Acupoint injection combined with pelvic floor rehabilitation in the treatment of postpartum pelvic floor disorders: A protocol of randomized controlled trial

Background:Female pelvic floor dysfunction is one of the common chronic diseases affecting women''s physical and mental health. Pregnancy and delivery are one of the main causes. Pelvic floor rehabilitation is a common method for the treatment of postpartum pelvic floor dysfunction, but it has some defects. Acupoint injection has advantages in the treatment of postpartum pelvic floor dysfunction, but there is a lack of standard clinical research to verify it. Therefore, the purpose of this randomized controlled trial is to evaluate the efficacy and safety of acupoint injection combined with pelvic floor rehabilitation in the treatment of postpartum pelvic floor disorders.Methods:This is a prospective randomized controlled trial to study the efficacy and safety of acupoints injection combined with pelvic floor rehabilitation. And it is approved by the Ethics Committee of Clinical Research of our hospital. Patients were randomly divided into observation group (acupoint injection combined with pelvic floor rehabilitation group) or control group (pelvic floor rehabilitation group alone). The patients were followed up for 8 weeks after 12 weeks of treatment. The observation indexes included: pelvic organ prolapse degree, pelvic floor muscle strength, urinary incontinence score, adverse reactions, among others. Data were analyzed using the statistical software package SPSS version 18.0.Conclusions:This study will evaluate the efficacy and safety of acupoint injection combined with pelvic floor rehabilitation in the treatment of postpartum pelvic floor dysfunction, and provide reliable reference for the clinical application of this project.Trial registration:OSF Registration number: DOI 10.17605/OSF.IO/VC65Z     

Is there a role for concomitant pelvic floor repair in patients with sphincter defects in the treatment of fecal incontinence?

BACKGROUND AND AIMS: More than half of all patients who undergo overlapping anal sphincter repair for fecal incontinence develop recurrent symptoms. Many have associated pelvic floor disorders that are not surgically addressed during sphincter repair. We evaluate the outcomes of combined overlapping anal sphincteroplasty and pelvic floor repair (PFR) vs. anterior sphincteroplasty alone in patients with concomitant sphincter and pelvic floor defects. PATIENTS AND METHODS: We reviewed all patients with concomitant defects who underwent surgery between February 1998 and August 2001. Patients were assessed preoperatively by anorectal manometry, pudendal nerve terminal motor latency, and endoanal ultrasound. The degree of continence was assessed both preoperatively and postoperatively using the Cleveland Clinic Florida fecal incontinence score. Postoperative success was defined as a score of 相似文献   

Dynamic magnetic resonance imaging evaluation of the structural and functional results of postanal repair for neuropathic fecal incontinence

PURPOSE: The aim of this study was to determine whether dynamic magnetic resonance imaging of the pelvic floor can discriminate between patients who improve after postanal repair for neurogenic fecal incontinence and those who remain symptomatic. METHODS: Pelvic floor measurements obtained during dynamic magnetic resonance imaging in eight females whose anal incontinence had improved after postanal repair were compared with those from nine females who remained symptomatic. All subjects also underwent standard anorectal physiology testing. RESULTS: There was no significant difference between groups with respect to any measurement of anterior or middle pelvic floor compartments. Additionally, there was no difference in posterior pelvic floor configuration when symptomatic patients were compared with those who had improved. However, dynamic magnetic resonance measurements revealed patients who remained symptomatic had significantly greater posterior pelvic floor weakness. Anorectal physiology was unable to differentiate between groups. CONCLUSIONS: There is no difference in static pelvic floor measurements when subjects remaining symptomatic after postanal repair are compared with those who have improved. In contrast, dynamic measurements may be able to predict failure in those who demonstrate excessive posterior pelvic floor mobility.     

Geriatrische Patientinnen mit Harninkontinenz-Symptomen und ihre Kontrolle über den Beckenboden

Not only do anatomy and function of the pelvic floor play an important role as possible causes of female urinary incontinence, they are also crucial for its therapy. The aim of this case control study of female geriatric patients with symptoms of urinary incontinence was to determine the knowledge about their pelvic floor and to assess their ability to contract pelvic floor muscles voluntarily and reflexly. METHODS: A total of 377 female geriatric patients with symptoms of urinary incontinence were investigated in a Basis Assessment for Urinary incontinence. The ability to contract their pelvic floor muscles was examined by a digital vaginal palpation. The extent of the registered muscle strength was graded by the Modified Oxford Grading Scale by Laycock (1994). RESULTS: Of the patients, 65.5% were not aware of their pelvic floor and were not able to contract the pelvic floor muscles (Grade 0 to 1 by Laycock), 22% had an inaccurate knowledge and only performed an insufficient pelvic floor muscle contraction (Grade 2 by Laycock). Only 12.5% could contract their pelvic floor muscles properly (Grade 3 to 4 by Laycock). A subgroup of 83 patients had already absolved pelvic floor exercises in the past, 80 patients with conventional instructions, 3 patients with digital vaginal control. In this subgroup 54.2% of the patients were not able to contract the pelvic floor muscles (Grade 0 to 1 by Laycock) 25.3% only performed an insufficient contraction (Grade 2 by Laycock), while 20% were able to perform a sufficient and powerful contraction (Grade 3 to 4 by Laycock). The three patients in the past controlled by a digital vaginal palpation were part of this group and managed a pelvic floor muscle strength Grade 4 by Laycock. A high percentage of female geriatric patients with symptoms of urinary incontinence have a lack of understanding regarding the position and function of their pelvic floor. These results suggest that conventional pelvic floor muscle exercises without specific control are not an appropriate method to improve geriatric patients' ability to contract their pelvic floor muscles and to prevent urine leakage.     

Simultaneous dynamic proctography and peritoneography for pelvic floor disorders

PURPOSE: We sought to evaluate a new diagnostic technique for the identification of rectal and pelvic floor pathology in patients with obstructed defecation, pelvic fullness/ prolapse, and/or chronic intermittent pelvic floor pain. METHODS: Thirteen symptomatic women with either a nondiagnostic physical examination or nondiagnostic dynamic proctography (DPG) were studied. After placement of intraperitoneal and intrarectal contrast material, resting and straining pelvic x-rays were obtained in all patients, and defecation was videotaped using fluoroscopy. RESULTS: Simultaneous DPG and peritoneography identified clinically suspected and unsuspected enteroceles in 10 of the 13 patients studied. An enterocele or other pelvic floor hernia was ruled out by the technique in three of the women studied. Rectoceles and rectal prolapse that were identified during physical examination were confirmed by DPG with peritoneography. Simultaneous DPG and peritoneography also gave a qualitative assessment of the severity and clinical significance of the identified pelvic floor disorders. Results of simultaneous DPG and peritoneography affected operative treatment planning in 85 percent of patients studied. CONCLUSION: Simultaneous DPG and peritoneography identifies both rectal and pelvic floor pathology and provides a qualitative assessment of pelvic floor pathology severity, which allows for better treatment planning in selected patients with obstructed defecation and pelvic prolapse.Video presentation at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

High-impact aerobics programme supplemented by pelvic floor muscle training does not impair the function of pelvic floor muscles in active nulliparous women: A randomized control trial

Background:We aimed to test the hypothesis that high-impact aerobics programme, combined with pelvic floor muscle training does not impair pelvic floor muscle function in young active women.Methods:A randomized control trial was conducted among active nulliparous, sport university students (age 23 ± 3 years, mean ± SD). Experimental group (n = 13) attended high-impact aerobics programme, supplemented by pelvic floor muscle training with one biofeedback session, for 6 weeks. The control group (n = 19) did not get any intervention. Before and after the experiment, we assessed pelvic floor muscle function in both groups with surface electromyography using vaginal probes. In both groups, we assessed the participants’ quality of life related to pelvic floor functions with the Incontinence Impact Questionnaires.Results:We recorded no impairments in neuromuscular activity of pelvic floor muscles and in quality of life in women regularly performing high-impact aerobics. What is even more positive, after 6 weeks, experimental group presented better skills both in contracting and relaxing their pelvic floor muscles, although the pre-post intervention EMG change was not statistically significant. All participants maintained good quality of life related to pelvic floor functions.Conclusions:High-impact aerobics, supplemented by pelvic floor muscle training can be recommended for active nulliparas.     

盆底失弛缓综合征患者盆底表面肌电的改变及临床意义

目的:探讨盆底失弛缓患者盆底表面肌电的特征.方法:盆底失弛缓综合征患者73例,其中男31例,女42例,年龄18-40岁,平均28.04岁±5.83岁;正常志愿者80例,其中男31例,女49例,年龄21-40岁,平均27.20岁±4.28岁.采用Glazer盆底表面肌电评估方案采集2组表面肌电值,分析比较静息状态的肌电波幅、变异系数和不同收缩状态下的肌电波幅、变异系数、收缩反应时间及中值频率.结果:与正常人群相比,盆底失弛缓患者前基线阶段静息波幅明显升高(4.93±3.01vs3.80±1.97,P<0.05);快速收缩阶段最大收缩波幅低(59.15±28.14vs69.95±31.05,P<0.05);持续收缩阶段变异系数升高(0.38±0.13vs0.31±0.11,P<0.05);耐久收缩阶段变异系数也明显升高(0.35±0.14vs0.28±0.10,P<0.05);不同性别盆底失弛缓患者各指标间无差异.同时,持续及耐久收缩阶段的变异系数与患者年龄呈正相关(P<0.05).结论:初步获得了盆底失弛缓患者盆底表面肌电值的特征,有利于指导临床诊断和治疗.     

Clinical Measurement of Pelvic Floor Movement: Evaluation of a New Device

PURPOSE: A new device that measures pelvic floor movement clinically was evaluated.METHODS: The device consists of a rectal balloon with a magnet at its exterior end. The magnet moves in an electromagnetic field synchronous with the pelvic floor movements. This movement is measured and displayed on a computer screen in front of the seated patient. Twenty-eight healthy volunteers (15 females) were examined. On a separate day, 17 of them were tested a second time by the same investigator and a third time by a different investigator.RESULTS: One volunteer developed a vasovagal reaction. The median (range) pelvic floor lift and descent was 2 (range, 0.6–4.5) cm and 1.8 (range, 0.5–5.6) cm respectively. Day-to-day and interobserver reproducibility was good. Coughing and blowing a party balloon caused pelvic floor descent in the majority of participants. Twenty of 28 volunteers were able to expel the rectal balloon.CONCLUSIONS: The device measures cranial and caudal movements of the pelvic floor with minimal discomfort and good reproducibility. The device may have a large potential as biofeedback device in pelvic floor training.Reprints are not available.     

Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation

BACKGROUND & AIMS: Biofeedback is reported to be as effective for slow transit constipation as for pelvic floor dyssynergia and no more effective than education. We aimed to test the hypothesis that biofeedback benefits only patients with pelvic floor dyssynergia, describe the physiologic mechanism of treatment, and identify predictors of success. METHODS: Fifty-two patients (49 women; average age, 35 years), all with delayed whole gut transit, included 34 with pelvic floor dyssynergia, 12 with slow transit only, and 6 who met only 1 of 2 criteria for pelvic floor dyssynergia. All received 5 weekly biofeedback sessions directed at increasing rectal pressure and relaxing pelvic floor muscles during straining plus practice defecating a balloon. Patients were retested by questionnaire; symptom diary; balloon defecation; transit study at 1, 6, 12, and 24 months; and anorectal manometry at 1 and 6 months. RESULTS: At 6 months, greater improvements were seen in pelvic floor dyssynergia compared with slow transit only; 71% versus 8% reported satisfaction ( P = .001), and 76% versus 8% reported >/=3 bowel movements per week ( P < .001). Improvements were maintained at 24 months of follow-up. Biofeedback eliminated dyssynergia in 91% and enabled 85% to defecate the balloon. Satisfaction was correlated with improved ability to defecate the balloon (rho = .73; P < .001), reductions in dyssynergia (rho = .69; P < .001), and increased rectal pressure during straining (rho = .36; P < .01). Success was predicted by pelvic floor dyssynergia, milder constipation, and less frequent abdominal pain at baseline. CONCLUSIONS: Biofeedback is an effective treatment for pelvic floor dyssynergia but not slow transit constipation.     

Botulinum toxin type-A injection to treat patients with intractable anismus unresponsive to simple biofeedback training

AIM: To evaluate the efficacy of botulinum toxin type A injection to the puborectalis and external sphincter muscle in the treatment of patients with anismus unresponsive to simple biofeedback training.METHODS: This retrospective study included 31 patients suffering from anismus who were unresponsive to simple biofeedback training. Diagnosis was made by anorectal manometry, balloon expulsion test, surface electromyography of the pelvic floor muscle, and defecography. Patients were given botulinum toxin type A (BTX-A) injection and pelvic floor biofeedback training. Follow-up was conducted before the paper was written. Improvement was evaluated using the chronic constipation scoring system.RESULTS: BTX-A injection combined with pelvic floor biofeedback training achieved success in 24 patients, with 23 maintaining persistent satisfaction during a mean period of 8.4 mo.CONCLUSION: BTX-A injection combined with pelvic floor biofeedback training seems to be successful for intractable anismus.     

Long-term results of surgery for chronic constipation

BACKGROUND: Developments in anorectal physiologic testing have facilitated better understanding of the process of defecation and factors that might cause chronic constipation. AIM: Patients with severe idiopathic chronic constipation were evaluated using colonic transit and pelvic floor function in an attempt to identify those patients suitable for aggressive surgical intervention. MATERIALS AND RESULTS: Among 1,009 patients studied using either a marker or scintigraphic transit technique and tests of pelvic floor function, 52 with slow-transit constipation (STC) were identified and underwent abdominal colectomy and ileorectostomy (IRA). Twenty-two patients had pelvic floor dysfunction and STC; these patients underwent initial pelvic floor retraining followed by IRA. A total of 249 patients had pelvic floor dysfunction without evidence of slow-transit and were offered pelvic floor retraining alone. The remaining 597 patients had no quantifiable abnormality of colon or pelvic floor dysfunction; these patients had normal transit constipation/irritable bowel syndrome and were treated medically. There were, thus, 74 patients operated on, 68 women, with a mean age of 53 years and a mean follow-up of 56 months. There was no operative mortality, seven patients (9 percent) had small-bowel obstruction, and nine patients (12 percent) had prolonged ileus. All patients were able to pass a stool spontaneously, 97 percent of patients were satisfied with the results of surgery, and 90 percent have a good or improved quality of life. There was no difference in the outcome of surgery in patients with STC alone compared with STC and pelvic floor dysfunction. CONCLUSION: Physiologic evaluation reliably identified patients with severe chronic constipation who might benefit from surgery. IRA is safe and effective, resulting in prompt and prolonged relief of constipation.     

Magnetic resonance imaging of anatomic and dynamic defects of the pelvic floor in defecatory disorders

OBJECTIVE: Endoanal ultrasound identifies anal sphincter anatomy, and evacuation proctography visualizes pelvic floor motion during simulated defecation. These complementary techniques can evaluate obstructed defecation and fecal incontinence. Our aim was to develop a single, nonionizing, minimally invasive modality to image global pelvic floor anatomy and motion. METHODS: We studied six patients with fecal incontinence and seven patients with obstructed defecation. The anal sphincters were imaged with an endoanal magnetic resonance imaging (MRI) coil and endoanal ultrasound (five patients). MR fluoroscopy acquired images every 1.4-2 s, using a modified real-time, T2-weighted, single-shot, fast-spin echo sequence, recording motion as patients squeezed pelvic floor muscles and expelled ultrasound gel; no contrast was added to other pelvic organs. Six patients also had scintigraphic defecography. RESULTS: Endoanal ultrasound and MRI were comparable for imaging defects of the internal and external sphincters. Only MRI revealed puborectalis and/or external sphincter atrophy; four of these patients had fecal incontinence. MR fluoroscopy recorded pelvic floor contraction during squeeze and recorded relaxation during simulated defecation. Corresponding comparisons for angle change and perineal descent during defecation were not significant; only MRI, but not scintigraphy, identified excessive perineal descent in two patients. CONCLUSIONS: Pelvic MRI is a promising single, comprehensive, nonradioactive modality to measure structural and functional pelvic floor disturbances in defecatory disorders. This method may provide insights into mechanisms of normal and disordered pelvic floor function in health and disease.     

Pelvic Floor Imaging

The purpose of this paper is to describe the current modalities of pelvic floor imaging: pelvic floor and endoanal ultrasonography, cystourethrography, evacuation proctography, dynamic colpocystoproctography, magnetic resonance imaging and endoanal magnetic resonance imaging.As there are no set standards for prescribing imaging tests in pelvic floor disorders, we drew up a table of tests to be performed according to the anatomical abnormality observed on physical examination or functional sign reported by the patient.     

Long-Term Study on the Effects of Visual Biofeedback and Muscle Training as a Therapeutic Modality in Pelvic Floor Dyssynergia and Slow-Transit Constipation

PURPOSE: Biofeedback training has been shown as an effective therapeutic measure in patients with pelvic floor dyssynergia, at least in the short term. Long-term effects have received less attention. Moreover, its effects in patients with slow-transit constipation have been scarcely investigated. This study was designed to assess in an objective way the medium- and long-term effects of biofeedback and muscle training in patients with pelvic floor dyssynergia and slow-transit constipation. METHODS: Twenty-four patients (14 with pelvic floor dyssynergia and 10 with slow transit) meeting the Rome II criteria for constipation, and unresponsive to conventional treatments, entered the study. Clinical evaluation and anorectal manometry were performed basally and three months after a cycle of electromyographic biofeedback and muscle training; moreover, a clinical interview was obtained one year after biofeedback. Patients with slow-transit constipation also had colonic transit time reassessed at one year. RESULTS: Clinical variables (abdominal pain, straining, number of evacuations/week, use of laxatives) all significantly improved in both groups at three-month assessment; anorectal manometric variables remained unchanged, apart from a significant decrease of sensation threshold in the pelvic floor dyssynergia group and of the maximum rectal tolerable volume in the slow-transit constipation group. At one-year control, 50 percent of patients with pelvic floor dyssynergia still maintained a beneficial effect from biofeedback, whereas only 20 percent of those complaining of slow-transit constipation did so. Moreover, the latter displayed no improvement in colonic transit time. CONCLUSIONS: In our experience, patients with pelvic floor dyssynergia are likely to have continued benefit from biofeedback training in the time course, whereas its effects on slow-transit constipation seems to be maximal in the short-term course.     

Role of body position,gender, and age on pelvic floor location and mobility

The location and mobility of pelvic floor in different body positions and their relation to age and gender was assessed in 117 patients (19 men, 98 women, age range 10–77 years) with chronic nonorganic constipation (defined as less than three bowel movements per week for at least three years) by means of defecography. Eleven females (age range 16–69 years), without gastrointestinal symptoms, affected by noninvasive carcinoma of the cervix represented a control group. Pelvic floor location was measured as the distance in centimeters of the anorectal junction from the pubococcygeal line; pelvic floor mobility was measured during squeezing, straining, and defecation assuming the pelvic location at rest as zero reference. Pelvic floor location and mobility did not differ between controls and constipated patients. In both groups pelvic floor location at rest was significantly higher (P=0.001) with patients lying down than sitting up, whereas pelvic floor mobility during squeezing was greater with the patients sitting up than lying down (P=0.003). In both positions, pelvic floor location at rest was significantly lower (P=0.01) in females than in males. Pelvic floor mobility during squeezing was significantly different between gender. Parity and hysterectomy did not appear to affect pelvic floor location. Data emerging from this study indicate that body position is one of the major determinants of the pelvic floor location.Part of this work was presented at the annual meeting of the American Gastroenterological Association in Washington DC, May 13–19, 1989, and has been published in abstract from (Gastroenterology 96:192, 1989).     

Are pelvic floor movements abnormal in disordered defecation?

Pelvic floor movements were assessed by videoproctography in 126 subjects: neuropathic fecal incontinence patients (n=44), chronic constipation patients (n =52), and controls (n=30). A significantly lower pelvic floor position at rest and a more obtuse anorectal angle were found in incontinent patients than in controls (P <0.01). constipated patients showed no significant difference from controls at rest. There was less pelvic floor movement during contraction in incontinent patients than in controls, indicating a flaccid, noncontractile pelvic floor in neuropathic incontinence. Movement during contraction in constipated subjects was also less than in controls. Changes in the pelvic floor position during straining were the same as in controls. These data indicate that the pelvic floor is flaccid and noncontractile in neuropathic fecal incontinence, which supports the concept of a progressive neuropathy involving the sacral outflow. Similar changes are not seen at rest in patients with constipation even though they have a long history of straining.     

Clinical value of symptom assessment in patients with constipation

PURPOSE: This study was designed to evaluate symptoms and clinical findings in a prospective series of patients with chronic constipation. METHODS: A total of 155 consecutive patients with intractable constipation underwent detailed symptom registration, anorectal manometry, electromyography, colonic transit time measurement, and defecography. RESULTS: All investigations were completed by 134 patients (112 females) with a median age of 52 (range, 17–79) years. Whole-gut transit time was delayed in 55 patients (41 percent), pelvic floor dysfunction was diagnosed in 59 patients (44 percent), but in 35 percent of patients both transit time and pelvic floor function were found to be normal. Three symptoms were shown to have an independent value for the diagnosis of slow-transit constipation. Patients with slow transit more often reported two or fewer stools per week (84vs. 46 percent), laxative dependence (87vs. 44 percent), and a history of constipation since childhood (58vs. 22 percent) than did those with normal transit. Pelvic floor dysfunction was associated with a higher prevalence of backache (53vs. 33 percent) and a lower prevalence of normal stool frequency (19vs. 36 percent), heartburn (12vs. 27 percent), and a history of anorectal surgery (7vs. 21 percent) compared with those with normal pelvic floor function. All four symptoms retained an independent value in the logistic regression analysis for pelvic floor dysfunction. Two symptoms characterized the group with normal transit and normal pelvic floor function: normal stool frequency and alternating diarrhea and constipation. CONCLUSIONS: Symptoms are good predictors of transit time but poorer predictors of pelvic floor function in patients with constipation.     

Anatomy and nerve supply of the pelvic floor

In order to guarantee urinary and fecal continence as well as correct pelvic statics, the perfect neuroanatomical integrity of the pelvic floor muscles is mandatory. As Dickinson stated: "There is no considerable muscle in the body whose form and function are more difficult to understand than those of the levator ani, and about which such nebulous impressions prevail". Clinical implications of pelvic floor anatomy and nerve supply are evident: a denervation of this muscle group and the consequent muscle dysfunction could result in urinary and/or fecal incontinence, as well as pelvic organ prolapse.     

Reconstruction of the Pelvic Floor Using the Rectus Abdominis Muscles After Radical Pelvic Surgery

PURPOSE: To support the small intestine out of the pelvic cavity, many methods have been described to reconstruct the pelvic floor after radical pelvic surgery. I describe a new technique using the rectus abdominis muscles for pelvic floor reconstruction. METHODS: The posterior rectus sheath and peritoneum are opened. The rectus muscles are exposed at both sides and they are divided between paired clamps at the level of the umbilicus. Then, the rectus muscles are carefully retracted downward, and the edges are sutured posteriorly to the promontorium and laterally around the linea terminalis. RESULTS: This method was used in 11 patients who underwent radical pelvic surgery. Seven of 11 patients had radiation therapy started 4 weeks postoperatively. The patients were followed up for two years. No patient showed any complication such as adhesive obstruction of the bowel or radiation enteritis, even in the patients who underwent radiotherapy. CONCLUSIONS: Reconstruction of the pelvic floor using the rectus abdominis muscles after radical pelvic surgery is an easy and safe technique that avoids complications and serves as a barrier to radiation injury. Therefore, we believe that this method is a promising proposal requiring further investigation in a larger number of patients.     

Should patients with combined colonic inertia and nonrelaxing pelvic floor undergo subtotal colectomy?

PURPOSE: Treatment of severe constipation caused by combined colonic inertia and nonrelaxing pelvic floor is controversial. This study is designed to evaluate the outcome of preoperative biofeedback and subtotal colectomy for patients with combined colonic inertia and nonrelaxing pelvic floor. METHODS: One hundred six patients who underwent subtotal colectomy for intractable constipation from 1982 through 1995 answered a detailed questionnaire regarding postoperative bowel function, symptoms of abdominal pain and bloating, and degree of satisfaction after the operation. Sixteen of these patients had a combination of colonic inertia and nonrelaxing pelvic floor diagnosed by transit marker study, electromyography, and defecography. These patients completed preoperative biofeedback training. RESULTS: Electromyographic relaxation of pelvic floor musculature was demonstrated after the biofeedback treatment in all patients, but symptoms of difficult evacuation persisted. Postoperatively, seven patients (43 percent) had complete resolution of symptoms of constipation or difficult evacuation. Six patients still complained of incomplete evacuation that was severe in two and unresponsive to postoperative biofeedback. Three patients (18 percent) complained of diarrhea (>5 bowel movements per day) and incontinence of liquid stools (at least one episode a week). Nine patients (56 percent) were satisfied despite persistent symptoms. CONCLUSIONS: Subtotal colectomy can improve some symptoms in patients with slow transit constipation and nonrelaxing pelvic floor. However, incomplete evacuation persists in a significant number of patients and almost one-half of patients are dissatisfied with their surgery.