Idiopathic chronic constipation: pathophysiology, diagnosis and treatment

Constipation is one of the most common disease in Western countries. Its prevalence is widely variable (5-30%), depending on criteria utilized for diagnosis. Usually constipated patients have mild-moderate symptoms and are self-treated. Only patients that do not benefit from simple therapy (dietary supplementation of fiber and water, laxatives) need examinations such as blood tests, colonoscopy, radiography with bario-enemas, intestinal transit time and manometry. These tests are able to differentiate idiopathic from secondary constipation. Idiopathic chronic constipation is a collective term that involves different functional disorders. More specific investigations (oro-cecal transit time, manometry, electromyography) allow one to distinguish between two different patterns of idiopathic chronic constipation (slow transit constipation and pelvic floor disease) and to utilize the appropriate treatment of disease. The aims of this paper are to review the recent world literature on chronic constipation and to propose a diagnostic and a therapeutic flow chart for this disorder.     

Defecation disorders: Neuromuscular aspects and treatment

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.     

生物反馈联合普芦卡必利治疗老年功能性便秘的疗效观察

［摘要］　目的　观察生物反馈（BF）联合普芦卡必利治疗老年功能性便秘（FC）的效果。方法　选择2020年7月至2021年12月苏州科技城医院收治的老年FC患者84例,采用随机数字表法分为观察组和对照组,每组42例。观察组采用BF疗法联合普芦卡必利进行治疗,对照组采用普芦卡必利进行治疗,连续治疗6周。比较两组的临床疗效、便秘评分、每周自发性完全排便（SCBM）次数、复发率和不良反应发生情况。结果　与治疗前比较,观察组和对照组治疗后的便秘评分降低,每周SCBM次数增加,差异有统计学意义（P<0.05）,且观察组较对照组改善更显著（P<0.05）。观察组总有效率高于对照组,差异有统计学意义（83.33% vs 61.90%, χ²=4.850,P=0.028）。随访3个月,观察组复发5例（11.90%）,对照组12例（28.57%）,两组复发率比较差异有统计学意义（χ²=30.612,P<0.001）。两组不良反应发生率比较差异无统计学意义（7.14% vs 9.52%, χ²=0.000,P=1.000）。结论　BF联合普芦卡必利能够有效治疗老年FC,复发率低,且安全性良好。     

Prospective study of biofeedback retraining in patients with chronic idiopathic functional constipation

AIM: To determine the efficacy and long-term outcome of biofeedback treatment for chronic idiopathic constipation and to compare the efficacy of two modes of biofeedback(EMG-based and manometry-based biofeedback).METHODS: Fifty consecutive contactable patients included 8 cases of slow transit constipation, 36 cases of anorectic outlet obstruction and 6 cases of mixed constipation. Two modes of biofeedback were used for these 50 patients, 30 of whom had EMG-based biofeedback, and 20 had manometry-based biofeedback. Before treatment, a consultation and physical examination were done for all the patients, related information such as bowel function and gut transit time was documented, psychological test (symptom checklist 90, SCL90)and anorectic physiological test and defecography were applied. After biofeedback management, all the patients were followed up. The Student‘s t-test, chi-squared test and Logistic regression were used for statistical analysis.RESULTS: The period of following up ranged from 12 to 24 months (Median 18 months). 70 % of patients felt that biofeedback was helpful, and 62.5 % of patients with constipation were improved. Clinical manifestations induding straining, abdominal pain, bloating, were relieved, and less oral laxative was used. Spontaneous bowel frequency and psychological state were improved significantly after treatment. Patients with slow and normal transit, and those with and without paradoxical contraction of the anal sphincter on straining, benefited equally from the treatment. Thepsychological status rather than anorectal test could pre dictoutcome. The efficacy of the two modes of biofeedback was similar without side effects.CONCLUSION: This study suggests that biofeedback has a long-term effect with no side effects, for the majority of patients with chronic idiopathic constipation unresponsive to traditional treatment. Pelvic floor abnormalities and transit time should not be the selection criteria for treatment.     

Male sexual function and its disorders: physiology, pathophysiology, clinical investigation, and treatment

This review is designed to help the reproductive endocrinologist integrate his or her professional activity with those of other disciplines including urology, radiology, neurology, and psychology in order to successfully manage all of the inseparable aspects of male sexual and reproductive functioning. Significant advances in the field of male sexual physiology and pathophysiology and new methods of investigation and treatment of male sexual disorders are outlined. The review synthesizes available data on the following: norms of sexual organs, aging and sexuality, role of central and peripheral neurochemicals in each stage of the sexual cycle, role of corporeal smooth muscles in the hemodynamic control of erection and detumescence, influence of psychological factors, drugs, and disease on all aspects of sexual functioning, and use of nocturnal penile tumescence monitoring, imaging investigations, and neurophysiologic studies in the diagnostic workup of males with sexual dysfunction. Clinical algorithms are presented where appropriate. Extensive discussions on newly developed strategies in psychological and behavioral counseling, drug therapy, tissue engineering, nonsurgical devices, and surgical treatments for all forms of sexual disorders are also provided. Lastly, the effect of sexual dysfunction and its treatment on quality of life in affected men is addressed, along with recommendations for future research endeavors.     

Management and pathophysiology of functional gastrointestinal disorders

Since 2005, every annual meeting of the Japanese Gastroenterological Association has included a core symposium for functional gastrointestinal disorders. At the 6th annual meeting, the core symposium was 'Pathophysiology and New Treatment'. At the 7th annual meeting, the core symposium was 'Pathophysiology and Motility'. This review summarizes the papers presented at these meetings. At the 6th meeting, we recognized that Japanese researchers successfully produced and developed many agents that are safe and effective for the treatment of functional gastrointestinal disorders, such as 5-hydroxytryptamine receptor-associated compounds, lubiprostone, Japanese herbal medicine, and other drugs. Data were validated from a clinical as well as an experimental viewpoint. Findings included the effects of sumatriptan and nizatidine, acylated or des-acylated ghrelin, T-cell-activating anti-CD3 antibody, and transient receptor potential vanilloid-1. At the 7th meeting, not only functional dyspepsia and irritable bowel syndrome (IBS), but also non-erosive esophageal reflux disease (NERD) and chronic intestinal pseudo-obstruction were actively discussed from a motility viewpoint, including papers about sham feeding and gastric motility, genetic polymorphism and motility, the role of transient receptor potential A1 on gastric accommodation, esophageal motility and NERD, diagnosis and treatment of chronic intestinal pseudo-obstruction, immunological basis of motility in IBS, developing non-invasive colonic function test, and fecal distribution in IBS patients.     

Childhood constipation: evaluation and treatment

Constipation is common in children. It is estimated that between 5% and 10% of pediatric patients have constipation and/or encopresis. Constipation is the second most referred condition in pediatric gastroenterology practices, accounting for up to 25% of all visits. In this article, a practical approach is laid out for those not familiar with constipation in children. Emphasis is placed on the evaluation and management options that are available to the treating practitioner. The diagnosis of constipation requires careful history taking and interpretation. Diagnostic tests are not often needed and are reserved for those who are severely affected. The daily bowel habits of children are extremely susceptible to any changes in routine environment. Constipation and subsequent fecal retention behavior often begins soon after a child has experienced a painful evacuation. Childhood constipation can be very difficult to treat. It often requires prolonged support by physicians and parents, explanation, medical treatment, and, most important, the child's cooperation.     

Sleep disorders with aging: evaluation and treatment.

Sleep disorders are especially common among elderly patients and may be the result of psychiatric illness, a medical problem, poor sleep habits, or a primary sleep disorder. Because a sleep complaint (especially insomnia) is only a symptom, the physician must undertake a careful evaluation in an attempt to identify a specific treatable cause. Although some patients may require referral to a psychiatrist or sleep disorders clinic, many patients may benefit from behavioral strategies, such as improved sleep hygiene. In general, hypnotics should be prescribed for only a limited period of time and should be combined with other therapeutic approaches in patients with chronic insomnia.     

功能性便秘的诊断与治疗

功能性便秘根据结肠动力学特点和肛门直肠功能可分为三类：慢传输型便秘、出口梗阻型便秘和混合型便秘。功能性便秘的诊断目前采用罗马Ⅲ诊断标准,须注意排除器质性病变所致。对于功能性便秘,目前尚无确切有效的治疗药物和方案。在治疗上采取个体化综合性的治疗措施,包括生活习惯、饮食结构调整及合理选择药物等,生物反馈治疗是功能性出口梗阻型便秘患者的首选治疗,而外科手术可能对部分严重慢传输型便秘患者有良好效果。     

生物反馈联合莫沙必利治疗慢传输型便秘的疗效观察

目的观察生物反馈联合莫沙必利治疗慢传输型便秘(STC)的临床效果。方法 108例STC患者采取随机分组方式分为3组,其中治疗A组38例给予生物反馈+莫沙必利治疗,对照B组33例给予莫沙必利+虚拟生物反馈治疗,对照C组37例给予生物反馈+安慰剂治疗。3组均治疗4周后观察疗效。结果三种不同的治疗方案均可改善慢传输型便秘患者的临床症状,提高结肠排出率,治疗A组治愈11例、显效10例、有效13例、无效4例,对照B组依次为4例、7例、4例、18例,对照C组依次为5例、7例、8例、17例。治疗A组疗效高于对照B组和对照C组(χ2=12.914,P=0.002)。治疗A组治疗后结肠排出个数明显升高,与对照组比较差异有统计学意义(P0.05)。结论生物反馈联合莫沙必利治疗慢传输型便秘的疗效优于莫沙必利或生物反馈的单一治疗,并且能有效促进结肠排空,值得临床推广及进一步研究参考。     

生物反馈训练对功能性便秘患者临床症状、心理状况和生活质量的影响

目的 探讨生物反馈训练对功能性便秘(FC)患者临床症状、心理状况和生活质量的影响.方法 对49例符合FC罗马Ⅲ标准的患者进行生物反馈训练,应用临床症状积分量表、Zung焦虑自评量表(SAS)、抑郁自评量表(SDS)、汉化版简明健康调查量表(SF-36)评定患者治疗前后的临床症状、心理状况和生活质量的综合改善情况.结果 生物反馈训练后,FC患者临床症状显著改善,临床症状积分量表中排便间隔天数、费力程度、排便不尽和坠胀感、粪便性状、腹胀评分及总积分均有显著降低(临床症状改善).SF-36量表的8个维度(总体健康、生理功能、生理职能、躯体疼痛、活力、社会功能、情感职能和精神健康)的评分均显著提高(生活质量改善).患者治疗后与治疗前相比,SAS量表评分(41.0±8.1比46.5±11.9)和SDS量表评分(44.0±8.2比51.2±11.5)亦显著降低(焦虑、抑郁状况改善).结论 生物反馈训练不仅能有效改善FC患者的临床症状,还可提高患者的生活质量和心理健康水平.     

生物反馈训练对功能性便秘患者临床症状、心理状况和生活质量的影响

Objective To explore the effects of biofeedback training on clinical symptom,psychological state and quality of life in patients with functional constipation (FC).Methods Forty-nine patients with FC diagnosed by Rome Ⅲ were enrolled and received biofeedback training Bowel symptom measure, Zung's self-rating anxiety scale (SAS), self-rating depression scale (SDS) and Chinese version of the MOS 36-item short form healthy survey (SF-36) were recorded to assess the effects before and aftertreatment.Results After biofeedback training, clinical symptom of patients with FC was greatly improved:there was a very significant decrease in total and subscales scores of bowel symptom including spontaneous frequency of bowel movements, straining effort, sensation of anorectal obstruction/blockage, stool consistence and bloating.Patients with FC also improved their quality of life as well as psychological status after biofeedback.All subcategories of SF-36 including general health, physical function, bodily pain, role physical, vitality, social function, role emotion and mental health showed marked increase.Compared to the scores before biofeedback training, SAS (41.0 ±8.1 vs 46.5 ± 11.9) and SDS (44.0 ±8.2 vs 51.2 ±11.5) scores decreased significantly after biofeedback training Conclusion Biofeedback training can improve clinical symptom, psychological status and quality of life in patients with FC.     

Defecation disorders. Characteristics of manometric studies and rehabilitation

The authors review the literature and their personal experience about the systematic exploration of defecation disorders by anorectal manometry and colpocystodefecography. They stress the importance of combining functional and morphological evaluation, in order to avoid inappropriate surgery. Concerning anorectal manometry, the determination of the smallest volume of rectal distention inducing a complete relaxation of the internal anal sphincter was found more useful than the maximal tolerable volume in the exploration of defecation disorders. Finally, the authors report the results of biofeedback conditioning prescribed in 30 patients (27 women, 3 men, mean age: 55 years) with defecation disorders (terminal constipation in 21, fecal incontinence in 9 patients). Several characteristics of anorectal manometry and of defecography were significantly improved after biofeedback conditioning.     

生物反馈训练对功能性便秘患者临床症状、心理状况和生活质量的影响

Objective To explore the effects of biofeedback training on clinical symptom,psychological state and quality of life in patients with functional constipation (FC).Methods Forty-nine patients with FC diagnosed by Rome Ⅲ were enrolled and received biofeedback training Bowel symptom measure, Zung's self-rating anxiety scale (SAS), self-rating depression scale (SDS) and Chinese version of the MOS 36-item short form healthy survey (SF-36) were recorded to assess the effects before and aftertreatment.Results After biofeedback training, clinical symptom of patients with FC was greatly improved:there was a very significant decrease in total and subscales scores of bowel symptom including spontaneous frequency of bowel movements, straining effort, sensation of anorectal obstruction/blockage, stool consistence and bloating.Patients with FC also improved their quality of life as well as psychological status after biofeedback.All subcategories of SF-36 including general health, physical function, bodily pain, role physical, vitality, social function, role emotion and mental health showed marked increase.Compared to the scores before biofeedback training, SAS (41.0 ±8.1 vs 46.5 ± 11.9) and SDS (44.0 ±8.2 vs 51.2 ±11.5) scores decreased significantly after biofeedback training Conclusion Biofeedback training can improve clinical symptom, psychological status and quality of life in patients with FC.     

微生态制剂在功能性便秘中的临床应用

[目的]综合评价微生态制剂治疗成人功能性便秘（FC）中的临床效果。[方法]82例FC患者随机分为2组,对照组40例,治疗组42例。所有病例均嘱其改善不良生活习惯;对照组给予乳果糖溶液联合莫沙比利口服;治疗组在对照组治疗基础上加服双岐四联活菌片。观察治疗2周及治疗结束后3个月的临床疗效。[结果]治疗2周后,治疗组的总有效率明显高于对照组（P〈0．01）;停止治疗3个月时,治疗组的总有效率、显效率均高于对照组（P〈0．01）。[结论]微生态制剂在FC的治疗中有良好的协同、增效作用,有利于疗效的巩固和维持。     

Colectomy for slow-transit constipation: Preoperative functional evaluation is important but not a guarantee for a successful outcome

PURPOSE: This study was designed to assess the results of preoperative functional evaluation of patients with severe slow-transit constipation in relation to functional outcome. METHODS: Four hundred thirty-nine patients with chronic intractable constipation were evaluated by marker studies. Twenty-one patients underwent colectomy and ileorectal anastomosis for slow-transit constipation. Mean colorectal transit time was 156 hours (normal, <45 hours). Small-bowel transit time was normal in ten patients and delayed in five patients. Six were nonresponders. Morbidity was 33 percent. Small-bowel obstruction occurred in six patients; relaparotomy was done in four patients. Follow-up varied from 14 to 153 (mean, 62) months. RESULTS: After three months, defecation frequency was increased in all. Mean stool frequency improved from one bowel movement per 5.9 days to 2.8 times per day. Sixteen patients felt improved after surgery. Seventeen continued to experience abdominal pain, and 13 still used laxatives and enemas. Satisfaction rate was 76 percent (16 patients). After one year, defection frequency was back at the preoperative level in five patients. An ileostomy was created in two more patients because of incontinence and persistent diarrhea. Eleven patients (52 percent) still felt improved. A relation between small-bowel function and functional results could not be demonstrated. CONCLUSIONS: Preoperative evaluation is important but not a guarantee for successful outcome. Colectomy remains an ultimate option for patients with disabling slow-transit constipation, but patients should be informed that, despite an increased defecation frequency, abdominal symptoms might persist. Any promiscuous use of colectomy to treat constipation should be discouraged.