T1356 Anorectal Function Evaluation in Patients With Fecal Incontinence Compared to Patients Without...

AG

AA

bst

ract

sT1353

Fecal Incontinence in Males: Anal Sphincter Pressure is Not the AnswerKenny A. Moreau, Daniel C. Sadowski

Introduction: The factors leading to fecal incontinence (FI) in males are less well studiedthan in females. Our objective was to compare physiologic measurements of anorectalfunction in males to females with similar levels of fecal incontinence severity. Methods: 51consecutive males presenting to our laboratory with FI were evaluated. For each male patient,two age-matched female patients with FI were randomly selected from our motility databaseas controls. Anorectal testing was carried out using an eight-channel water-perfusion cathetersystem (Mui Scientific). Rectal capacity and sensation was assessed using balloon distensionwith air. The severity of fecal incontinence was assessed using the Vaizey Incontinence Score.Results: Between male and female groups, there were no significant differences in mean age(61 years) or symptom duration (2.8 years). 81% of female patients had a history of perianaltrauma (males 47% P<0.001). There was no difference between males and females in balloonvolume at first rectal sensation (females= 38.76 ml, males= 39.71 ml). Males had a higherballoon volume at the sensation of defecation desire (females= 135.01, males= 155.43,P<0.05). For all levels of FI severity, 44% of females had a normal internal sphincter pressurecompared to 67% of males and 16% of females had a normal external sphincter pressurecompared to 83% of males (P<0.01). Table 1 compares anal sphincter pressures betweenmales and females at similar degrees of FI severity. Conclusions: At comparable levels of FIseverity, males have higher internal and external anal sphincter pressures. Effective treatmentof FI in males will require therapy that addresses other mechanisms of incontinence besideslow anal sphincter tone.Table 1.

T1354

Pelvic Muscle Rehabilitation for Fecal Incontinence: Quantitative Assessmentof Physiologic OutcomesMadhu Ragupathi, Chirag B. Patel, Dhruvil P. Gandhi, Diego I. Ramos-Valadez, Eric M.Haas

Background: Pelvic muscle rehabilitation (PMR) is a modern modification of traditionalbiofeedback involving cognitive retraining of the pelvic floor muscles. Patients are counseledto optimize strength, endurance and reproducibility of pelvic muscle contractions underthe guidance of a trained therapist with continuous anal manometry and electromyographynot visible to the patient. The purpose of this study was to assess quantitative outcomesfollowing PMR for patients with fecal incontinence (FI). Methods: Between June 2006 andNovember 2009, patients who underwent PMR for FI were identified. All patients underwenta minimum of 4 sessions, each consisting of: 1) muscle strength and endurance, 2) isolationand control of accessory muscles and 3) electrical muscle stimulation. At each session,alternating squeeze and rest trials of 10 seconds each were analyzed to determine quantitativeoutcomes. The squeeze trial with the maximum area under the curve (AUC) was identifiedfor comparative analysis of overall muscle strength and endurance (see figure). Results: Atotal of 100 patients (14 males and 86 females) were analyzed. The mean Cleveland ClinicIncontinence Score (CCIS) was 13.5±4.2 (range: 5-21). The median number of completedPMR sessions was 6 (range: 4-11). The maximum AUC during the 1st, 4th and final PMRsessions was 84.1±79.9 sec×mm Hg, 101.3±85.5 sec×mm Hg and 114.3±104.3 sec×mmHg, respectively (p<0.02 between 1st and 4th sessions; p<0.01 between 1st and final sessions).This represents a 20.5% increase in sphincter muscle strength and endurance at 4 sessionsand a 35.9% increase at the final session. Conclusion: PMR is an effective treatment modalityfor the management of fecal incontinence. In this series, patients demonstrated a significantincrease in quantitative measures of pelvic muscle strength and endurance. Additional studiesaddressing correlations between biometrics and established qualitative outcomes are ongoing.

S-544AGA Abstracts

T1355

High Prevalence of Obstructive Defecation in Inflammatory Bowel DiseasePatients in RemissionLilani P. Perera, Ashwin N. Ananthakrishnan, Yelena Zadvornova, Mazen Issa, Amar S.Naik, Susan Skaros, Kathryn Johnson, Kathryn Tyler, Antia Ward, Benson T. Massey

Introduction:Introduction of biologic agents in Inflammatory Bowel Disease (IBD; Crohn'sdisease (CD), Ulcerative colitis (UC)) has increased the likelihood of disease remission.Despite resolution of active inflammation a subset of IBD patients (pts) report persistentcolonic symptoms. We retrospectively determined the prevalence of functional defecatorydisturbance in this pt group on anorectal manometry (AM) Methods: This was a singleacademic IBD center study evaluating all pts who had AM for persistent defecatory symptoms,except for pts with known perirectal disease or ileoanal pouch. Demographic and clinicalinformation (type of IBD, location, disease behavior and treatment history) were recorded.Endoscopic disease activity most proximate to the data of manometry study was also notedto analyze the impact of active disease on anorectal dysfunction. Manometry included balloonexpulsion testing and motor response to stimulated defecation. Results: There were 26 pts:23 F, mean age 31 (25-67). 16 CD pts (2 small bowel (SB), 7 SB and large bowel (LB), 4LB and 3 pan enteric disease) and 10 UC pts (4 left sided disease, 5 pan colon and 1proctosigmoiditis). In CD pts 9 had SB stricturing disease and all others had inflammatorydisease. 19 pts (73%) had used immunomodulators while 12 pts (46%) had current /pastuse of biologics. 82% had no visible or pathologic inflammation at colonoscopy when thereminder showing mild or moderate activity. Principle symptoms leading to AM wereconstipation (12/26, 46%), alternating diarrhea and constipation (5/26, 19%), diarrhea (4/26, 15%), urgency/ incontinence (4/26, 15%) and rectal discomfort (3/26, 12%).All patientswith constipation exhibited anismus/paradoxical contraction of anal sphincter or/and failedballoon expulsion. 17/23(74%) received biofeedback therapy with 59% response rate. Con-clusions: IBD pts with persistent defecatory symptoms despite disease remission have highrate of defecatory disturbances. High index of suspicion, appropriate investigation withmanometry and referral for biofeedback therapy is warranted in this group, since they arelikely to respond to non pharmacological interventions.

T1356

Anorectal Function Evaluation in Patients With Fecal Incontinence Comparedto Patients Without Fecal Incontinence: Determination of Predictive Factorsfor Fecal IncontinenceTze Jui Lam, Dirk J. Kuik, Chris J.J. Mulder, Richelle J. Felt-Bersma

Aim: 1. To investigate the diagnostic potential of anorectal function tests in patients withfecal incontinence (FI) compared to patients without FI. 2. To evaluate the predictabilityof age and anorectal function tests on FI. Patients and methods: Between 2003 and 2009,all third referral patients were assessed by an extensive questionnaire regarding their perianalcomplaints and evaluated according to our anorectal function protocol including anorectalmanometry (ARM) and anal endosonography (EUS). ARM includes maximal basal pressure(MBP), maximal squeeze pressure (MSP), sphincter length (SL), relaxation during straining,rectoanal inhibition reflex, rectal sensitivity (volume first sensation, urge to defecate andmaximal tolerable volume (MTV)). EUS detects internal anal (ISD) and external anal (ESD)sphincter defects. Results: In total, 532 patients were prospectively evaluated for differentreasons. Of them, 258 patients (48%) had complaints of FI. The other patients were evaluateddue to constipation (21%), third degree obstetric injury (11%), anal soiling (4%), perinaland abdominal pain (6%), prolapse (3%), prior to surgery (2%), and others. Males andfemales were analyzed separately. In both groups, incontinent and continent patients showedan enormous overlap in tests results. Females with FI were significant older (57 years vs45 years; P<0.001) than without FI. In females, MBP (40 mmHg vs 54 mmHg; P<0.001)and MSP (30 mmHg vs 41 mmHg; P<0.001) were significantly lower, SL shorter (3.1 cmvs 3.3; P=0.045) and MTV lower (183 ml vs 217 ml; P<0.001). Furthermore, female patientswith FI had more watery stool (P< 0.001). In males, MSP was significantly lower in patientswith FI (45 mmHg vs 67 mmHg; P=0.03). More sphincter defects were detected in femalepatients with FI (53% vs 45%) which was mainly due to combined ISD and ESD (17% vs8%; P=0.01). Five predictors were identified by logistic regression analysis included patient'sage, consistence of stool, MBP, MSP, MTV and combined ISD/ESD. A formula was constructedfor predicting FI in female patients and a ROC-curve was calculated. The area under thecurve was 0.83 (P < 0.001, 95% CI: 0.79 to 0.87). When probability was >0.4, FI waspredicted with sensitivity of 87%, specificity of 64%, positive predictive value of 74%, andnegative predictive value (NPV) of 81%. Conclusion: Incontinent and continent patientsshowed an overlap in ARM and EUS. Female patients with FI have a lower MBP and MSP,a shorter SL, a lower MTV and more often watery stool. Male patients with FI have a lowerMSP. Our predictor model showed a relatively high sensitivity and NPV for predicting FIin patients.

T1357

Investigation of Anal Motor Characteristics of the Sensori-Motor Response(SMR)Gregory Cheeney, Jose M. Remes Troche, Ashok Attaluri, Satish S. Rao

Introduction: Desire to defecate is associated with a unique anal contractile response, oftenoverlying RAIR, the sensori-motor response (SMR) (Figure 1 Left) (Dis Colon Rectum 2007).However, the precise muscles involved are not known. Aim: To examine the role of External