Thorough assessment of obstructed defaecation syndrome (ODS) is imperative for the selection of treatment options. The present study aimed to examine the utility of the Mansoura Numeroalphabetic Constipation Score (MNCS) in distinguishing patients with ODS from healthy control subjects and in predicting the outcome of treatment of ODS.

Patients with ODS associated with anterior rectocele and/or rectoanal intussusception were assessed with the MNCS at the first visit to the clinic. All patients were offered conservative treatment for 3 months and patients who improved were continued on conservative treatment for six more months while patients who failed were treated surgically. The MNCS was reassessed at the end of follow-up in both groups. A cohort of healthy controls was compared to ODS patients with regard to age, sex and baseline MNCS.

In all, 124 ODS patients and 53 healthy controls were included. The ODS patients had a significantly higher baseline MNCS than controls (9.5 ± 1.5 vs 0.76 ± 0.71, P < 0.0001). Forty of 124 patients improved after conservative management and showed a significant decrease in MNCS (6.9 ± 1.08 to 3.1 ± 1.2, P < 0.0001). Eighty-four (67.8%) patients failed to respond to conservative measures and were surgically treated, 77 (91.6%) of whom showed significant improvement in symptoms postoperatively while seven (8.4%) failed to improve; the difference in postoperative MNCS between the two groups was significant.

The MNCS successfully distinguished ODS patients from controls and was able to predict the outcome of ODS treatment.

The primary aims of this study were to evaluate the content quality of YouTube videos on exercises to help relieve constipation and to assess whether the video source, exercise types, and popularity affected their quality.

Eight gastroenterologists independently evaluated the exercises presented in the constipation YouTube videos for seven items: image quality, usefulness in relieving constipation (quality 1), usefulness for general physical health (quality 2), difficulty in following, activity intensity, fun, and overall quality. Raters were asked open-ended questions to evaluate the strengths and weaknesses of the videos. Five-point ordinal scales were used to score each item aforementioned, with the exception of image quality and overall quality that used a six-point Likert scale.

The 20 videos had a mean length of 268 seconds and a mean viewership of 32,694. The most common video source was commercial (n=10), and the most common type of physical activity was yoga (n=11). The median values of image quality, quality 1, quality 2, difficulty in following, activity intensity, fun, and overall quality were 3, 2, 2, 2, 2, 2, and 2, respectively. Yoga videos had significantly higher median quality 1 values (3) compared with massage videos (2, adjusted p=0.006) and 'others' videos (2, adjusted p<0.001). A lack of medical evidence was the most common answer to open-ended questions about the weaknesses of each video.

Overall, YouTube exercise videos presented a low-quality content. This study highlights the need for evidence-based comprehensive educational videos addressing exercises for treating constipation.

Obstructed defecation syndrome (ODS) is a functional disorder commonly encountered by colorectal surgeons and gastroenterologists, and greatly affects the quality of life of patients from both societal and psychological aspects. The underlying anatomical and pathophysiological changes of ODS are complex. However, intra-rectal intussusception and rectocele are frequently found in patients with ODS and both are thought to play an important role in the pathogenesis of ODS. With the development of evaluation methods in anorectal physiology laboratories and radiology studies, a great variety of new operative procedures, especially transanal procedures, have been invented to treat ODS. However, no procedure has been proved to be superior to others at present. Each operation has its own merits and defects. Thus, choosing appropriate transanal surgical procedures for the treatment of ODS remains a challenge for all surgeons. This review provides an introduction of the current problems and options for treatment of ODS and a detailed summary of the essential assessments needed for patient evaluation before carrying out transanal surgery. Besides, an overview of the benefits and problems of current transanal surgical procedures for treatment of ODS is summarized in this review. A report of clinical experience of some transanal surgical techniques used in the authors' center is also presented.

The aim of this study is to examine the feasibility, efficacy, and safety of a group-based yoga therapy intervention for middle-aged and older women with urinary incontinence.

We conducted a pilot randomized trial of ambulatory women aged 40 years and older with stress, urgency, or mixed-type incontinence. Women were randomized to a 6-week yoga therapy program (n = 10) consisting of twice weekly group classes and once weekly home practice or a wait-list control group (n = 9). All participants also received written pamphlets about standard behavioral self-management strategies for incontinence. Changes in incontinence were assessed with 7-day voiding diaries.

The mean (SD) age was 61.4 (8.2) years, and the mean baseline frequency of incontinence was 2.5 (1.3) episodes/d. After 6 weeks, the total incontinence frequency decreased by 70% (1.8 [0.9] fewer episodes/d) in the yoga therapy versus 13% (0.3 [1.7] fewer episodes/d) in the control group (P = 0.049). Participants in the yoga therapy group also reported an average of 71% decrease in stress incontinence frequency (0.7 [0.8] fewer episodes/d) compared with a 25% increase in controls (0.2 [1.1] more episodes/d) (P = 0.039). No significant differences in reduction in urgency incontinence were detected between the yoga therapy versus control groups (1.0 [1.0] versus 0.5 [0.5] fewer episodes/d; P = 0.20). All women starting the yoga therapy program completed at least 90% of the group classes and practice sessions. Two participants in each group reported adverse events unrelated to the intervention.

Findings provide preliminary evidence to support the feasibility, efficacy, and safety of a group-based yoga therapy intervention to improve urinary incontinence in women.

Anismus or non-relaxing puborectalis muscle (PRM), detectable with anal/vaginal ultrasound (US), is a cause of obstructed defecation (OD) and may be treated with biofeedback (BFB). Many patients with anismus are anxious and/or depressed. The aim of this prospective study was to evaluate the outcome of the novel procedure psycho-echo-BFB in patients with anismus and psychological disorders.

Patients presenting at our unit with anismus and psychological disorders between January 2009 and December 2013, and not responding to conventional conservative treatment, were enrolled in the study. All underwent four sessions of psycho-echo-BFB, carried out by two psychologists and a coloproctologist, consisting of guided imagery, relaxation techniques and anal/vaginal US-assisted BFB. A validated score for OD was used, and PRM relaxation on straining measured before and after the treatment. PRM relaxation was also measured in a control group of 7 patients with normal bowel habits.

Ten patients (8 females, median age 47 years, range 26-72 years) underwent psycho-echo-BFB. The OD score, evaluated prior to and at a median of 25 months (range 1-52 months) after the treatment, improved in 7 out of 10 patients, from 13.5 ± 1.2 to 9.6 ± 2.2 (mean ± standard error of the mean (SEM)), p = 0.06. At the end of the last session, PRM relaxed on straining in all cases, from 0 to 7.1 ± 1.1 mm, i.e., physiological values, not statistically different from those of controls (6.6 ± 1.5 mm). Two patients reported were cured, 3 improved and 5, all of whom had undergone prior anorectal surgery, unchanged. No side effects were reported.

Psycho-echo-BFB is safe and inexpensive and allows all patients with anismus to relax PRM on straining. Previous anorectal surgery may be a negative predictor.

Anismus or non-relaxing puborectalis muscle (PRM), detectable with anal/vaginal ultrasound (US), is a cause of obstructed defecation (OD) and may be treated with biofeedback (BFB). Many patients with anismus are anxious and/or depressed. The aim of this prospective study was to evaluate the outcome of the novel procedure psycho-echo-BFB in patients with anismus and psychological disorders.

Patients presenting at our unit with anismus and psychological disorders between January 2009 and December 2013, and not responding to conventional conservative treatment, were enrolled in the study. All underwent four sessions of psycho-echo-BFB, carried out by two psychologists and a coloproctologist, consisting of guided imagery, relaxation techniques and anal/vaginal US-assisted BFB. A validated score for OD was used, and PRM relaxation on straining measured before and after the treatment. PRM relaxation was also measured in a control group of 7 patients with normal bowel habits.

Ten patients (8 females, median age 47 years, range 26-72 years) underwent psycho-echo-BFB. The OD score, evaluated prior to and at a median of 25 months (range 1-52 months) after the treatment, improved in 7 out of 10 patients, from 13.5 ± 1.2 to 9.6 ± 2.2 (mean ± standard error of the mean (SEM)), p = 0.06. At the end of the last session, PRM relaxed on straining in all cases, from 0 to 7.1 ± 1.1 mm, i.e., physiological values, not statistically different from those of controls (6.6 ± 1.5 mm). Two patients reported were cured, 3 improved and 5, all of whom had undergone prior anorectal surgery, unchanged. No side effects were reported.

Psycho-echo-BFB is safe and inexpensive and allows all patients with anismus to relax PRM on straining. Previous anorectal surgery may be a negative predictor.

Biofeedback for outlet obstruction constipation has a varying success rate. The aim of this study was to identify which patients are likely to respond to biofeedback.

Thirty patients with severe outlet obstruction constipation were treated by a specialist nurse using three or four sessions of visual and auditory feedback of anal sphincter pressures. All patients were assessed by evacuating proctography, whole-gut transit studies and anorectal physiology before treatment.

Two patients did not complete the course of biofeedback. Nine patients improved. Before treatment these patients had predominantly normal anorectal physiology and were all able to open the anorectal angle at evacuating proctography. Nineteen patients did not improve, of whom only three had no measured abnormality other than inability to empty the rectum. Ten of these patients had abnormal anorectal physiology which may have been due to previous vaginal delivery.

Biofeedback for outlet obstruction constipation is more likely to be successful in patients without evidence of severe pelvic floor damage.

Paradoxical sphincter reaction is frequently found in constipated patients but sometimes also in incontinent patients and in asymptomatic subjects. Its significance in defecation disorders has, therefore, been debated. The aim of the present study was to investigate whether paradoxical sphincter reaction is influenced by rectal filling volume.

Eighteen patients with defecation disorders and paradoxical sphincter reaction shown by electromyography were reinvestigated with an extended electromyographic investigation while in the lying position and while in the sitting position, with 50-ml, 100-ml, and 150-ml water-filled rectal balloons.

All 18 patients showing paradoxical sphincter reaction in the first investigation also showed the reaction at the second investigation in the lying position with a 0-ml volume of rectal contents. In the sitting position, with a volume of 150 ml of rectal contents, the increase in electromyographic activity disappeared in seven patients (39 percent) and no longer showed paradoxical sphincter reaction. Electromyography showed decreased activity in one patient and unchanged activity in six patients during straining. A closing reflex was seen after completed straining in all of these seven patients.

The present study demonstrates that paradoxical sphincter reaction diagnosed by electromyography is influenced by the rectal filling volume and might diminish when the rectum is filled with contents. The conventional electrophysiologic technique in the diagnosis of paradoxical sphincter reaction might, therefore, overdiagnose this condition.

Gynecologists have traditionally evaluated rectocele repair by its effect on vaginal function; coloproctologists have traditionally evaluated its effect on bowel function. Hence different operative criteria and surgical techniques have arisen, but with very little prospective, objective evaluation. The purpose of this review is to describe the surgical techniques used to repair the rectocele and the most common investigations used during its evaluation. Anorectal investigations identify concomitant pathology, may explain pathophysiology, provide objective outcome criteria and attempt to predict the patients that will most benefit from surgery. However, because of the complex neuromuscular, physiological and mechanical interactions that contribute to impaired rectal emptying, their usefulness in improving functional outcome has been limited. Many patients experience improvement, but still are left with some symptoms of impaired defecation despite anatomic correction.

A study was undertaken to determine outcome and to identify predictors of success for biofeedback for constipation.

Patients who had at least one biofeedback session were evaluated whether or not they completed a treatment course. Parameters assessed included use of cathartics, number of spontaneous bowel movements per week, presence of rectal pain, number of biofeedback sessions and results of anorectal physiology.

A total of 194 patients (59 male, 135 female) of median age 71 (range 11-96) years, including 30 with concomitant rectal pain, were treated. The median number of spontaneous bowel movements per week before treatment was 0. Some 35 per cent of patients had complete success (three or more spontaneous bowel movements per week with discontinuation of cathartics), 13 per cent had partial success (fewer than three spontaneous bowel movements per week with continued use of cathartics) and 51 per cent had no improvement. Neither patient age, sex nor duration of symptoms significantly affected outcome. Only 18 per cent of patients who had between two and four sessions had complete success, compared with 44 per cent of those who had five or more (P < 0.001). A total of 63 per cent of patients who completed the treatment protocol experienced complete success, compared with 25 per cent of those who self-discharged (P < 0.0001).

This large study indicates that the success rate of biofeedback for patients with constipation is less than previously reported. However, the success rate improves significantly after five or more sessions and is significantly related to the patient's willingness to complete treatment.

Training to contract the abdominal muscles effectively and to relax the pelvic floor during defecation straining helps some patients with severe constipation. Hitherto all such training has used a visible or audible signal of sphincter muscle activity as a biofeedback method to assist in relaxation. A randomised controlled trial comparing the outcome of muscular training without any biofeedback device with the same training supplemented by an electromyographic (EMG) record visible to the patient is reported. Significant symptomatic improvement was noted and electromyographic measurements confirmed a decrease in pelvic floor muscle activity during defecation straining after treatment in both groups. The outcome was similar in the two treatment groups. Muscular coordination training using personal instruction and encouragement without a visual display is thus a potentially successful treatment suitable for outpatient use by paramedical personnel.

For 20 years now, biofeedback applications in the treatment of fecal incontinence and, more recently, chronic constipation in adults have proven that improvement of anorectal function can be achieved in a majority of patients. Despite this evidence, the definitive mode of action of biofeedback training remains obscure but may include improvement of both motor and sensory functions of the anorectum. In addition, behavioral modification of individual defecatory behavior in these patients may be effective as well. The long-term results of such treatment need to be tested in future research.

A prospective study was undertaken to assess the correlation between electromyography (EMG) and cinedefecography (CD) for the diagnosis of nonrelaxing puborectalis syndrome (NRPR). Clinical criteria for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. EMG criteria included failure to achieve a significant decrease in electrical activity of the puborectalis (PR) during attempted evacuation. CD criteria included either paradoxical contraction or failure of relaxation of the PR along with incomplete evacuation. In addition, other etiologies for incomplete evacuation, such as rectoanal intussusception or nonemptying rectocele, were excluded by proctoscopy and defecography in all cases. One hundred twelve patients with constipation, 81 females and 31 males, with a mean age of 59 (range, 12-83) years were studied by routine office evaluation, CD, and EMG. Forty-two patients (37 percent) had evidence of NRPR on CD (rectal emptying: none, 24; incomplete, 18). Twenty-eight of these patients (67 percent) also had evidence of NRPR on EMG. EMG findings of NRPR were present in 12 of 70 patients (17 percent) with normal rectal emptying. Conversely, 14 of 72 patients (19 percent) with normal PR relaxation on EMG had an NRPR pattern on CD. The sensitivity and specificity for the EMG diagnosis of NRPR were 67 percent and 83 percent, and the positive and negative predictive values were 70 percent and 80 percent, respectively. Conversely, if EMG is considered as the ideal test for the diagnosis of NRPR, CD had a sensitivity of 70 percent, a specificity of 80 percent, and positive and negative predictive values of 66 percent and 82 percent, respectively. In summary, sensitivity, specificity, and predictive values of EMG and CD are suboptimal. Therefore, a combination of these two tests is suggested for the diagnosis of NRPR.

Of 71 patients with paradoxical sphincter reaction, 54 had symptoms of constipation or outlet obstruction and 17 were incontinent. The patients were investigated with defecography, colon transit time, anorectal manometry and electromyography. Ninety-six percent of the patients had additional changes in anorectal anatomy and physiology; 70% of the patients had abnormal defecography and 42% had delayed colon transit time. Decreased maximal anal pressure (MAP) and maximal squeeze pressure (MSP), indicating impaired function of the anal sphincters might be one reason for incontinence in patients with paradoxical sphincter reaction. The paradoxical reaction occurred in the puborectalis muscle and in three tested sites in the external sphincter. It is sufficient to record the EMG activity in one muscle and at one point to diagnose a paradoxical sphincter reaction. The absence of a normal closing reflex on electromyography is evidence for a paradoxical sphincter reaction. Denervation was more pronounced in the external sphincter than in the puborectalis muscle. The right pudendal nerve was subjected to damage more often than the left nerve.

Rectocele as well as paradoxical sphincter reaction may lead to rectal emptying difficulties and outlet obstruction. Forty-one patients with emptying disturbances and rectocele were investigated with defecography, anorectal manometry, colon transit time, and electromyography. Twenty-nine patients (71 percent) had concomitant paradoxical sphincter reaction, and 13 of these also had increased colon transit time. The functional results after surgical treatment of rectocele are not always satisfactory, probably because patients often have several causes for their emptying disturbances. It is emphasized that careful preoperative investigations are important before surgical treatment of rectocele in patients with emptying difficulties.