnaires were completed; 80 during the second trimester of pregnancy, 73 during the third and 68 post-natally, including women sustaining obstetric anal sphincter injury (OASI). e-PAQ score and ODS-S were compared and Pearson's correlation coefficient calculated. Areas under the curve assessed the diagnostic ability of e-PAQ scores to identify patients with ODS-S of ≥9.

The e-PAQ and ODS-S scores showed a positive correlation in the second and third trimesters of pregnancy, post-natally and following OASI. Pearson's correlation coefficient was calculated (0.77; p < 0.001, 0.79; p < 0.001, 0.66; p = 0.001 and 0.79; p < 0.001 respectively). An e-PAQ evacuatory domain score of ≥33 identified women with an ODS score of ≥9 with a sensitivity and specificity of 71% and 94% in the second trimester, 86% and 95% third trimester and 78% and 97% in the OASI group respectively. Area under the curve was >0.90 for all groups.

Comparison of e-PAQ evacuatory domain scores and ODS-S show a strong correlation, with an e-PAQ score of ≥33 promising for identifying women with an ODS score of ≥9, indicating ODS. This study will enable us to identify women during pregnancy and post-natally with ODS for whom early recognition and intervention may be beneficial.

To evaluate symptom presentation and underlying pathophysiology of colonic/anorectal dysfunction in females with functional constipation (FC) and hypermobile Ehlers-Danlos syndrome (hEDS)/hypermobility spectrum disorder (HSD) METHODS: Case-control study of 67 consecutive female patients with an established diagnosis of hEDS/HSD referred to a specialist centre for investigation of FC (Rome III criteria), age-matched (1:2 ratio) to 134 female controls with FC scoring 0 on the validated 5-point joint hypermobility questionnaire. Symptoms and results of colonic/anorectal physiology testing were compared. An independent series of 72 consecutive females with hEDS/HSD, referred to a separate hospital for investigation of FC, was used to validate physiological findings.

Females with hEDS/HSD were more likely to report constipation for ≥ 5 years (76.1% vs. 61.2%, p = 0.035), and a greater proportion had a high Cleveland Clinic constipation score (≥12: 97.0% vs. 87.3%; p = 0.027). The proportions with delayed whole-gut transit were similar between groups (35.3% vs. 41.7%; p = 0.462), as were the proportions with functional or structural abnormalities on defaecography (functional: 47.8% vs. 36.6%; p = 0.127; structural: 65.7% vs. 66.4%; p = 0.916). However, rectal hyposensitivity was more common in those with hEDS/HSD (43.3% vs. 20.1%; p = 0.0006); this was confirmed in the validation cohort (rectal hyposensitivity: 45.8%).

Rectal hyposensitivity is a common pathophysiological factor in females with FC and hEDS/HSD as confirmed in two separate cohorts. The rectal hyposensitivity may be due to altered rectal biomechanics/neuronal pathway dysfunction. Management may be better focused on enhancement of sensory perception (e.g., sensory biofeedback).

People with spinal cord injury (SCI) suffer from the sequela of neurogenic bowel and its disabling complications primarily constipation, fecal incontinence, and gastrointestinal (GI) symptoms. Neurogenic bowel is a functional bowel disorder with a spectrum of defecatory disorders as well as colonic and gastrointestinal motility dysfunction. This manuscript will review the anatomy and physiology of gastrointestinal innervation, as well as the pathophysiology associated with SCI. It will provide essential information on the recent guidelines for neurogenic bowel assessment and medical management. This will allow medical providers to partner with their patients to develop an individualized bowel plan utilizing a combination of various pharmacological, mechanical and surgical interventions that prevent complications and ensure successful management and compliance. For people with SCI and neurogenic bowel dysfunction, the fundamental goal is to maintain health and well-being, promote a good quality of life and support active, fulfilled lives in their homes and communities.

Although the association of absent or attenuated "call to stool" with constipation is well-recognized, no studies have systematically evaluated the perception of urge to defecate in a well-defined cohort of patients with chronic constipation (CC).

A prospective study of 43 healthy adult women and 140 consecutive adult women attending a tertiary center for investigation of CC. All participants completed a 5-day viscerosensory questionnaire, and all women with CC also underwent anorectal physiologic investigations. Normal urge perception and abnormal urge perception were defined using a Naive Bayes model trained in healthy women (95% having normal urge).

In total, 181 toilet visits in healthy women and 595 in women with CC were analyzed. Abnormal urge perception occurred in 70 (50.0%) women with CC. In this group, the urge to defecate was more often experienced as abdominal sensation (69.3% vs 41.4%; P < 0.0001), and the viscerosensory referral area was 81% larger (median pixels anterior: 1,849 vs 1,022; P < 0.0001) compared to women with CC and normal urge perception. Abnormal (vs normal) urge in women with CC was associated with more severe constipation (Cleveland Clinic constipation score: 19 vs 15 P < 0.0001), irritable bowel syndrome (45.7% vs 22.9% P < 0.0001), and a functional evacuation disorder on defecography (31.3% vs 14.3% P = 0.023). A distinct pattern of abnormal urge was found in women with CC and rectal hyposensitivity.

Abnormal urge perception was observed in 50% of women with CC and was frequently described as abdominal sensation, supporting the concept that sensory dysfunction makes an important contribution to the pathophysiology of constipation.

Performing injections with a bulking agent consisting of nonanimal stabilized hyaluronic acid and dextranomer is a well-tolerated and efficacious treatment for mild to moderate fecal incontinence. Here, we discuss a case of a patient with a history of a bulking procedure for fecal incontinence who presented to the obstetrics/gynecology clinic for evaluation of a new vaginal "cyst," which was excised. Histopathologic examination revealed migrated bulking agent within the excised specimen.

Lower urinary tract symptoms (LUTS) are frequently reported by constipated patients. Prospective studies investigating the association between defecatory disorders (DDs) and voiding dysfunction, predominantly in women, have reported conflicting results. This study investigated (1) the prevalence of LUTS in young men with DDs and (2) the association between objectively documented DDs and voiding dysfunction in constipated young men with LUTS.

We reviewed the medical records, including validated questionnaires, of men aged 18-40 with confirmed DDs treated with pelvic floor physical therapy (PT) at our institution from May 2018 to November 2020. In a separate group of constipated young men with LUTS who underwent high-resolution anorectal manometry (HRM), rectal balloon expulsion test (BET), and uroflowmetry, we explored the relationship between DDs and voiding dysfunction.

A total of 72 men were evaluated in the study. Among 43 men receiving PT for a proven DD, 82% reported ≥ 1 LUTS, most commonly frequent urination. Over half of these men experienced a reduction in LUTS severity after bowel-directed pelvic floor PT. Among 29 constipated men with LUTS who had undergone HRM/BET and uroflowmetry, 28% had concurrent defecatory and voiding dysfunction, 10% had DD alone, 14% had only voiding dysfunction, and 48% had neither. The presence of DD was associated with significantly increased odds of concurrent voiding dysfunction (odds ratio 9.3 [95% CI 1.7-52.7]).

Most young men with DDs experience LUTS, which may respond to bowel-directed physical therapy. Patients with DD and urinary symptoms have increased odds of voiding dysfunction.

The first two objectives were to establish which stimulation parameters of kilohertz frequency alternating current (KHFAC) neuromodulation influence the effectiveness of pudendal nerve block and its safety. The third aim was to determine whether KHFAC neuromodulation of the pudendal nerve can relax the pelvic musculature, including the anal sphincter. Simulation experiments were conducted to establish which parameters can be adjusted to improve the effectiveness and safety of the nerve block. The outcome measures were block threshold (measure of effectiveness) and block threshold charge per phase (measure of safety). In vivo, the pudendal nerves in 11 male and 2 female anesthetized Sprague Dawley rats were stimulated in the range of 10 Hz to 40 kHz, and the effect on anal pressure was measured. The simulations showed that block threshold and block threshold charge per phase depend on waveform, interphase delay, electrode-to-axon distance, interpolar distance, and electrode array orientation. In vivo, the average anal pressure during unilateral KHFAC stimulation was significantly lower than the average peak anal pressure during low-frequency stimulation (p < 0.001). Stimulation with 20 kHz and 40 kHz (square wave, 10 V amplitude, 50% duty cycle, no interphase delay) induced the largest anal pressure decrease during both unilateral and bilateral stimulation. However, no statistically significant differences were detected between the different frequencies. This study showed that waveform, interphase delay and the alignment of the electrode along the nerve affect the effectiveness and safety of KHFAC stimulation. Additionally, we showed that KHFAC neuromodulation of the pudendal nerves with an electrode array effectively reduces anal pressure in rats.