Current Gastroenterology Reports

, Volume 8, Issue 4, pp 291–299 | Cite as

Defecation disorders: Neuromuscular aspects and treatment

  • Jose M. Remes-Troche
  • Satish S. C. RaoEmail author


Chronic constipation and fecal incontinence affect 20% of the population and are more prevalent in women, the elderly, those of lower socioeconomic status, and nursing home residents. These disorders pose a significant economic burden and affect quality of life. During the past decade, significant strides have been made in the understanding and treatment of defecation disorders, which have led to real advances in the management of these disorders. These treatments include biofeedback therapy, tegaserod, and lubiprostone for chronic constipation.


Irritable Bowel Syndrome Fecal Incontinence Anal Sphincter External Anal Sphincter Internal Anal Sphincter 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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References and Recommended Reading

  1. 1.
    Rao SS: Constipation: evaluation and treatment. Gastroenterol Clin North Am 2003, 32:659–683.PubMedCrossRefGoogle Scholar
  2. 2.
    Hobson AR, Aziz Q. Brain imaging and functional gastrointestinal disorders: has it helped our understanding? Gut 2004, 53:1198–1206. Excellent review of the most important findings regarding the new brain imaging techniques that have facilitated a better understanding of the neuroanatomy and functional relevance of the cortical and subcortical structures involved in the processing of gastrointestinal sensation.PubMedCrossRefGoogle Scholar
  3. 3.
    Mayer EA, Berman S, Suyenobu B, et al.: Differences in brain responses to visceral pain between patients with irritable bowel syndrome and ulcerative colitis. Pain 2005, 115:398–409.PubMedCrossRefGoogle Scholar
  4. 4.
    Hobday DI, Aziz Q, Thacker N, et al.: A study of the cortical processing of ano-rectal sensations using functional MRI. Brain 2001, 124:361–368.PubMedCrossRefGoogle Scholar
  5. 5.
    Lawal A, Kern M, Sanjeevi A, et al.: Cingulate cortex: a closer look at its gut-related functional topography. Am J Physiol Gastrointest Liver Physiol 2005, 289: G722-G730.PubMedGoogle Scholar
  6. 6.
    Derbyshire SW: A systematic review of neuroimaging data during visceral stimulation. Am J Gastroenterol 2003, 98:12–20.PubMedCrossRefGoogle Scholar
  7. 7.
    Lynn PA, Olsson C, Zagorodnyuk V, et al.: Rectal intraganglionic laminar endings are transduction sites of extrinsic mechanoreceptors in the guinea pig rectum. Gastroenterology 2003, 125:786–794.PubMedCrossRefGoogle Scholar
  8. 8.
    Wood JD: Enteric neuroimmunophysiology and pathophysiology. Gastroenterology 2004, 127:635–657.PubMedCrossRefGoogle Scholar
  9. 9.
    Rao SC, Miller M, DeOcampo S: Anorectal sensori-motor reflex in humans [abstract]. Gastroenterology 2005, 128(Suppl 2):A38 (250).Google Scholar
  10. 10.
    Remes-Troche JM, DeOcampo S, Miller MJ, et al.: Investigation of the sensori-motor, rectoanal inhibitory and contractile reflexes in rectal hyposensitivity [abstract]. Gastroenterology 2006, 130(Suppl 2):A115 (787).Google Scholar
  11. 11.
    Lembo A, Camilleri M: Chronic constipation. N Engl J Med 2003, 349:1360–1368.PubMedCrossRefGoogle Scholar
  12. 12.
    Rao SS, Sadeghi P, Beaty J, Kavlock R: Ambulatory 24-hour colonic manometry in slow-transit constipation. Am J Gastroenterol 2004, 99:2405–2416.PubMedCrossRefGoogle Scholar
  13. 13.
    Rao SSC, Welcher KD, Leistikow JS: Obstructive defecation: a failure of rectoanal coordination. Am J Gastroenterol 1998, 93:1042–1050.PubMedCrossRefGoogle Scholar
  14. 14.
    Bassoti G, de Roberto G, Castellani D, et al.: Normal aspects of colorectal motility and abnormalities in slow transit constipation. World J Gastroenterol 2005, 11:2691–2696.Google Scholar
  15. 15.
    Rao SS, Sadeghi P, Batterson K, Beaty J: Altered periodic rectal motor activity: a mechanism for slow transit constipation. Neurogastroenterol Motil 2001, 13:591–598.PubMedCrossRefGoogle Scholar
  16. 16.
    Herve S, Savoye G, Behbahani A, et al.: Results of 24-h manometric recording of colonic motor activity with endoluminal instillation of bisacodyl in patients with severe chronic slow transit constipation. Neurogastroenterol Motil 2004, 16:397–402.PubMedCrossRefGoogle Scholar
  17. 17.
    Lee JI, Park H, Kamm MA, Talbot IC: Decreased density of interstitial cells of Cajal and neuronal cells in patients with slow transit constipation and acquired megacolon. J Gastroenterol Hepatol 2005, 20:1292–1298.PubMedCrossRefGoogle Scholar
  18. 18.
    Bassotti G, Villanacci V, Maurer CA, et al.: The role of glial cells and apoptosis of the enteric neurons in the neuropathology of intractable slow transit constipation. Gut 2006, 55:41–46.PubMedCrossRefGoogle Scholar
  19. 19.
    Puri P, Shinkai T: Pathogenesis of Hirschsprung’s disease and its variants: recent progress. Semin Pediatr Surg 2004, 13:18–24.PubMedCrossRefGoogle Scholar
  20. 20.
    Xiao ZL, Pricolo V, Biancani P, Behar J: Role of progesterone signaling in the regulation of G-protein levels in female chronic constipation. Gastroenterology 2005, 128:667–675.PubMedCrossRefGoogle Scholar
  21. 21.
    Rao SS, Tuteja AK, Vellema T, et al.: Dyssynergic defecation: demographics, symptoms, stool patterns, and quality of life. J Clin Gastroenterol. 2004, 38:680–685.PubMedCrossRefGoogle Scholar
  22. 22.
    Bharucha AE, Fletcher JG, Seide B, et al.: Phenotypic variation in functional disorders of defecation. Gastroenterology 2005, 128:1199–1210.PubMedCrossRefGoogle Scholar
  23. 23.
    Crowell MD, Harris L, Jones MP, Chang L: New insights into the pathophysiology of irritable bowel syndrome: implications for future treatments. Curr Gastroenterol Rep 2005, 7:272–279.PubMedCrossRefGoogle Scholar
  24. 24.
    Muller-Lissner SA, Kamm MA, Scarpignato C, Wald A:.Myths and misconceptions about chronic constipation. Am J Gastroenterol 2005, 100: 32–242.CrossRefGoogle Scholar
  25. 25.
    Ramkumar D, Rao SSC. Efficacy and safety of traditional medical therapies for chronic constipation: Systematic review. Am J Gastroenterol 2005, 100: 936–971. One of two excellent systematic reviews. See following reference.PubMedCrossRefGoogle Scholar
  26. 26.
    Brandt LJ, Prather CM, Quigley EMM, et al.: Systematic review on the management of chronic constipation in North America. Am J Gastroenterol 2005, 100 (Suppl 1), S5-SS22. One of two excellent systematic reviews of the efficacy and safety of traditional medical therapies for chronic constipation. According to these reviews there is evidence to support the use of psyllium, lactulose, PEG, and tegaserod. See [25].PubMedCrossRefGoogle Scholar
  27. 27.
    Corazziari E, Badiali D, Bazzocchi G, et al.: Long term efficacy, safety and tolerability of low daily doses of isosmotic polyethylene glycol electrolyte balanced solution (PMF-100) in the treatment of functional chronic constipation. Gut 2000, 46:522–526.PubMedCrossRefGoogle Scholar
  28. 28.
    Fritz E, Hammer HF, Lipp RW, et al.: Effects of lactulose and polyethylene glycol on colonic transit. Aliment Pharmacol Ther 2005, 21:259–268.PubMedCrossRefGoogle Scholar
  29. 29.
    Johanson JF, Wald A, Tougas G, et al.: Effect of tegaserod in chronic constipation: a randomized, double-blind, controlled trial. Clin Gastroenterol Hepatol 2004, 2:796–805.PubMedCrossRefGoogle Scholar
  30. 30.
    Shetzline M, Dolker M, Bottoli I, Cohard-Radice M: Patients with chronic constipation who respond to tegaserod after 4 weeks maintain symptom improvement for over 13 months. Am J Gastroenterol 2005, 100(Suppl 7):S339.Google Scholar
  31. 31.
    Liu Z, Sakakibara R, Odaka T, et al.: Mosapride citrate, a novel 5-HT4 agonist and partial 5-HT3 antagonist, ameliorates constipation in Parkinsonian patients. Mov Disord 2005, 20:680–686.PubMedCrossRefGoogle Scholar
  32. 32.
    Camilleri M, McKinzie S, Fox J, et al.: Effect of renzapride on transit in constipation-predominant irritable bowel syndrome. Clin Gastroenterol Hepatol 2004, 2:895–904.PubMedCrossRefGoogle Scholar
  33. 33.
    Verne GN, Davis RH, Robinson ME, et al.: Treatment of chronic constipation with colchicine: randomized, double-blind, placebo-controlled, crossover trial. Am J Gastroenterol 2003, 98:1112–1116.PubMedGoogle Scholar
  34. 34.
    Johanson JF, Gargano MA, Holland PC, et al.: Phase III efficacy and safety of RU-0211, a novel chloride channel activator, for the treatment of constipation. Gastroenterology2003, 124(Suppl 1):A48.CrossRefGoogle Scholar
  35. 35.
    Parkman HP, Rao SS, Reynolds JC, et al.: Neurotrophin-3 improves functional constipation. Am J Gastroenterol 2003, 98:1338–1347.PubMedCrossRefGoogle Scholar
  36. 36.
    Gonenne J, Camilleri M, Ferber I, et al.: Effect of alvimopan and codeine on gastrointestinal transit: a randomized controlled study. Clin Gastroenterol Hepatol 2005, 3:784 -791.PubMedCrossRefGoogle Scholar
  37. 37.
    Rao SS, Kinkade KJ, Schulze KS, et al.: Biofeedback therapy for dyssynergy constipation-randomized controlled trial. Gastroenterology 2005, 128:A269.Google Scholar
  38. 38.
    Heymen S, Scarlett Y, Jones K, et al.: Randomized controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergya-type constipation. Gastroenterology 2005, 128:A266.Google Scholar
  39. 39.
    Chiarioni G, Whitehead WE, Pezza V, et al.: Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergya. Gastroenterology 2006, 130:657–664.PubMedCrossRefGoogle Scholar
  40. 40.
    Rao SSC: Pathophysiology of adult fecal incontinence. Gastroenterology 2004, 126 (Suppl 1): S14-S22.PubMedCrossRefGoogle Scholar
  41. 41.
    Bharucha AE, Zinsmeister AR, Locke GR, et al.: Prevalence and burden of fecal incontinence: a population-based study in women. Gastroenterology 2005, 129:42–49.PubMedCrossRefGoogle Scholar
  42. 42.
    Rao SS, American College of Gastroenterology Practice Parameters Committee. Diagnosis and management of fecal incontinence. American College of Gastroenterology Practice Parameters Committee. Am J Gastroenterol 2004, 99:1585–1604. This review provides useful information regarding the epidemiology and pathophysiology of FI, the diagnostic tests, and an evidence-based summary of recent therapies for FI.PubMedCrossRefGoogle Scholar
  43. 43.
    Fornell EU, Matthiessen L, Sjodahl R, Berg G.: Obstetric anal injury ten years after: subjective and objective long term effects. BJOG 2005, 112:312–316.PubMedCrossRefGoogle Scholar
  44. 44.
    Damon H, Bretones S, Henry L, et al.: Long-term consequences of first vaginal delivery-induced anal sphincter defect. Dis Colon Rectum 2005, 48:1772–1776.PubMedCrossRefGoogle Scholar
  45. 45.
    Johannsson HO, Graf W, Pahlman L: Long-term results of haemorrhoidectomy. Eur J Surg 2002, 168:485–489.PubMedCrossRefGoogle Scholar
  46. 46.
    Bharucha AE, Fletcher JG, Harper CM, et al.: Relationship between symptoms and disordered continence mechanisms in women with idiopathic faecal incontinence. Gut 2005, 54:546–555.PubMedCrossRefGoogle Scholar
  47. 47.
    Fernandez-Fraga X, Azpiroz F, Malagelada JR: Significance of pelvic floor muscles in anal incontinence. Gastroenterology 2002, 123:1441–1450.PubMedCrossRefGoogle Scholar
  48. 48.
    Chan CL, Lunniss PJ, Wang D, et al.: Rectal sensorimotor dysfunction in patients with urge faecal incontinence: evidence from prolonged manometric studies. Gut 2005, 54:1263–1272.PubMedCrossRefGoogle Scholar
  49. 49.
    Chan CL, Scott SM, Williams NS, Lunniss PJ: Rectal hypersensitivity worsens stool frequency, urgency, and lifestyle in patients with urge fecal incontinence. Dis Colon Rectum 2005, 48:134–140.PubMedCrossRefGoogle Scholar
  50. 50.
    Rao SS, Ozturk R, Stessman M: Investigation of the pathophysiology of fecal seepage. Am J Gastroenterol 2004, 99:2204–2209.PubMedCrossRefGoogle Scholar
  51. 51.
    Andrews CN, Bharucha A: The etiology, assessment, and treatment of fecal incontinence. Nat Clin Pract Gastroenterol Hepatol 2005, 2:516–525.PubMedCrossRefGoogle Scholar
  52. 52.
    Norton C, Chelvanayagam S, Wilson-Barnett J, et al.: Randomized controlled trial of biofeedback for fecal incontinence. Gastroenterology 2003, 125:1320–1329. This large randomized controlled trial of behavioral approaches showed equal efficacy for Kegel exercises and biofeedback therapy. The authors concluded that patient-physician interaction may be as important as biofeedback therapy.PubMedCrossRefGoogle Scholar
  53. 53.
    Ozturk R, Niazi S, Stessman M, Rao SS: Long-term outcome and objective changes of anorectal function after biofeedback therapy for faecal incontinence. Aliment Pharmacol Ther 2004, 20:667–674.PubMedCrossRefGoogle Scholar
  54. 54.
    Byrne CM, Solomon MJ, Rex J, et al.: Telephone vs. faceto-face biofeedback for fecal incontinence: comparison for two techniques in 239 patients. Dis Colon Rectum 2005, 48:2281–2288.PubMedCrossRefGoogle Scholar
  55. 55.
    Madoff RD: Surgical treatment options for fecal incontinence. Gastroenterology 2004, 126 (Suppl 1):S48-S54.PubMedCrossRefGoogle Scholar
  56. 56.
    Zorcolo L, Covotta L, Bartolo DC: Outcome of anterior sphincter repair for obstetric injury: comparison of early and late results. Dis Colon Rectum 2005, 48:524–531.PubMedCrossRefGoogle Scholar
  57. 57.
    Thornton MJ, Kennedy ML, Lubowski DZ, King DW: Long-term follow-up of dynamic graciloplasty for faecal incontinence. Colorectal Disease 2004, 6:470–476.PubMedCrossRefGoogle Scholar
  58. 58.
    Mundy L, Merlin TL, Maddern GJ, Hiller JE: Systematic review of safety and effectiveness of an artificial bowel sphincter for faecal incontinence. Br J Surg 2004, 91:665–672.PubMedCrossRefGoogle Scholar
  59. 59.
    Norton C, Burch J, Kamm MA: Patient’s views of a colostomy for fecal incontinence. Dis Colon Rectum 2005, 48:1062–1069.PubMedCrossRefGoogle Scholar
  60. 60.
    Deutekom M, Dobben A: Plugs for containing faecal incontinence. Cochrane Database Syst Rev 2005, 3:CD005086.PubMedGoogle Scholar
  61. 61.
    Vaizey CJ, Kamm MA: Injectable bulking agents for treating faecal incontinence. Br J Surg 2005, 92:521–527.PubMedCrossRefGoogle Scholar
  62. 62.
    Norton C, Gibbs A, Kamm MA: Randomized, controlled trial of anal electrical stimulation for fecal incontinence. Dis Colon Rectum 2006, 49:190–196PubMedCrossRefGoogle Scholar
  63. 63.
    Leroi AM, Parc Y, Lehur PA et al.: Sacral nerve stimulation for fecal incontinence. Results of a multicenter double-blind crossover study. Ann Surg 2005, 242:662–669.PubMedCrossRefGoogle Scholar
  64. 64.
    Takahashi T, Garcia-Osogobio S, Valdovinos MA, et al.: Extended two-year results of radio-frequency energy delivery for the treatment of fecal incontinence (the Secca procedure). Dis Colon Rectum 2003, 46:711–775.PubMedCrossRefGoogle Scholar
  65. 65.
    Efron JE, Corman ML, Fleshman J, et al.: Safety and effectiveness of temperature-controlled radio-frequency energy delivery to the anal canal (Secca(R) procedure) for the treatment of fecal incontinence. Dis Colon Rectum 2003, 46:1606–1616.PubMedGoogle Scholar
  66. 66.
    Garcia-Olmo D, Garcia-Arranz M, Garcia LG, et al.: Autologous stem cell transplantation for treatment of rectovaginal fistula in perianal Crohn’s disease: a new cell-based therapy. Int J Colorectal Dis 2003, 18:451–454.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2006

Authors and Affiliations

  1. 1.Internal Medicine, GI DivisionThe University of Iowa Hospital & ClinicsIowa CityUSA

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