From the Guidelines
Abnormal anal manometry is an indication for biofeedback therapy (BT) in patients with dyssynergic defecation, as it has been shown to effectively treat 70% to 80% of patients with this condition 1.
Treatment Options
The treatment approach depends on the specific abnormality found, such as high or low resting pressure, impaired sensation, or paradoxical contraction.
- For high resting pressure (as in anal fissures), topical nitroglycerin 0.2% ointment applied to the anal canal twice daily for 6-8 weeks can help relax the sphincter.
- For low resting pressure causing fecal incontinence, pelvic floor physical therapy with biofeedback training twice weekly for 8-12 weeks is recommended, along with fiber supplementation (psyllium 1 tablespoon daily) 1.
- For dyssynergic defecation with paradoxical contraction, biofeedback therapy is the primary treatment, combined with proper toileting techniques (knees above hips, avoiding straining) 1.
Diagnostic Approach
Anorectal manometry (ARM) is a diagnostic tool for identifying pathophysiological mechanisms, helping explain symptoms of fecal incontinence (FI), constipation, irritable bowel syndrome (IBS), rectal prolapse, and anorectal pain 1.
- ARM provides objective, evidence-based assessments that help identify patient subgroups likely to experience symptom and quality-of-life improvements after BT 1.
- The clinical utility of BT is not universally understood, and guidance is lacking on what constitutes the phenotypical patient who would benefit from BT 1.
Patient Selection
Patients with dyssynergic defecation and lower or more normal baseline thresholds for first rectal sensation and urge were more likely to respond to BT, while depression and elevated first rectal sensory threshold volume were independent predictors of poor BT efficacy 1.
- Identifying patients with FI who may respond better to BT has been challenging 1.
- Lower baseline constipation scores, shorter colonic transit times, and lower intolerable urgency thresholds can predict treatment outcomes in patients with dyssynergic defecation regardless of IBS 1.
From the Research
Anal Manometry Abnormalities
Anal manometry is a diagnostic tool used to assess anorectal function and identify abnormalities in patients with evacuation disorders, such as fecal incontinence and constipation. The following are some key points related to anal manometry abnormalities:
- Anal manometry can help diagnose pelvic floor dysfunction, which is a significant contributor to evacuation disorders 2.
- Abnormalities in anal manometry can include low resting pressure, low squeeze pressure, and impaired rectal sensation, which are commonly seen in patients with fecal incontinence 3.
- The prevalence of pelvic floor changes in patients with evacuation disorders is high, and anal manometry can guide conservative treatment, such as anorectal biofeedback and pelvic floor physical therapy 2.
Types of Anal Manometry Abnormalities
There are different types of anal manometry abnormalities, including:
- Internal anal sphincter dysfunction, which is the most common finding in patients with fecal incontinence 3.
- External anal sphincter dysfunction, which can also contribute to fecal incontinence 3.
- Outflow tract obstruction, which is commonly seen in patients with constipation 2.
Clinical Utility of Anal Manometry
Anal manometry has several clinical applications, including:
- Diagnosing defecatory disorders, such as fecal incontinence and constipation 4, 5.
- Guiding management in patients with fecal incontinence and constipation 2, 6.
- Screening for anorectal structural abnormalities, such as rectal intussusception 5.
Treatment of Anal Manometry Abnormalities
Treatment of anal manometry abnormalities depends on the underlying condition and can include: