Characterization of obstructive defecation from a structural and a functional perspective

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Left: Patient with dyssynergia Type I and rectocele with incomplete rectal emptying and intrarectal prolapse. Right. Patient with a megarectum and a large rectocele, with increased rectal compliance and impaired RAIR, enterocele and external rectal prolapse." ] ] ] "textoCompleto" => "IntroductionChronic constipation is a prevalent anorectal disorder which affects 14% of the general population,<a class="elsevierStyleCrossRef" href="#bib0185">1</a> is more common in women and in older people,<a class="elsevierStyleCrossRef" href="#bib0190">2</a> and has a major impact on quality of life and health economics.<a class="elsevierStyleCrossRef" href="#bib0195">3</a> In western countries, it is common and closely associated with low fibre intake.<a class="elsevierStyleCrossRef" href="#bib0200">4</a> The pathophysiology of constipation can be related to irritable bowel syndrome, opioid medication or a dysfunction in colon motility, but also to an inability to expel stools,<a class="elsevierStyleCrossRef" href="#bib0205">5</a> which constitutes the basis of functional defecatory disorders (FDD). FDD are included in what is known as evacuation disorders, with clinical symptoms of obstructive defecation (OD). We often find, in our daily practice, that gastroenterologists and colorectal surgeons have different perspectives (functional vs structural, respectively) on managing these conditions.Evacuation disorders have two major mechanisms: (a) FDD, characterized by dyssynergic defecation (with paradoxical contraction or inadequate relaxation of the external anal sphincter (EAS) and/or inadequate propulsive forces, which make up the four patterns of dyssynergia<a class="elsevierStyleCrossRef" href="#bib0210">6</a>) or (b) structural defecation disorders (SDD), defined by dynamic alterations in the rectal wall or the posterior component of the pelvic floor, such as rectocele, rectal prolapse and enterocele, which can interfere with defecation. Patients with severe symptoms of OD that do not respond to fibre or laxative treatments should undergo specific tests in order to determine whether the impairment in defecatory dynamics is induced by functional and/or structural factors.<a class="elsevierStyleCrossRefs" href="#bib0215">7,8</a>Evacuation disorders can be examined using different techniques such as anorectal manometry (ARM), evacuation defaecography (ED), dynamic pelvic magnetic resonance imaging (MRI) and pelvic floor ultrasonography. The first two are the most common as they are readily available and excel in evaluating functional aspects and dynamics of the posterior compartment.<a class="elsevierStyleCrossRefs" href="#bib0225">9,10</a>ARM is the most common, available and accepted method used to diagnose evacuation disorders from a functional perspective.<a class="elsevierStyleCrossRef" href="#bib0235">11</a> ARM has the capacity to assess sphincteric function, recto-anal reflexes, rectal sensitivity, and defecatory manoeuvres in an attempted defecation. The latter has special importance in the diagnosis of FDD.<a class="elsevierStyleCrossRef" href="#bib0235">11</a> In the last decade, there has been a transition to high-resolution ARM which provides better spatial resolution, although advances at the diagnostic level are yet to be demonstrated.On the other hand, ED is a useful method for assessing evacuation disorders when SDD are suspected.<a class="elsevierStyleCrossRefs" href="#bib0240">12,13</a> The fact that it is based on dynamic images and is carried out under similar conditions to physiological evacuation implies a great potential to explore dynamic structural factors only visible during defecation.<a class="elsevierStyleCrossRef" href="#bib0250">14</a> Furthermore, it can indirectly assess functional aspects like anorectal angle (ARA), corresponding to puborectalis function change, perineum descent (PD), corresponding to the pubococcygeal, iliococcygeus and puborectalis function, and evacuation capacity. The Rome consensus requires either impaired rectal evacuation by imaging (ED or MRI) or the balloon expulsion test to confirm FDD indicated in an ARM study.<a class="elsevierStyleCrossRef" href="#bib0205">5</a> The main limitation of ED is the known overlapping between what is normal and what is abnormal.<a class="elsevierStyleCrossRef" href="#bib0255">15</a>Neither ARM nor ED alone can provide a complete assessment of the complex mechanism of defecation but together they offer the best of both worlds: the evaluation of the biomechanics by means of anorectal pressure dynamics and dynamic imaging of the posterior compartment during voiding.<a class="elsevierStyleCrossRef" href="#bib0260">16</a>The aim of this study is to review our experience in the study of patients with OD and describe our findings on FDD and SDD using ED and ARM, as well as clinical manifestations of OD, differences between genders, and factors associated with impaired expulsive capacity.Patients and methodsThis was a retrospective study of 588 adult patients referred to our GI physiology unit with complaints of OD and with Rome III criteria of constipation, and who underwent ED between 2012 and 2020. Anorectal manometry was additionally performed on 294 of these patients (230 conventional, 64 high-resolution), and a complete description of symptoms was collected. All patients underwent a digital rectal examination to clinically evaluate possible structural defects in the anal canal or at the end of the rectal ampulla and for an initial assessment of the anorectal function (at rest, at squeeze and when pushing). Patients with concomitant faecal incontinence (42) or a poor quality ED (21) were excluded. Sociodemographic data, reasons for referral, diagnosis and duration of the condition were collected. The study was approved by the hospital ethics committee with the code 82/20.SymptomsPatients’ clinical manifestations were collected according to Rome III criteria and included straining, sense of incomplete evacuation, anal blockage, hard stools, need for digitization and fewer than three bowel movements per week.DefecographyPatients self-administered a 250mL rectal enema (Casen Enema, Recordati, Italy) at home, and were orally administered 200mL of barium sulphate solution 1h before the procedure (Barigraph, Ern Labs, Barcelona), to opacify the small intestine.At X-ray facilities, in order to opacify the rectum, patients were administered a liquid barium sulphate dilution (Barigraph, Ern Labs, Barcelona) into the anal canal with a soft rectal catheter until desire to defecate was elicited (approximately 400mL). Patients were then seated on a radiotransparent commode, and were informed of all the steps of the procedure and to attempt to defecate when they were asked to in the same way they in their toilet at home.Defecographic measurements and interpretationFunctionalED provided two main measures of pelvic function during attempted defecation: aperture of ARA (from the relaxation of the puborectalis muscle) and PD (from the relaxation of the pubococcygeal and other pelvic floor muscles).Defecographic measurements were taken at rest and during straining, and are as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-ARA, defined as the angle between the axis line of the anal canal and a tangential line along the posterior line of the rectal wall<a class="elsevierStyleCrossRef" href="#bib0265">17</a>;</li><li class="elsevierStyleListItem" id="lsti0010">-PD, vertical distance in cm of anorectal junction between rest and squeeze status<a class="elsevierStyleCrossRef" href="#bib0265">17</a>;</li><li class="elsevierStyleListItem" id="lsti0015">-Expulsive capacity (normal or incomplete) of the rectum.</li></ul>See <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 1</a>.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>StructuralAbnormalities studied were identified as: rectocele, rectal prolapse (intrarectal, intra-anal, external), enterocele and megarectum according to accepted definitions.<a class="elsevierStyleCrossRefs" href="#bib0265">17–20</a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">-Rectal capacity: Normal/megarectum (>6.5cm).</li><li class="elsevierStyleListItem" id="lsti0025">-Rectocele: Anterior or posterior bulge of the rectal wall beyond the expected line of the rectum during straining (<2cm: small (not significant); 2–4cm: medium; >4cm: large).</li><li class="elsevierStyleListItem" id="lsti0030">-Prolapse:</li><li class="elsevierStyleListItem" id="lsti0035">•Intrarectal: Infolding of the rectal mucosa without reaching the anal canal.</li><li class="elsevierStyleListItem" id="lsti0040">•Intra-anal: Infolding of the rectal mucosa entering the anal canal.</li><li class="elsevierStyleListItem" id="lsti0045">•External: Infolding of the rectal mucosa exceeding the anal canal and exteriorizing.</li><li class="elsevierStyleListItem" id="lsti0050">-Enterocele: Small bowel occupying Douglas pouch at maximum evacuatory effort.</li></ul>Anorectal manometry. Technique and measurementsStudies performed prior to 2018 employed conventional ARM, consisting of a water-perfused system (Medtronic, USA) with two catheters to evaluate anorectal function. Technique and normal values have already been published.<a class="elsevierStyleCrossRef" href="#bib0285">21</a> Patients from 2018 onwards were studied with high-resolution ARM in a water-perfused 12-channel MMS system (MMS-Laborie, The Netherlands), following the IAPWG protocol<a class="elsevierStyleCrossRef" href="#bib0225">9</a> and reference values from our laboratory.<a class="elsevierStyleCrossRef" href="#bib0270">18</a>Data collected were mean resting pressure (MRP) categorized as normal (40–100mmHg), hypotense (<40mmHg), and hypertense (>100mmHg); rectal perception, categorized as normal, hyposensitivity, and hypersensitivity; recto-anal inhibitory reflex (RAIR) defined as normal when elicited by less than 100mL volume of rectal distention; and defecatory manoeuvre, which could be normal or abnormal, according to the Rao classification (Type I: paradoxical contraction of EAS; Type II: paradoxical contraction of EAS and insufficient intrarectal pressure; Type III: absence of relaxation of the anal canal; and Type IV: absence of relaxation of the anal canal and insufficient intrarectal pressure).<a class="elsevierStyleCrossRef" href="#bib0210">6</a>Categorization of patients into SDD, FDD or bothAccording to the data collected with ED and ARM, the patients were categorized into SDD, FDD or both disorders.Data analysisCategorical data were expressed as frequencies and percentages and continuous data as means and standard deviations. The χ2 was used to compare categorical variables, Student-t test to compare continuous ones; the U-Mann–Whitney test was used for non-normal distribution of data. Univariate and multivariate regression analyses were performed to identify factors associated with OD. A value of p<0.05 was considered to be statistically significant for all the performed tests. Statistical analyses were conducted using SPSS v15 software (IBM Corp, Armonk, NY, USA).With the data provided by ED, patients with some structural disorder but no signs of functional abnormality were categorized into the SDD group; those with a functional disorder but no signs of structural abnormality, into the FDD group; and when both kinds of disorder coexisted, into the mixed group.ResultsThe mean age of the 588 patients studied was 58.6±12.2 years, and most of them were women (90.1%).SymptomsSymptoms according to Rome criteria were collected in 294 patients who underwent ED and ARM. Prevalence of symptoms was: excessive straining, 86.8%; sensation of incomplete evacuation, 84.8%; anal blockage, 58.3%; fewer than 3 defecations/week, 43%; hard stools, 38.9%, and need for digitization, 35.8%. No differences between genders were found.Regarding duration of symptoms, 18.7% reported a history of less than 5 years with OD, 22.4% 5–9 years, 11.9% 10–14 years, 2.2% 15–20 years, and 44.8% reported lifelong OD symptoms.Rectal evacuation capacity was assessed in all 588 patients and was found impaired or incomplete in 71% of them.Structural findings (SDD) during defecographyRectal prolapse was the most common SDD observed in our patients (45.3%), followed by rectocele (43.7%), enterocele (19.1%) and megarectum (8.5%). Most prolapses were intrarectal (92.3%), 4.6% were intra-anal and only 3.1% exteriorized or complete.Regarding gender differences, the percentage of SDD was higher in women compared to men for rectocele (53.7% vs 14.6%; p<0.001), prolapse (48.9% vs 12.3%; p<0.001) and enterocele (20.2% vs 8.9%; p=0.041); in contrast, megarectum was more prevalent in men (7.7% vs 15.8%; p=0.038).Overlapping of structural disordersOverlap between SDD was observed mainly in the combination of rectocele and rectal prolapse, with a prevalence of 22.1%, surpassing the prevalence of any isolated SDD. Other significant combinations of SDD were those that aggregated rectocele and rectal prolapse with enterocele (5.3%) and rectocele with enterocele (4.5%). The remaining combinations were not significant (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 2 and 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Functional findings from the evacuation defecographyResults showed 51% of patients had insufficient ARA opening during straining, suggesting poor puborectalis relaxation or even contraction, and 31.6%, poor or absent PD. More than half of men (61.4%) showed inadequate ARA opening compared to 49.9% of women, although the difference was not significant (p=0.099). Regarding PD, the percentage of low PD was higher in men (40.9%) compared to women (30.7%), and excessive PD was slightly more prevalent in women (9.1%) than in men (6.8%); however, the differences were not significant in any case (p=0.374). Overall, 40.5% of patients showed some dynamic signs of functional disorder when assessed with ED.Functional findings from the anorectal manometryAnorectal function was further studied with ARM in a cohort of 294 patients, of whom 40.4% showed basal hypertension of the anal canal and 80.9%, defecatory manoeuvre with dyssynergia (Type 1, 89.8%, Type 2, 3.8%, Type 3, 3.4%, and Type 4, 3%).Regarding responses to rectal distension, 21.2% showed elicitation of RAIR at high volumes of rectal distention and 33.3%, rectal hyposensitivity, and both were more prevalent in men (p=0.027 and p=0.002, respectively).Categorization of patients according to the disorderOf the cohort of patients studied with ED, 16.3% had isolated FDD; 46.4%, isolated SDD, and 37.3%, both SDD and FDD. In women, isolated SDD was more common, while in more than 50% of men, OD symptoms were caused by isolated impaired anorectal function (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 4</a>).<elsevierMultimedia ident="fig0025"></elsevierMultimedia>Factors associated with reduced expulsive capacityThe patients with SDD with a higher prevalence of incomplete evacuation had prolapses, 74.5% of whom were unable to expel. From a functional perspective, 65.8% of patients with impaired ARA opening had reduced evacuation capacity compared with 83% of patients with low PD (p=0.032).With regard to the categorization of the origin of obstructive defecation – structural or functional – 66.2% of SDD showed incomplete evacuation, 71.3% of FFD, and 78% of patients with both (p=0.017) (see <a class="elsevierStyleCrossRef" href="#fig0030">Fig. 5</a>).<elsevierMultimedia ident="fig0030"></elsevierMultimedia>The study with ARM revealed other factors associated with reduced expulsive capacity such as impaired rectal sensitivity, defecation manoeuvre, MRP, and anal canal length. Age was also taken in consideration (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>A logistic regression was performed to determine the factors independently associated with impaired expulsive capacity. The main findings were that SDD+FDD and a high MRP were independently associated with impaired expulsive capacity (OR=2.675, 95% [1.185, 6.04]; p=0.018; and OR=1.015, 95% [1.003, 1.03]; p=0.009, respectively). To have FDD alone was nearly statistically significant (OR=2.34, 95% [0.911, 6.02]; p=0.07), and similarly, age was an almost significant protective factor (OR=0.973, 95% [0.942, 1]; p=0.089). Anal canal length and rectal hyposensitivity had no statistical significance (OR=1.439, 95% [0.794, 2.61]; p=0.230; and OR=1.403, 95% [0.626, 13.15]; p=0.41, respectively).DiscussionThis study provides a thorough characterization of SDD and FDD in a large cohort of patients with difficult evacuation assessed with ED. It also examines the association of FDD, SDD and other factors with the expulsive capacity of these patients. The main results show that there is a high prevalence of SDD in middle-aged women with OD complaints. However, incomplete rectal evacuation, present in many of our patients, was more prevalent in FDD than in SDD although FDD and SDD frequently coexisted. There is reasonable evidence<a class="elsevierStyleCrossRefs" href="#bib0290">22–24</a> that dysfunction in the evacuation mechanism may precede the structural abnormalities observed in patients with OD, which explains the large proportion of them with both. However, our results are different from those found in a recent study<a class="elsevierStyleCrossRef" href="#bib0215">7</a> with only 9.6% of reported overlapping of the functional and structural factors. This difference may be due to the higher overall prevalence of FDD found in our series. Other factors such as pregnancy, childbirth or hysterectomy could also contribute to the pathophysiology of SDD.<a class="elsevierStyleCrossRef" href="#bib0290">22</a>In women, isolated SDD was more common than FDD but the opposite was true for men. The coexistence of SDD and FDD in men was much lower than in women. Therefore, in our series, OD in men may be largely attributed to functional factors, while structural abnormalities and their combination with functional aspects would constitute the principal mechanism of OD in women. This higher prevalence of FDD in men vs women is consistent with that of Grossi's study (29.4% in women vs 21.1% in men),<a class="elsevierStyleCrossRef" href="#bib0215">7</a> although our numbers were much higher due to our higher overall rates of FDD. This overall prevalence of FDD is also high compared with the results of a recent systematic review with meta-analysis, which showed a pooled prevalence of FDD of 24.1% across 42 studies.<a class="elsevierStyleCrossRef" href="#bib0250">14</a> The observed discrepancy between other studies may be due to the fact that many of our patients were referred to our unit because of suspected FDD and had symptoms of constipation according to Rome criteria. The prevalence of SDD in our series were quite similar to the results found in the mentioned meta-analysis.<a class="elsevierStyleCrossRef" href="#bib0250">14</a> Rectoceles, prolapses and enteroceles were, to a large extent, more common in women than men. In contrast, megarectum was twice as prevalent in men. Similar results were found by Grossi et al.<a class="elsevierStyleCrossRef" href="#bib0215">7</a> and Savoye-Collet et al.,<a class="elsevierStyleCrossRef" href="#bib0305">25</a> except for prolapses, which were higher in men in those studies and the overall prevalence of megarectum was lower in the Grossi study. Our prevalence of enteroceles in men was in line with those in other studies.<a class="elsevierStyleCrossRefs" href="#bib0215">7,25</a> Regarding enteroceles in women, while common in those who have undergone hysterectomy, they do not necessarily cause OD.<a class="elsevierStyleCrossRef" href="#bib0310">26</a> Among SDD, only a little more than one third were presented in isolation, the most prominent being prolapses and enteroceles. Rectoceles rarely occurred alone, the most frequent combination being with prolapses, 22.1% – the same as in the Grossi study<a class="elsevierStyleCrossRef" href="#bib0215">7</a> – which was the most prevalent type of SDD.From the functional side, half the patients were unable to open the ARA to a normal degree to facilitate evacuation, and one third had low PD. ARM showed that more than 80% of patients had some kind of dyssynergia during attempted defecation, which contrasts with the less prevalent functional abnormalities found with ED. This result is also similar to that of a study on the accuracy of ARM in diagnosing dyssynergic defecation, where 94% of the patients with constipation studied showed dyssynergic defecation (and 87% of the healthy volunteers studied).<a class="elsevierStyleCrossRef" href="#bib0315">27</a> Although ARM is the most accepted method to study anorectal function, it is not exempt from criticism regarding the validity of a simulated defecation in a non-physiological position and without the intimate environment generally considered necessary.<a class="elsevierStyleCrossRef" href="#bib0320">28</a> For this reason, ARM has limited utility to diagnose abnormal defecation manoeuvre<a class="elsevierStyleCrossRef" href="#bib0315">27</a> and must be corroborated with either a balloon expulsion test or by ED.<a class="elsevierStyleCrossRef" href="#bib0205">5</a>Nevertheless, ARM enables further analysis in important functional components related to evacuation. Although in the functional realm OD is generally attributed to pelvic floor dyssynergia,<a class="elsevierStyleCrossRef" href="#bib0325">29</a> more than 40% of our patients also had anal canal hypertension, one third showed rectal hyposensitivity, and more than 20% needed increased volumes of rectal distension to elicit RAIR. A hypertensive anal sphincter<a class="elsevierStyleCrossRef" href="#bib0330">30</a> can interfere with defecation; during it the anal canal pressure should decrease as a consequence of RAIR while intrarectal pressure increases, reverting the recto-anal pressure gradient.<a class="elsevierStyleCrossRef" href="#bib0335">31</a> It is plausible to think that with a high MRP it is more difficult to achieve this reversal of the gradient and, eventually, expel the stool. On the other hand, rectal hyposensitivity is associated with chronic constipation<a class="elsevierStyleCrossRefs" href="#bib0340">32,33</a> where blunted sensation abolishes the desire to defecate leading to prolonged stool retention and subsequent increased rectal capacity and compliance, which in turn worsens rectal sensitivity, causing a vicious circle. The enlarged rectal capacity also explains the higher distention volumes needed to evoke RAIR. Delayed RAIR and hyposensitivity were more frequent in men, which matches the higher prevalence of megarectum observed during ED for this gender.Expulsive capacity was poorer in patients with FDD than those with SDD, probably because the latter had preserved an expulsive function and were able to evacuate with increased straining. The expulsive capacity was even worse in patients with both disorders, probably by the addition of anatomical pouches (rectoceles) and obstructions (prolapses) to the impaired anorectal function.Expulsive capacity is the key point from the patients’ perspective, which may favour the decision for a surgical solution in the case of SDD. ED was carried out with barium contrast in liquid form, which facilitates expulsion despite being less physiological than barium paste. From a clinical point of view this has important implications: if a patient can expel stools of that consistency, a laxative treatment should be successful, preferable to surgical treatments that are sometimes not. On the other hand, the large proportion of FDD that overlaps with SDD, strongly suggests a conservative approach with biofeedback therapy addressing FDD as the first line of treatment,<a class="elsevierStyleCrossRefs" href="#bib0350">34,35</a> especially taking into account the fact that the coexistence of FDD+SDD is closely related to reduced expulsive capacity. It is well known that increased MRP due to IAS hypertonicity in patients with impaired evacuation capacity reduces the chance for a positive clinical outcome of the biofeedback techniques,<a class="elsevierStyleCrossRef" href="#bib0360">36</a> so other treatments such as botulinum toxin injection or pharmacological approach with calcium channel antagonists or NO donors should be considered in these cases.This study has some limitations. The evaluation of only the posterior compartment omits other factors relevant to expulsive difficulties, particularly considering the high proportion of women with these disorders. However, a urogynecological assessment was made, paramount when assessing female patients with OD given the close interplay between posterior and middle compartments of the pelvic floor. Another limitation was the retrospective design over 8 years of our cohort of patients with ED studies, which led to the lack of some data; and finally, the fact that it was a selected clinical cohort, recruiting patients referred to a specialised unit due to the severity of their symptoms which can generate bias from an epidemiological perspective.It should be noted that almost half our patients reported lifelong symptoms of OD, which may reflect, on the one hand, the difficult management of many of these patients, and on the other, that difficult evacuation and chronic constipation in general probably deserve more attention than they get.ConclusionsED and ARM can provide a complete picture of the mechanisms of OD which should guide the ideal therapeutic strategy for each patient. A stepwise functional therapeutic approach can improve many defecation disorders, whether FDD or SDD. Regarding the indications for surgery, in our opinion, individually-selected procedures should only be performed on patients with severe symptoms of OD plus severe structural disorders and minimal or even absent FDD. Most of these surgical patients will require long term postoperative medical care and rehabilitation to improve rectal emptying and avoid recurrences.FundingPart of this research was funded through a PERIS grant from Catalonian Health Department (SLT017/20/000125 and SLT017/20/000236). Ciberehd is founded by Instituto de Salud Carlos III, Barcelona, Spain.Conflicts of interestThe authors have no conflicts of interest to declare.Declaration of generative AI and AI-assisted technologies in the writing processNo use of generative AI or AI-assisted technologies have been used in the writing process of this scientific manuscript." "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres2193474" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background/aims" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1843739" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1843738" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres2193473" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes/objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1843737" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Symptoms" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Defecography" ] 2 => array:3 [ "identificador" => "sec0025" "titulo" => "Defecographic measurements and interpretation" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Functional" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Structural" ] ] ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Anorectal manometry. Technique and measurements" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Categorization of patients into SDD, FDD or both" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Data analysis" ] ] ] 7 => array:3 [ "identificador" => "sec0055" "titulo" => "Results" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Symptoms" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Structural findings (SDD) during defecography" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Overlapping of structural disorders" ] 3 => array:2 [ "identificador" => "sec0075" "titulo" => "Functional findings from the evacuation defecography" ] 4 => array:2 [ "identificador" => "sec0080" "titulo" => "Functional findings from the anorectal manometry" ] 5 => array:2 [ "identificador" => "sec0085" "titulo" => "Categorization of patients according to the disorder" ] 6 => array:2 [ "identificador" => "sec0090" "titulo" => "Factors associated with reduced expulsive capacity" ] ] ] 8 => array:2 [ "identificador" => "sec0095" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0100" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0105" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0110" "titulo" => "Conflicts of interest" ] 12 => array:2 [ "identificador" => "sec0115" "titulo" => "Declaration of generative AI and AI-assisted technologies in the writing process" ] 13 => array:2 [ "identificador" => "xack755595" "titulo" => "Acknowledgements" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-12-11" "fechaAceptado" => "2024-05-24" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1843739" "palabras" => array:5 [ 0 => "Constipation" 1 => "Defecation" 2 => "Rectal diseases" 3 => "Defecography" 4 => "Manometry" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1843738" "palabras" => array:11 [ 0 => "FDD" 1 => "SDD" 2 => "ED" 3 => "ARM" 4 => "OD" 5 => "EAS" 6 => "IAS" 7 => "ARA" 8 => "PD" 9 => "MRI" 10 => "MRP" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1843737" "palabras" => array:5 [ 0 => "Estreñimiento" 1 => "Defecación" 2 => "Enfermedades rectales" 3 => "Videoproctografía" 4 => "Manometría" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Background/aimsDefecation disorders can occur as a consequence of functional or structural anorectal dysfunctions during voiding. The aims of this study is to assess the prevalence of structural (SDD) vs functional (FDD) defecation disorders among patients with clinical complaints of obstructive defecation (OD) and their relationship with patients’ expulsive capacity. Patients and methodsRetrospective study of 588 patients with OD studied between 2012 and 2020 with evacuation defecography (ED), and anorectal manometry (ARM) in a subgroup of 294. Results90.3% patients were women, age was 58.5±12.4 years. Most (83.7%) had SDD (43.7% rectocele, 45.3% prolapse, 19.3% enterocele, and 8.5% megarectum), all SDD being more prevalent in women except for megarectum. Functional assessments showed: (a) absence of rectification of anorectal angle in 51% of patients and poor pelvic descent in 31.6% at ED and (b) dyssynergic defecation in 89.9%, hypertonic IAS in 44%, and 33.3% rectal hyposensitivity, at ARM. Overall, 46.4% of patients were categorized as pure SDD, 37.3% a combination of SDD+FDD, and 16.3% as having pure FDD.Rectal emptying was impaired in 66.2% of SDD, 71.3% of FDD and in 78% of patients with both (p=0.017). ConclusionsThere was a high prevalence of SDD in middle-aged women with complaints of OD. Incomplete rectal emptying was more prevalent in FDD than in SDD although FDD and SDD frequently coexist. We recommend a stepwise therapeutic approach always starting with therapy directed to improve FDD and relaxation of striated pelvic floor muscles." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background/aims" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Antecedentes/objetivosLos trastornos defecatorios ocurren como consecuencia de disfunciones anorrectales funcionales o estructurales. El objetivo del estudio es evaluar la prevalencia de trastornos estructurales defecatorios (TED) versus funcionales (TFD) entre pacientes con síntomas de defecación obstructiva (DO) y su relación con la capacidad expulsiva. Pacientes y métodosEstudio retrospectivo con 588 pacientes con DO estudiados entre 2012 y 2020 con videodefecografía (VD), y manometría anorrectal (MAR) en un subgrupo de 294. ResultadosEl 90,3% de los pacientes eran mujeres, con 58,5±12,4 años. La mayoría (83,7%) presentaban TED (43,7% rectocele, 45,3% prolapso, 19,3% enterocele y 8,5% megarrecto), siendo más prevalentes en mujeres excepto el megarrecto. Evaluación funcional: a) VD: ausencia de rectificación del ángulo anorrectal en el 51% de los pacientes y escaso o nulo descenso perineal en el 31,6; y b) MAR: defecación disinérgica en el 89,9%, EAI hipertónico en el 44% e hiposensibilidad rectal en el 33,3%. En conjunto, el 46,4% de los pacientes se clasificaron como SDD puro, el 37,3% TED+TFD y el 16,3% como TFD puro. La capacidad expulsiva estaba afectada en el 66,2% de los TED, el 71,3% de los TFD y en el 78% de los pacientes con ambos trastornos (p=0,017). ConclusionesHubo una alta prevalencia de TED en mujeres con síntomas de DO. El vaciamiento rectal incompleto era más prevalente en los pacientes con TFD que en aquellos con TED, pero más cuando ambos coexistían. Recomendamos un enfoque terapéutico empezando siempre con terapia dirigida a mejorar el TFD y la relajación de los músculos estriados del suelo pélvico." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes/objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="fig0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0125" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2162 "Ancho" => 3167 "Tamanyo" => 494938 ] ] "descripcion" => array:1 [ "en" => "Metrics for video proctography: (A) at rest and (B) during straining." ] ] 1 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1318 "Ancho" => 3167 "Tamanyo" => 385877 ] ] "descripcion" => array:1 [ "en" => "Overlapping structural disorders. Left: Patient with dyssynergia Type I and rectocele with incomplete rectal emptying and intrarectal prolapse. Right. Patient with a megarectum and a large rectocele, with increased rectal compliance and impaired RAIR, enterocele and external rectal prolapse." ] ] 2 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1483 "Ancho" => 2065 "Tamanyo" => 135190 ] ] "descripcion" => array:1 [ "en" => "Prevalence of isolated structural defecation disorders and their combinations. Percentage (in italics and darker colour) of the overlap with a functional defecation disorder. SDD: structural defecation disorders." ] ] 3 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2994 "Ancho" => 2145 "Tamanyo" => 198345 ] ] "descripcion" => array:1 [ "en" => "Prevalence of SDD, FDD and a combination of both in patients with OD, women, men and overall. SDD: structural defecation disorders; FDD: functional defecation disorders." ] ] 4 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2645 "Ancho" => 2475 "Tamanyo" => 265670 ] ] "descripcion" => array:1 [ "en" => "Prevalence of patients with incomplete rectal emptying and associated disorders. SDD: structural defecation disorders; FDD: functional defecation disorders; ARA: anorectal angle; PD: perineal descent." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "MRP: mean resting pressure; AC: anal canal." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Expulsive capacity</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">p-Value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preserved \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Impaired \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rectal sensitivity</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.043 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hyposensitivity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypersensitivity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Defecation manoeuvre</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">0.026</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyssynergia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60.5±11.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57.5±12.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.009 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MRP (mmHg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68±33.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.9±36.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AC length (cm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.05±0.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.29±0.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.025 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3582974.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Expulsive capacity according to rectal sensitivity, defecation manoeuvre, MRP, anal canal length, and age." ] ] 6 => array:5 [ "identificador" => "fig0005" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "mmc1.jpeg" "Alto" => 1298 "Ancho" => 1890 "Tamanyo" => 149132 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:36 [ 0 => array:3 [ "identificador" => "bib0185" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N.C. 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Characterization of obstructive defecation from a structural and a functional perspective

Caracterización de la defecación obstructiva desde una perspectiva estructural y funcional

Lluís Mundeta,b,

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lluismundetp@gmail.com

Corresponding author.

, Alba Raventósa, Sílvia Carrióna, Cristina Bascomptea, Pere Clavéa,b

a Gastrointestinal Motility Unit, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain

b Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic constipation is a prevalent anorectal disorder which affects 14&#37; of the general population&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">1</span></a> is more common in women and in older people&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">2</span></a> and has a major impact on quality of life and health economics&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">3</span></a> In western countries&#44; it is common and closely associated with low fibre intake&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">4</span></a> The pathophysiology of constipation can be related to irritable bowel syndrome&#44; opioid medication or a dysfunction in colon motility&#44; but also to an inability to expel stools&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a> which constitutes the basis of functional defecatory disorders &#40;FDD&#41;&#46; FDD are included in what is known as evacuation disorders&#44; with clinical symptoms of obstructive defecation &#40;OD&#41;&#46; We often find&#44; in our daily practice&#44; that gastroenterologists and colorectal surgeons have different perspectives &#40;functional vs structural&#44; respectively&#41; on managing these conditions&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Evacuation disorders have two major mechanisms&#58; &#40;a&#41; FDD&#44; characterized by dyssynergic defecation &#40;with paradoxical contraction or inadequate relaxation of the external anal sphincter &#40;EAS&#41; and&#47;or inadequate propulsive forces&#44; which make up the four patterns of dyssynergia<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">6</span></a>&#41; or &#40;b&#41; structural defecation disorders &#40;SDD&#41;&#44; defined by dynamic alterations in the rectal wall or the posterior component of the pelvic floor&#44; such as rectocele&#44; rectal prolapse and enterocele&#44; which can interfere with defecation&#46; Patients with severe symptoms of OD that do not respond to fibre or laxative treatments should undergo specific tests in order to determine whether the impairment in defecatory dynamics is induced by functional and&#47;or structural factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Evacuation disorders can be examined using different techniques such as anorectal manometry &#40;ARM&#41;&#44; evacuation defaecography &#40;ED&#41;&#44; dynamic pelvic magnetic resonance imaging &#40;MRI&#41; and pelvic floor ultrasonography&#46; The first two are the most common as they are readily available and excel in evaluating functional aspects and dynamics of the posterior compartment&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">ARM is the most common&#44; available and accepted method used to diagnose evacuation disorders from a functional perspective&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">11</span></a> ARM has the capacity to assess sphincteric function&#44; recto-anal reflexes&#44; rectal sensitivity&#44; and defecatory manoeuvres in an attempted defecation&#46; The latter has special importance in the diagnosis of FDD&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">11</span></a> In the last decade&#44; there has been a transition to high-resolution ARM which provides better spatial resolution&#44; although advances at the diagnostic level are yet to be demonstrated&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">On the other hand&#44; ED is a useful method for assessing evacuation disorders when SDD are suspected&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">12&#44;13</span></a> The fact that it is based on dynamic images and is carried out under similar conditions to physiological evacuation implies a great potential to explore dynamic structural factors only visible during defecation&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">14</span></a> Furthermore&#44; it can indirectly assess functional aspects like anorectal angle &#40;ARA&#41;&#44; corresponding to puborectalis function change&#44; perineum descent &#40;PD&#41;&#44; corresponding to the pubococcygeal&#44; iliococcygeus and puborectalis function&#44; and evacuation capacity&#46; The Rome consensus requires either impaired rectal evacuation by imaging &#40;ED or MRI&#41; or the balloon expulsion test to confirm FDD indicated in an ARM study&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a> The main limitation of ED is the known overlapping between what is normal and what is abnormal&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Neither ARM nor ED alone can provide a complete assessment of the complex mechanism of defecation but together they offer the best of both worlds&#58; the evaluation of the biomechanics by means of anorectal pressure dynamics and dynamic imaging of the posterior compartment during voiding&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">16</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The aim of this study is to review our experience in the study of patients with OD and describe our findings on FDD and SDD using ED and ARM&#44; as well as clinical manifestations of OD&#44; differences between genders&#44; and factors associated with impaired expulsive capacity&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">This was a retrospective study of 588 adult patients referred to our GI physiology unit with complaints of OD and with Rome III criteria of constipation&#44; and who underwent ED between 2012 and 2020&#46; Anorectal manometry was additionally performed on 294 of these patients &#40;230 conventional&#44; 64 high-resolution&#41;&#44; and a complete description of symptoms was collected&#46; All patients underwent a digital rectal examination to clinically evaluate possible structural defects in the anal canal or at the end of the rectal ampulla and for an initial assessment of the anorectal function &#40;at rest&#44; at squeeze and when pushing&#41;&#46; Patients with concomitant faecal incontinence &#40;42&#41; or a poor quality ED &#40;21&#41; were excluded&#46; Sociodemographic data&#44; reasons for referral&#44; diagnosis and duration of the condition were collected&#46; The study was approved by the hospital ethics committee with the code 82&#47;20&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Symptoms</span><p id="par0045" class="elsevierStylePara elsevierViewall">Patients&#8217; clinical manifestations were collected according to Rome III criteria and included straining&#44; sense of incomplete evacuation&#44; anal blockage&#44; hard stools&#44; need for digitization and fewer than three bowel movements per week&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Defecography</span><p id="par0050" class="elsevierStylePara elsevierViewall">Patients self-administered a 250<span class="elsevierStyleHsp" style=""></span>mL rectal enema &#40;Casen Enema&#44; Recordati&#44; Italy&#41; at home&#44; and were orally administered 200<span class="elsevierStyleHsp" style=""></span>mL of barium sulphate solution 1<span class="elsevierStyleHsp" style=""></span>h before the procedure &#40;Barigraph&#44; Ern Labs&#44; Barcelona&#41;&#44; to opacify the small intestine&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">At X-ray facilities&#44; in order to opacify the rectum&#44; patients were administered a liquid barium sulphate dilution &#40;Barigraph&#44; Ern Labs&#44; Barcelona&#41; into the anal canal with a soft rectal catheter until desire to defecate was elicited &#40;approximately 400<span class="elsevierStyleHsp" style=""></span>mL&#41;&#46; Patients were then seated on a radiotransparent commode&#44; and were informed of all the steps of the procedure and to attempt to defecate when they were asked to in the same way they in their toilet at home&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Defecographic measurements and interpretation</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Functional</span><p id="par0060" class="elsevierStylePara elsevierViewall">ED provided two main measures of pelvic function during attempted defecation&#58; aperture of ARA &#40;from the relaxation of the puborectalis muscle&#41; and PD &#40;from the relaxation of the pubococcygeal and other pelvic floor muscles&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Defecographic measurements were taken at rest and during straining&#44; and are as follows&#58;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">ARA</span>&#44; defined as the angle between the axis line of the anal canal and a tangential line along the posterior line of the rectal wall<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">PD</span>&#44; vertical distance in cm of anorectal junction between rest and squeeze status<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Expulsive capacity</span> &#40;normal or incomplete&#41; of the rectum&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">See <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Structural</span><p id="par0095" class="elsevierStylePara elsevierViewall">Abnormalities studied were identified as&#58; rectocele&#44; rectal prolapse &#40;intrarectal&#44; intra-anal&#44; external&#41;&#44; enterocele and megarectum according to accepted definitions&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">17&#8211;20</span></a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rectal capacity</span>&#58; Normal&#47;megarectum &#40;&#62;6&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rectocele</span>&#58; Anterior or posterior bulge of the rectal wall beyond the expected line of the rectum during straining &#40;&#60;2<span class="elsevierStyleHsp" style=""></span>cm&#58; small &#40;not significant&#41;&#59; 2&#8211;4<span class="elsevierStyleHsp" style=""></span>cm&#58; medium&#59; &#62;4<span class="elsevierStyleHsp" style=""></span>cm&#58; large&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Prolapse</span>&#58;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intrarectal</span>&#58; Infolding of the rectal mucosa without reaching the anal canal&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intra-anal</span>&#58; Infolding of the rectal mucosa entering the anal canal&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">External</span>&#58; Infolding of the rectal mucosa exceeding the anal canal and exteriorizing&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Enterocele</span>&#58; Small bowel occupying Douglas pouch at maximum evacuatory effort&#46;</p></li></ul></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Anorectal manometry&#46; Technique and measurements</span><p id="par0135" class="elsevierStylePara elsevierViewall">Studies performed prior to 2018 employed conventional ARM&#44; consisting of a water-perfused system &#40;Medtronic&#44; USA&#41; with two catheters to evaluate anorectal function&#46; Technique and normal values have already been published&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">21</span></a> Patients from 2018 onwards were studied with high-resolution ARM in a water-perfused 12-channel MMS system &#40;MMS-Laborie&#44; The Netherlands&#41;&#44; following the IAPWG protocol<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">9</span></a> and reference values from our laboratory&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">18</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Data collected were mean resting pressure &#40;MRP&#41; categorized as normal &#40;40&#8211;100<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; hypotense &#40;&#60;40<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; and hypertense &#40;&#62;100<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#59; rectal perception&#44; categorized as normal&#44; hyposensitivity&#44; and hypersensitivity&#59; recto-anal inhibitory reflex &#40;RAIR&#41; defined as normal when elicited by less than 100<span class="elsevierStyleHsp" style=""></span>mL volume of rectal distention&#59; and defecatory manoeuvre&#44; which could be normal or abnormal&#44; according to the Rao classification &#40;Type I&#58; paradoxical contraction of EAS&#59; Type II&#58; paradoxical contraction of EAS and insufficient intrarectal pressure&#59; Type III&#58; absence of relaxation of the anal canal&#59; and Type IV&#58; absence of relaxation of the anal canal and insufficient intrarectal pressure&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Categorization of patients into SDD&#44; FDD or both</span><p id="par0145" class="elsevierStylePara elsevierViewall">According to the data collected with ED and ARM&#44; the patients were categorized into SDD&#44; FDD or both disorders&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Data analysis</span><p id="par0150" class="elsevierStylePara elsevierViewall">Categorical data were expressed as frequencies and percentages and continuous data as means and standard deviations&#46; The <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> was used to compare categorical variables&#44; Student-<span class="elsevierStyleItalic">t</span> test to compare continuous ones&#59; the <span class="elsevierStyleItalic">U</span>-Mann&#8211;Whitney test was used for non-normal distribution of data&#46; Univariate and multivariate regression analyses were performed to identify factors associated with OD&#46; A value of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered to be statistically significant for all the performed tests&#46; Statistical analyses were conducted using SPSS v15 software &#40;IBM Corp&#44; Armonk&#44; NY&#44; USA&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">With the data provided by ED&#44; patients with some structural disorder but no signs of functional abnormality were categorized into the SDD group&#59; those with a functional disorder but no signs of structural abnormality&#44; into the FDD group&#59; and when both kinds of disorder coexisted&#44; into the mixed group&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><p id="par0160" class="elsevierStylePara elsevierViewall">The mean age of the 588 patients studied was 58&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;2 years&#44; and most of them were women &#40;90&#46;1&#37;&#41;&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Symptoms</span><p id="par0165" class="elsevierStylePara elsevierViewall">Symptoms according to Rome criteria were collected in 294 patients who underwent ED and ARM&#46; Prevalence of symptoms was&#58; excessive straining&#44; 86&#46;8&#37;&#59; sensation of incomplete evacuation&#44; 84&#46;8&#37;&#59; anal blockage&#44; 58&#46;3&#37;&#59; fewer than 3 defecations&#47;week&#44; 43&#37;&#59; hard stools&#44; 38&#46;9&#37;&#44; and need for digitization&#44; 35&#46;8&#37;&#46; No differences between genders were found&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Regarding duration of symptoms&#44; 18&#46;7&#37; reported a history of less than 5 years with OD&#44; 22&#46;4&#37; 5&#8211;9 years&#44; 11&#46;9&#37; 10&#8211;14 years&#44; 2&#46;2&#37; 15&#8211;20 years&#44; and 44&#46;8&#37; reported lifelong OD symptoms&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Rectal evacuation capacity was assessed in all 588 patients and was found impaired or incomplete in 71&#37; of them&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Structural findings &#40;SDD&#41; during defecography</span><p id="par0180" class="elsevierStylePara elsevierViewall">Rectal prolapse was the most common SDD observed in our patients &#40;45&#46;3&#37;&#41;&#44; followed by rectocele &#40;43&#46;7&#37;&#41;&#44; enterocele &#40;19&#46;1&#37;&#41; and megarectum &#40;8&#46;5&#37;&#41;&#46; Most prolapses were intrarectal &#40;92&#46;3&#37;&#41;&#44; 4&#46;6&#37; were intra-anal and only 3&#46;1&#37; exteriorized or complete&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Regarding gender differences&#44; the percentage of SDD was higher in women compared to men for rectocele &#40;53&#46;7&#37; vs 14&#46;6&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; prolapse &#40;48&#46;9&#37; vs 12&#46;3&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and enterocele &#40;20&#46;2&#37; vs 8&#46;9&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;041&#41;&#59; in contrast&#44; megarectum was more prevalent in men &#40;7&#46;7&#37; vs 15&#46;8&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;038&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Overlapping of structural disorders</span><p id="par0190" class="elsevierStylePara elsevierViewall">Overlap between SDD was observed mainly in the combination of rectocele and rectal prolapse&#44; with a prevalence of 22&#46;1&#37;&#44; surpassing the prevalence of any isolated SDD&#46; Other significant combinations of SDD were those that aggregated rectocele and rectal prolapse with enterocele &#40;5&#46;3&#37;&#41; and rectocele with enterocele &#40;4&#46;5&#37;&#41;&#46; The remaining combinations were not significant &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 2 and 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Functional findings from the evacuation defecography</span><p id="par0195" class="elsevierStylePara elsevierViewall">Results showed 51&#37; of patients had insufficient ARA opening during straining&#44; suggesting poor puborectalis relaxation or even contraction&#44; and 31&#46;6&#37;&#44; poor or absent PD&#46; More than half of men &#40;61&#46;4&#37;&#41; showed inadequate ARA opening compared to 49&#46;9&#37; of women&#44; although the difference was not significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;099&#41;&#46; Regarding PD&#44; the percentage of low PD was higher in men &#40;40&#46;9&#37;&#41; compared to women &#40;30&#46;7&#37;&#41;&#44; and excessive PD was slightly more prevalent in women &#40;9&#46;1&#37;&#41; than in men &#40;6&#46;8&#37;&#41;&#59; however&#44; the differences were not significant in any case &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;374&#41;&#46; Overall&#44; 40&#46;5&#37; of patients showed some dynamic signs of functional disorder when assessed with ED&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Functional findings from the anorectal manometry</span><p id="par0200" class="elsevierStylePara elsevierViewall">Anorectal function was further studied with ARM in a cohort of 294 patients&#44; of whom 40&#46;4&#37; showed basal hypertension of the anal canal and 80&#46;9&#37;&#44; defecatory manoeuvre with dyssynergia &#40;Type 1&#44; 89&#46;8&#37;&#44; Type 2&#44; 3&#46;8&#37;&#44; Type 3&#44; 3&#46;4&#37;&#44; and Type 4&#44; 3&#37;&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Regarding responses to rectal distension&#44; 21&#46;2&#37; showed elicitation of RAIR at high volumes of rectal distention and 33&#46;3&#37;&#44; rectal hyposensitivity&#44; and both were more prevalent in men &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;027 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#44; respectively&#41;&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Categorization of patients according to the disorder</span><p id="par0210" class="elsevierStylePara elsevierViewall">Of the cohort of patients studied with ED&#44; 16&#46;3&#37; had isolated FDD&#59; 46&#46;4&#37;&#44; isolated SDD&#44; and 37&#46;3&#37;&#44; both SDD and FDD&#46; In women&#44; isolated SDD was more common&#44; while in more than 50&#37; of men&#44; OD symptoms were caused by isolated impaired anorectal function &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Factors associated with reduced expulsive capacity</span><p id="par0215" class="elsevierStylePara elsevierViewall">The patients with SDD with a higher prevalence of incomplete evacuation had prolapses&#44; 74&#46;5&#37; of whom were unable to expel&#46; From a functional perspective&#44; 65&#46;8&#37; of patients with impaired ARA opening had reduced evacuation capacity compared with 83&#37; of patients with low PD &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;032&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">With regard to the categorization of the origin of obstructive defecation &#8211; structural or functional &#8211; 66&#46;2&#37; of SDD showed incomplete evacuation&#44; 71&#46;3&#37; of FFD&#44; and 78&#37; of patients with both &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;017&#41; &#40;see <a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0225" class="elsevierStylePara elsevierViewall">The study with ARM revealed other factors associated with reduced expulsive capacity such as impaired rectal sensitivity&#44; defecation manoeuvre&#44; MRP&#44; and anal canal length&#46; Age was also taken in consideration &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0230" class="elsevierStylePara elsevierViewall">A logistic regression was performed to determine the factors independently associated with impaired expulsive capacity&#46; The main findings were that SDD<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>FDD and a high MRP were independently associated with impaired expulsive capacity &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;675&#44; 95&#37; &#91;1&#46;185&#44; 6&#46;04&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;018&#59; and OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;015&#44; 95&#37; &#91;1&#46;003&#44; 1&#46;03&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#44; respectively&#41;&#46; To have FDD alone was nearly statistically significant &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;34&#44; 95&#37; &#91;0&#46;911&#44; 6&#46;02&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;07&#41;&#44; and similarly&#44; age was an almost significant protective factor &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;973&#44; 95&#37; &#91;0&#46;942&#44; 1&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;089&#41;&#46; Anal canal length and rectal hyposensitivity had no statistical significance &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;439&#44; 95&#37; &#91;0&#46;794&#44; 2&#46;61&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;230&#59; and OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;403&#44; 95&#37; &#91;0&#46;626&#44; 13&#46;15&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;41&#44; respectively&#41;&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Discussion</span><p id="par0235" class="elsevierStylePara elsevierViewall">This study provides a thorough characterization of SDD and FDD in a large cohort of patients with difficult evacuation assessed with ED&#46; It also examines the association of FDD&#44; SDD and other factors with the expulsive capacity of these patients&#46; The main results show that there is a high prevalence of SDD in middle-aged women with OD complaints&#46; However&#44; incomplete rectal evacuation&#44; present in many of our patients&#44; was more prevalent in FDD than in SDD although FDD and SDD frequently coexisted&#46; There is reasonable evidence<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">22&#8211;24</span></a> that dysfunction in the evacuation mechanism may precede the structural abnormalities observed in patients with OD&#44; which explains the large proportion of them with both&#46; However&#44; our results are different from those found in a recent study<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">7</span></a> with only 9&#46;6&#37; of reported overlapping of the functional and structural factors&#46; This difference may be due to the higher overall prevalence of FDD found in our series&#46; Other factors such as pregnancy&#44; childbirth or hysterectomy could also contribute to the pathophysiology of SDD&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">22</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">In women&#44; isolated SDD was more common than FDD but the opposite was true for men&#46; The coexistence of SDD and FDD in men was much lower than in women&#46; Therefore&#44; in our series&#44; OD in men may be largely attributed to functional factors&#44; while structural abnormalities and their combination with functional aspects would constitute the principal mechanism of OD in women&#46; This higher prevalence of FDD in men vs women is consistent with that of Grossi&#39;s study &#40;29&#46;4&#37; in women vs 21&#46;1&#37; in men&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">7</span></a> although our numbers were much higher due to our higher overall rates of FDD&#46; This overall prevalence of FDD is also high compared with the results of a recent systematic review with meta-analysis&#44; which showed a pooled prevalence of FDD of 24&#46;1&#37; across 42 studies&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">14</span></a> The observed discrepancy between other studies may be due to the fact that many of our patients were referred to our unit because of suspected FDD and had symptoms of constipation according to Rome criteria&#46; The prevalence of SDD in our series were quite similar to the results found in the mentioned meta-analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">14</span></a> Rectoceles&#44; prolapses and enteroceles were&#44; to a large extent&#44; more common in women than men&#46; In contrast&#44; megarectum was twice as prevalent in men&#46; Similar results were found by Grossi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">7</span></a> and Savoye-Collet et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">25</span></a> except for prolapses&#44; which were higher in men in those studies and the overall prevalence of megarectum was lower in the Grossi study&#46; Our prevalence of enteroceles in men was in line with those in other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">7&#44;25</span></a> Regarding enteroceles in women&#44; while common in those who have undergone hysterectomy&#44; they do not necessarily cause OD&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">26</span></a> Among SDD&#44; only a little more than one third were presented in isolation&#44; the most prominent being prolapses and enteroceles&#46; Rectoceles rarely occurred alone&#44; the most frequent combination being with prolapses&#44; 22&#46;1&#37; &#8211; the same as in the Grossi study<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">7</span></a> &#8211; which was the most prevalent type of SDD&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">From the functional side&#44; half the patients were unable to open the ARA to a normal degree to facilitate evacuation&#44; and one third had low PD&#46; ARM showed that more than 80&#37; of patients had some kind of dyssynergia during attempted defecation&#44; which contrasts with the less prevalent functional abnormalities found with ED&#46; This result is also similar to that of a study on the accuracy of ARM in diagnosing dyssynergic defecation&#44; where 94&#37; of the patients with constipation studied showed dyssynergic defecation &#40;and 87&#37; of the healthy volunteers studied&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">27</span></a> Although ARM is the most accepted method to study anorectal function&#44; it is not exempt from criticism regarding the validity of a simulated defecation in a non-physiological position and without the intimate environment generally considered necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">28</span></a> For this reason&#44; ARM has limited utility to diagnose abnormal defecation manoeuvre<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">27</span></a> and must be corroborated with either a balloon expulsion test or by ED&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Nevertheless&#44; ARM enables further analysis in important functional components related to evacuation&#46; Although in the functional realm OD is generally attributed to pelvic floor dyssynergia&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">29</span></a> more than 40&#37; of our patients also had anal canal hypertension&#44; one third showed rectal hyposensitivity&#44; and more than 20&#37; needed increased volumes of rectal distension to elicit RAIR&#46; A hypertensive anal sphincter<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">30</span></a> can interfere with defecation&#59; during it the anal canal pressure should decrease as a consequence of RAIR while intrarectal pressure increases&#44; reverting the recto-anal pressure gradient&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">31</span></a> It is plausible to think that with a high MRP it is more difficult to achieve this reversal of the gradient and&#44; eventually&#44; expel the stool&#46; On the other hand&#44; rectal hyposensitivity is associated with chronic constipation<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">32&#44;33</span></a> where blunted sensation abolishes the desire to defecate leading to prolonged stool retention and subsequent increased rectal capacity and compliance&#44; which in turn worsens rectal sensitivity&#44; causing a vicious circle&#46; The enlarged rectal capacity also explains the higher distention volumes needed to evoke RAIR&#46; Delayed RAIR and hyposensitivity were more frequent in men&#44; which matches the higher prevalence of megarectum observed during ED for this gender&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Expulsive capacity was poorer in patients with FDD than those with SDD&#44; probably because the latter had preserved an expulsive function and were able to evacuate with increased straining&#46; The expulsive capacity was even worse in patients with both disorders&#44; probably by the addition of anatomical pouches &#40;rectoceles&#41; and obstructions &#40;prolapses&#41; to the impaired anorectal function&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Expulsive capacity is the key point from the patients&#8217; perspective&#44; which may favour the decision for a surgical solution in the case of SDD&#46; ED was carried out with barium contrast in liquid form&#44; which facilitates expulsion despite being less physiological than barium paste&#46; From a clinical point of view this has important implications&#58; if a patient can expel stools of that consistency&#44; a laxative treatment should be successful&#44; preferable to surgical treatments that are sometimes not&#46; On the other hand&#44; the large proportion of FDD that overlaps with SDD&#44; strongly suggests a conservative approach with biofeedback therapy addressing FDD as the first line of treatment&#44;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">34&#44;35</span></a> especially taking into account the fact that the coexistence of FDD<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>SDD is closely related to reduced expulsive capacity&#46; It is well known that increased MRP due to IAS hypertonicity in patients with impaired evacuation capacity reduces the chance for a positive clinical outcome of the biofeedback techniques&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">36</span></a> so other treatments such as botulinum toxin injection or pharmacological approach with calcium channel antagonists or NO donors should be considered in these cases&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">This study has some limitations&#46; The evaluation of only the posterior compartment omits other factors relevant to expulsive difficulties&#44; particularly considering the high proportion of women with these disorders&#46; However&#44; a urogynecological assessment was made&#44; paramount when assessing female patients with OD given the close interplay between posterior and middle compartments of the pelvic floor&#46; Another limitation was the retrospective design over 8 years of our cohort of patients with ED studies&#44; which led to the lack of some data&#59; and finally&#44; the fact that it was a selected clinical cohort&#44; recruiting patients referred to a specialised unit due to the severity of their symptoms which can generate bias from an epidemiological perspective&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">It should be noted that almost half our patients reported lifelong symptoms of OD&#44; which may reflect&#44; on the one hand&#44; the difficult management of many of these patients&#44; and on the other&#44; that difficult evacuation and chronic constipation in general probably deserve more attention than they get&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conclusions</span><p id="par0275" class="elsevierStylePara elsevierViewall">ED and ARM can provide a complete picture of the mechanisms of OD which should guide the ideal therapeutic strategy for each patient&#46; A stepwise functional therapeutic approach can improve many defecation disorders&#44; whether FDD or SDD&#46; Regarding the indications for surgery&#44; in our opinion&#44; individually-selected procedures should only be performed on patients with severe symptoms of OD plus severe structural disorders and minimal or even absent FDD&#46; Most of these surgical patients will require long term postoperative medical care and rehabilitation to improve rectal emptying and avoid recurrences&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Funding</span><p id="par0280" class="elsevierStylePara elsevierViewall">Part of this research was funded through a <span class="elsevierStyleGrantSponsor" id="gs1">PERIS</span> grant from Catalonian Health Department &#40;<span class="elsevierStyleGrantNumber" refid="gs1">SLT017&#47;20&#47;000125</span> and <span class="elsevierStyleGrantNumber" refid="gs1">SLT017&#47;20&#47;000236</span>&#41;&#46; Ciberehd is founded by <span class="elsevierStyleGrantSponsor" id="gs2">Instituto de Salud Carlos III&#44; Barcelona&#44; Spain</span>&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conflicts of interest</span><p id="par0285" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Declaration of generative AI and AI-assisted technologies in the writing process</span><p id="par0290" class="elsevierStylePara elsevierViewall">No use of generative AI or AI-assisted technologies have been used in the writing process of this scientific manuscript&#46;</p></span></span>"
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          "titulo" => "Abstract"
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              "titulo" => "Background&#47;aims"
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          "titulo" => "Keywords"
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          "identificador" => "xpalclavsec1843738"
          "titulo" => "Abbreviations"
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          "identificador" => "xres2193473"
          "titulo" => "Resumen"
          "secciones" => array:4 [
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              "titulo" => "Antecedentes&#47;objetivos"
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              "titulo" => "Pacientes y m&#233;todos"
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              "titulo" => "Defecography"
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            2 => array:3 [
              "identificador" => "sec0025"
              "titulo" => "Defecographic measurements and interpretation"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0030"
                  "titulo" => "Functional"
                ]
                1 => array:2 [
                  "identificador" => "sec0035"
                  "titulo" => "Structural"
                ]
              ]
            ]
            3 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Anorectal manometry&#46; Technique and measurements"
            ]
            4 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Categorization of patients into SDD&#44; FDD or both"
            ]
            5 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Data analysis"
            ]
          ]
        ]
        7 => array:3 [
          "identificador" => "sec0055"
          "titulo" => "Results"
          "secciones" => array:7 [
            0 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Symptoms"
            ]
            1 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Structural findings &#40;SDD&#41; during defecography"
            ]
            2 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Overlapping of structural disorders"
            ]
            3 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Functional findings from the evacuation defecography"
            ]
            4 => array:2 [
              "identificador" => "sec0080"
              "titulo" => "Functional findings from the anorectal manometry"
            ]
            5 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "Categorization of patients according to the disorder"
            ]
            6 => array:2 [
              "identificador" => "sec0090"
              "titulo" => "Factors associated with reduced expulsive capacity"
            ]
          ]
        ]
        8 => array:2 [
          "identificador" => "sec0095"
          "titulo" => "Discussion"
        ]
        9 => array:2 [
          "identificador" => "sec0100"
          "titulo" => "Conclusions"
        ]
        10 => array:2 [
          "identificador" => "sec0105"
          "titulo" => "Funding"
        ]
        11 => array:2 [
          "identificador" => "sec0110"
          "titulo" => "Conflicts of interest"
        ]
        12 => array:2 [
          "identificador" => "sec0115"
          "titulo" => "Declaration of generative AI and AI-assisted technologies in the writing process"
        ]
        13 => array:2 [
          "identificador" => "xack755595"
          "titulo" => "Acknowledgements"
        ]
        14 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2023-12-11"
    "fechaAceptado" => "2024-05-24"
    "PalabrasClave" => array:2 [
      "en" => array:2 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1843739"
          "palabras" => array:5 [
            0 => "Constipation"
            1 => "Defecation"
            2 => "Rectal diseases"
            3 => "Defecography"
            4 => "Manometry"
          ]
        ]
        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec1843738"
          "palabras" => array:11 [
            0 => "FDD"
            1 => "SDD"
            2 => "ED"
            3 => "ARM"
            4 => "OD"
            5 => "EAS"
            6 => "IAS"
            7 => "ARA"
            8 => "PD"
            9 => "MRI"
            10 => "MRP"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1843737"
          "palabras" => array:5 [
            0 => "Estre&#241;imiento"
            1 => "Defecaci&#243;n"
            2 => "Enfermedades rectales"
            3 => "Videoproctograf&#237;a"
            4 => "Manometr&#237;a"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background&#47;aims</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Defecation disorders can occur as a consequence of functional or structural anorectal dysfunctions during voiding&#46; The aims of this study is to assess the prevalence of structural &#40;SDD&#41; vs functional &#40;FDD&#41; defecation disorders among patients with clinical complaints of obstructive defecation &#40;OD&#41; and their relationship with patients&#8217; expulsive capacity&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of 588 patients with OD studied between 2012 and 2020 with evacuation defecography &#40;ED&#41;&#44; and anorectal manometry &#40;ARM&#41; in a subgroup of 294&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">90&#46;3&#37; patients were women&#44; age was 58&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;4 years&#46; Most &#40;83&#46;7&#37;&#41; had SDD &#40;43&#46;7&#37; rectocele&#44; 45&#46;3&#37; prolapse&#44; 19&#46;3&#37; enterocele&#44; and 8&#46;5&#37; megarectum&#41;&#44; all SDD being more prevalent in women except for megarectum&#46; Functional assessments showed&#58; &#40;a&#41; absence of rectification of anorectal angle in 51&#37; of patients and poor pelvic descent in 31&#46;6&#37; at ED and &#40;b&#41; dyssynergic defecation in 89&#46;9&#37;&#44; hypertonic IAS in 44&#37;&#44; and 33&#46;3&#37; rectal hyposensitivity&#44; at ARM&#46; Overall&#44; 46&#46;4&#37; of patients were categorized as pure SDD&#44; 37&#46;3&#37; a combination of SDD<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>FDD&#44; and 16&#46;3&#37; as having pure FDD&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Rectal emptying was impaired in 66&#46;2&#37; of SDD&#44; 71&#46;3&#37; of FDD and in 78&#37; of patients with both &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;017&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">There was a high prevalence of SDD in middle-aged women with complaints of OD&#46; Incomplete rectal emptying was more prevalent in FDD than in SDD although FDD and SDD frequently coexist&#46; We recommend a stepwise therapeutic approach always starting with therapy directed to improve FDD and relaxation of striated pelvic floor muscles&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background&#47;aims"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes&#47;objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los trastornos defecatorios ocurren como consecuencia de disfunciones anorrectales funcionales o estructurales&#46; El objetivo del estudio es evaluar la prevalencia de trastornos estructurales defecatorios &#40;TED&#41; versus funcionales &#40;TFD&#41; entre pacientes con s&#237;ntomas de defecaci&#243;n obstructiva &#40;DO&#41; y su relaci&#243;n con la capacidad expulsiva&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo con 588 pacientes con DO estudiados entre 2012 y 2020 con videodefecograf&#237;a &#40;VD&#41;&#44; y manometr&#237;a anorrectal &#40;MAR&#41; en un subgrupo de 294&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El 90&#44;3&#37; de los pacientes eran mujeres&#44; con 58&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;4 a&#241;os&#46; La mayor&#237;a &#40;83&#44;7&#37;&#41; presentaban TED &#40;43&#44;7&#37; rectocele&#44; 45&#44;3&#37; prolapso&#44; 19&#44;3&#37; enterocele y 8&#44;5&#37; megarrecto&#41;&#44; siendo m&#225;s prevalentes en mujeres excepto el megarrecto&#46; Evaluaci&#243;n funcional&#58; a&#41; VD&#58; ausencia de rectificaci&#243;n del &#225;ngulo anorrectal en el 51&#37; de los pacientes y escaso o nulo descenso perineal en el 31&#44;6&#59; y b&#41; MAR&#58; defecaci&#243;n disin&#233;rgica en el 89&#44;9&#37;&#44; EAI hipert&#243;nico en el 44&#37; e hiposensibilidad rectal en el 33&#44;3&#37;&#46; En conjunto&#44; el 46&#44;4&#37; de los pacientes se clasificaron como SDD puro&#44; el 37&#44;3&#37; TED<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TFD y el 16&#44;3&#37; como TFD puro&#46; La capacidad expulsiva estaba afectada en el 66&#44;2&#37; de los TED&#44; el 71&#44;3&#37; de los TFD y en el 78&#37; de los pacientes con ambos trastornos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;017&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Hubo una alta prevalencia de TED en mujeres con s&#237;ntomas de DO&#46; El vaciamiento rectal incompleto era m&#225;s prevalente en los pacientes con TFD que en aquellos con TED&#44; pero m&#225;s cuando ambos coexist&#237;an&#46; Recomendamos un enfoque terap&#233;utico empezando siempre con terapia dirigida a mejorar el TFD y la relajaci&#243;n de los m&#250;sculos estriados del suelo p&#233;lvico&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Antecedentes&#47;objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Pacientes y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0305" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="fig0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0125"
          ]
        ]
      ]
    ]
    "multimedia" => array:7 [
      0 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2162
            "Ancho" => 3167
            "Tamanyo" => 494938
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Metrics for video proctography&#58; &#40;A&#41; at rest and &#40;B&#41; during straining&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1318
            "Ancho" => 3167
            "Tamanyo" => 385877
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Overlapping structural disorders&#46; Left&#58; Patient with dyssynergia Type I and rectocele with incomplete rectal emptying and intrarectal prolapse&#46; Right&#46; Patient with a megarectum and a large rectocele&#44; with increased rectal compliance and impaired RAIR&#44; enterocele and external rectal prolapse&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1483
            "Ancho" => 2065
            "Tamanyo" => 135190
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Prevalence of isolated structural defecation disorders and their combinations&#46; Percentage &#40;in <span class="elsevierStyleItalic">italics</span> and darker colour&#41; of the overlap with a functional defecation disorder&#46; SDD&#58; structural defecation disorders&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 2994
            "Ancho" => 2145
            "Tamanyo" => 198345
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Prevalence of SDD&#44; FDD and a combination of both in patients with OD&#44; women&#44; men and overall&#46; SDD&#58; structural defecation disorders&#59; FDD&#58; functional defecation disorders&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 2645
            "Ancho" => 2475
            "Tamanyo" => 265670
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Prevalence of patients with incomplete rectal emptying and associated disorders&#46; SDD&#58; structural defecation disorders&#59; FDD&#58; functional defecation disorders&#59; ARA&#58; anorectal angle&#59; PD&#58; perineal descent&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">MRP&#58; mean resting pressure&#59; AC&#58; anal canal&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Expulsive capacity</th><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preserved&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Impaired&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">32&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;043&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">19&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">80&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypersensitivity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">39&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">60&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
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