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358
P.J. Mitchell and E.S. Kiff
25.7 Assessment of Sphincter Neurophysiology
For over 30 years, it has been recognized that sphincter dysfunction may be second-
ary to a neurological injury. Neurophysiological assessment of sphincter function
involves conduction studies of the pudendal nerve and evaluation of motor unit
function by electromyography.
25.7.1 Pudendal Nerve Terminal Motor Latency
The St. Mark’s Electrode (rubber fi nger-mounted device) which contains a stimulat-
ing electrode at the tip and recording electrodes at the base of the fi nger is inserted into
the rectum. After palpation of the ischial spine, supramaximal stimuli are delivered to
the pudendal nerve. The delay from the time of stimulation to the beginning of EAS
contraction is recorded and represents the pudendal nerve terminal motor latency. A
value of less than 2.2 ms is generally taken as normal, with greater values indicating
prolonged latency and pudendal nerve dysfunction. PNTMLs have been shown to be
signifi cantly greater in incontinent subjects compared with normal controls [ 25 ] and
have been proposed as a method of predicting those with sphincter disruption that
would have a successful sphincter repair.
Unfortunately, for practical purposes, the test is too insensitive to accurately rep-
resent the neurophysiological status of the pudendal nerve. Problems include the
exact placement of the stimulating electrode adjacent to the pudendal nerve, a lack
of correlation with anal manometry, and the fact that normal values have not been
clearly established. In addition, the procedure only records conduction in the fastest
nerve fi bers. This means that despite signifi cant damage, a normal latency will be
recorded even if only a few of the fastest conducting fi bers remain.
25.7.2 Electromyography
With the advent of EAUS, the role of EMG has changed from a valuable tool in the
assessment of sphincter defects to use mainly in the research setting. It can be per-
formed by two methods, concentric needle and single fi ber studies. Concentric nee-
dle studies are able to record the activity of up to 30 muscle fi bers around the needle,
both at rest and during contraction, whereas single fi ber studies use a smaller record-
ing area and are able to record the action potential from individual motor units.
EMG provides valuable information on the integrity of the neuromuscular con-
nection between the pudendal nerve and the sphincter muscle fi bers. The param-
eters assessed include the presence or absence of spontaneous activity, the ability
of the patient to voluntarily activate muscles, and specifi c measures of the motor
unit action potential waveform (MUAP) such as amplitude, duration, and number
359
25 Assessment and Investigation of Fecal Incontinence and Constipation
of phases. If more than four phases are present in the MUAP then the signal is
termed polyphasic. Measurements from muscle that are outside the normal range
for amplitude and duration, and are polyphasic, are indicative of prior denervation
injury and reinnervation of the muscle. Single fi ber needles can be used to calcu-
late the mean fi ber density (MFD). This is the mean number of single muscle fi ber
action potentials recorded within the electrode uptake area. Normal MFD is
between 1 and 2. However, if the nerve supply to a muscle fi ber is irreversibly
damaged, then muscles fi bers will either die or become reinnervated by adjacent
nerve fi ber endings which will result in an increased MFD. Patients with FI have
been shown to have higher single fi ber densities when compared with control
subjects [
26 ] .
Although the role of EMG in the detection of sphincter defects has been super-
seded by EAUS, some feel it may still be useful in the assessment of patients with
constipation and associated anorectal dysfunction, particularly those with anismus.
Wexner et al. found that paradoxical puborectalis contraction was more frequently
diagnosed with EMG than defecation proctography in a study of 40 subjects with
chronic constipation and 19 subjects with intractable pelvic pain [ 27 ] .
25.7.3 Anal Sensation
The mucosa of the anal canal is richly innervated with sensory nerve endings (of the
pudendal nerve) which respond to the stimuli of touch, pain, and temperature.
Specialized probes have been used to assess the response to thermal stimuli, but this
is mainly limited to the research setting. More commonly performed is anal mucosal
electrosensitivity, in which a current is passed to the anal mucosa from a probe
within the anal canal. The current is increased until the sensation threshold is noted
by the subject. Felt-Bersma et al. studied 387 patients with various anorectal condi-
tions with anal mucosal electrosensitivity and found subjects with FI, constipation,
mucosal prolapse, hemorrhoids, and sphincter defects; all had reduced anal sensitiv-
ity compared with controls [ 28 ] .
25.8 Assessment of Rectal Function
25.8.1 Sensation
Rectal sensory function can be assessed in a number of ways:
The most commonly performed is the simple balloon distension method. A latex •
balloon inserted into the rectum is infl ated with air from a syringe, and the patient
is asked to signify the onset of sensation, call to stool, and maximum tolerated
threshold. Although commonly used in everyday clinical practice, the sensory
360
P.J. Mitchell and E.S. Kiff
responses obtained will vary with the speed of infl ation, type of infl ation (con-
tinuous or intermittent), size of balloon, and depth of insertion into the rectum.
Despite these limitations, it is an easy to perform test which provides a quick
crude assessment of rectal sensation.
A more accurate method of recording sensations utilizes a visual analog scale during •
barostat distension. This computerized method overcomes many of the limitations of
simple balloon distension and also allows the continuous measurement of pressure
and volume within the balloon providing measurements of rectal compliance. Such
barostat setups are more time-consuming, expensive, and of limited availability.
Rectal sensation can also be assessed in terms of direct mucosal thermal and elec-•
trical stimulation. Mainly found in the research setting, this technique is limited
by the diffi culty of ensuring contact with the mucosa and the presence of stool
within the rectum.
Hyposensitivity of the rectum, defi ned with the fi nding of elevated sensory
thresholds, has been found to occur in a signifi cant proportion of patients with con-
stipation [
29 ] . In contrast, rectal hypersensitivity (characterized by reduced sensory
volumes) has been reported in up to 47% of FI patients [ 30 ] . Reduced rectal sensa-
tion can also occur in FI, for example, in patients with coexisting diabetes mellitus.
Improving rectal sensation in these patients with low readings using biofeedback
methods (sensory training) may improve symptoms.
25.8.2 Motor
Defecation proctography is a dynamic investigation that provides information about
structural changes of the anorectum and an assessment of functional performance.
Widely available and easy to perform, it has become a common and much used
investigation particularly for patients with constipation.
Radiopaque barium paste is introduced into the rectum via a Foley catheter and
bladder syringe, with patient lying in the left lateral position. The patient sits on a
commode, which rests on the footrest of a standard digital fl uoroscopic table;
30–45 min before the procedure, the patient drinks 100 ml barium sulfate 100%
(w/v) diluted with 200 ml water to opacify the small bowel. Static images using
fl uoroscopic image capture are obtained at rest and with active contraction
(“squeeze”) of the pelvic fl oor. Video capture of evacuation is then obtained until
the rectum is empty or at least three 30 s attempts have been made. A wide range of
conditions can be diagnosed on defecation proctography such as rectocele, entero-
cele, intussusception, prolapse, and anismus [
31 ] . The extent of evacuation can also
be assessed, with normal emptying being 90% complete [ 32 ] .
The test is not without its limitations. It is not an ideal assessment of defecation
as it is not performed in response to a desire to defecate, and patient embarrass-
ment may limit the outcome. During a proctogram, the rectum is passive, being
squeezed by the intra-abdominal pressure against the pelvic fl oor, which differs
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25 Assessment and Investigation of Fecal Incontinence and Constipation
from normal defecation when associated colonic and rectal contractions occur.
There is also a wide variation in normal parameters, and a number of conditions
such as rectocele and perineal descent, for example, can occur in normal asymp-
tomatic individuals. The clinician should be wary of overinterpretation and, as
with all tests of anorectal function, use the results in context of the history and
examination fi ndings.
Proctography is of value in the assessment of the patient with constipation in
order to exclude/include the presence of outlet obstruction. The presence of
pathologies that cause diffi cult defecation (e.g., rectoceles, internal prolapse)
may be surgically corrected in the constipated patient with normal transit.
Proctograms are of less use in the FI subject but may be helpful when signifi cant
connective tissue trauma is suspected giving rise to a rectocele, descent, or intus-
susception, for example, that may be contributing to the incontinent symptoms
experienced.
Dynamic magnetic resonance imaging is an alternative to contrast proctography.
More expensive that defecation proctography and limited to specialist centers,
dynamic MR has the advantage of avoidance of ionizing radiation while allowing a
global visualization of pelvic fl oor motion including the anorectum, bladder, and
genital organs. It can be performed as an evacuation (approx. 150 ml of ultrasound
gel from rectum) or nonevacuation procedure.
Often limited in that the patient is supine, the use of open magnets allows dynamic
imaging in the seated position and is more ideal. Other disadvantages include patient
tolerance of an enclosed space and a tendency to underestimate smaller anatomical
defects, such a rectal intussusception.
Rentsch et al. [
33 ] performed dynamic supine MR on 20 patients who had pelvic
fl oor abnormalities on clinical examination and found agreement with the clinical
diagnosis in 77% on MR imaging. In addition, MR identifi ed additional clinical
diagnoses in 17 of the 20 patients, thus emphasizing the importance of MR in the
assessment of pelvic fl oor abnormalities, which are often complex and involve more
than one pelvic compartment and medical discipline. The development of this imag-
ing modality and a greater availability will lead to a more accurate assessment of
patients with diffi cult defecation.
The balloon topography test simultaneously assesses anorectal and pelvic fl oor
function. It is performed with a cylindrical balloon placed into the anal canal and
rectum and fi lled with liquid radiopaque contrast under low pressure. The shape of
the balloon is recorded using fl uoroscopy with static and active anal canal function
and correlated anal pressures and anorectal angle. Patients with outlet obstruction
show a failure of relaxation of puborectalis muscle during straining with mainte-
nance of the anorectal angle.
The balloon expulsion test involves inserting the balloon into the rectum and fi ll-
ing it with either warm water or air (typically a volume of 50 ml), before the patient
is instructed to expel the balloon either in the left lateral position or on a commode.
A systematic review found that between 23% and 67% of patients with constipation
will be unable to expel the balloon. However, up to 16% of controls also had diffi -
culty in balloon expulsion [
34 ] .
362
P.J. Mitchell and E.S. Kiff
25.8.3 Biomechanical: Rectal Compliance
Initially, the rectum actively relaxes upon distension, the “accommodation response”
[
35 ] . Further distension leads to an increase in rectal pressure as the elastic limit of
the rectal walls is approached. This rectal distensibility is measured as the rectal
compliance (change in volume/change in pressure). Performed using a barostat and
highly compliant rectal balloon, the exact role of this test in the management of
patients with FI and constipation is uncertain at present. An increase in rectal com-
pliance has been found in patients with megarectum, whereas a reduced compliance
(implying a “stiffness” to the rectum) has been found following radiation therapy
and in those with infl ammatory bowel disease.
25.9 Assessment of Colonic Transit Function
25.9.1 Shape Studies
This is a simple and easy test of colonic function, but one that is performed in
numerous different ways related to the timing of X-rays, method of consuming the
shapes, and whether fi ber and/or dietary restrictions are followed. Commonly, the
subject ceases all laxatives for 48 h and then swallows 20 radiopaque markers. A
plain abdominal fi lm is performed on day 5, by which time at least 14 (80%) of the
markers will have been passed by a normal functioning colon [ 36 ] . A diffuse scatter
of markers is more in keeping with colonic inertia, while the concentration of mark-
ers within the pelvis suggests outlet obstruction/diffi cult defecation.
In ten studies that assessed colonic transit studies in subjects with constipation, an
abnormal study (supporting the presence of constipation) occurred in 38–80% of sub-
jects [ 34 ] . More detailed assessment with daily X-rays may identify segmental transit
problems [ 37 ] , but the clinical value of such assessment remains controversial. Indeed,
the clinical role of transit studies per se in patients with severe intractable constipation
is debatable. It is normally obvious from the history that the transit time is prolonged.
Nevertheless, studies are usually carried out in patients in whom surgery is being
considered. The presence of normal transit should focus the attention upon a disorder
of defecation and away from consideration of colectomy for such patients.
25.9.2 Colonic Scintigraphy
Compared to the simple shape studies, this method is more expensive, time-con-
suming, and less readily available, being confi ned to mainly specialist centers. Two
363
25 Assessment and Investigation of Fecal Incontinence and Constipation
forms of the study exist with the patient either consuming the isotope orally in a
nonabsorbable form mixed into a test meal or as a capsule coated with pH-sensitive
material that dissolves in the colon or terminal ileum releasing the isotope. A gamma
camera is used to measure the radioactivity of the colon, and a colonic scintigram
image is produced at 24, 48, and 72 h postingestion. At each of these screenings, the
“geometric center” is calculated, which represents a weighted average of the radio-
activity recorded in the specifi c sections of the colon. A low geometric center value
implies the majority of the isotope is close to the cecum, whereas a high value
occurs when most of the isotope is in the defecated stool or rectosigmoid [
38 ] .
This method is capable of measuring not only overall colonic transit but also
segmental transit and has been suggested as a method for identifying constipated
patients in whom a segmental resection may be performed [ 39 ] .
25.9.3 Lactulose Hydrogen Breath Test
In some patients with constipation, the prolonged transit and dysmotility is not lim-
ited only to the colon but to the entire gastrointestinal tract. Such patients are more
likely to have recurrent constipation after subtotal colectomy and ileorectal anasto-
mosis [ 40 ] . Measurement of upper gastrointestinal motility may therefore be of
benefi t in constipated patients in whom surgery is being considered. A lactulose
hydrogen breath test is a simple method assessing orocecal transit time. The increase
in exhaled hydrogen occurs when the lactulose bolus is fermented by the colonic
bacteria of the cecum [ 40 ] .
25.10 Overview
Both FI and constipation represent symptoms/signs of an underlying disease pro-
cess or pathology that should be actively identifi ed, as this will ensure correct
assessment and appropriate management. Patients with these conditions are often
embarrassed and may fi nd them diffi cult to talk about. Therefore, the clinician
should spend time establishing the full history and impact upon daily life. Careful
examination of the anorectum and perineum will provide useful information. A
number of specialist tests of anorectal and colonic function exist and can be utilized
once a neoplasm or colitis has been excluded. There are numerous specialist tests
and each have limitations. Anal manometry and EAUS are vital in the assessment of
a patient with FI, whereas the defecating proctogram and colonic transit studies are
of great use in constipated patients. Information obtained from the history, examina-
tion, and specialist tests should allow the appropriate management of these complex
and common conditions.
364
P.J. Mitchell and E.S. Kiff
Case Scenario Answers 1
Always consider the change in bowel habit. Do not miss neoplasia, infl amma-
tory bowel disease or the occasional celiac disease, lactose intolerance, or
drug side effect that might lead to loose stool. The length of history may give
a clue. The nature of the stool is important since the looser it is, the more dif-
fi cult it will be to hold on to. Ask about prolapse on defecation. Is there any
diffi culty with defecation suggestive of connective tissue weakness? Stretchy
tissues in the pelvis are part of perineal trauma. You will need to examine for
this too and may discover rectal prolapse or rectocele. Since she has fecal
incontinence, think about the other two compartments in the pelvis. Does she
have uterine prolapse? Has she had a hysterectomy and if so why? Does she
have urinary incontinence? Does she have sexual diffi culties perhaps due to a
rectocele or distortion of the vagina? History taking is paramount. You will
need time to listen.
The examination may show perineal descent at rest or on straining. Prolapse
or rectocele may become obvious on straining. Gaping of the anus suggests
poor tone at rest. The length of the anal canal and the bulk of the sphincter
muscles can be estimated digitally as can the amount of voluntary contraction.
You may want to consider endoscopy of the bowel if you are concerned about
other causes of loose stool. Physiological studies will quantify the anal pres-
sure at rest and on contraction, and ultrasound will tell you what degree of
muscle damage has occurred. If you suspect a prolapse then a defecating
proctogram may be helpful.
Key Points
Take time to establish the full history, impact upon quality of life, and to •
perform a careful examination of the anorectum and perineum.
Both FI and constipation are symptoms of an underlying pathology and •
diagnosis. Be active in identifying the underlying cause to ensure appropri-
ate management.
There is no perfect test of anorectal or colonic function, all have their limi-•
tations, therefore interpret the results in context of the clinical history and
examination.
Anal manometry and endoanal ultrasound are useful in the FI patient to •
establish the function and structure of the anal sphincters.
Transit studies and a defecating proctogram are necessary in the consti-•
pated patient to identify whether the problem is in defecation, colonic tran-
sit, or both.
365
25 Assessment and Investigation of Fecal Incontinence and Constipation
Case Scenario Answers 2
Patients with constipation want to tell you how bad they are now. You need to
fi nd out what symptoms were like in the past. When did all this start?
Were they constipated as a child? Were they so constipated that they were
impacted with overfl ow? This may suggest a congenital abnormality.
Did the constipation start in their teenage years? Particularly for girls, this is
the period of onset of IBS or dysmotility. Constipation will be associated with
abdominal distension and griping pain. Dysmotility is often triggered by sig-
nifi cant emotional issues. Ask about issues at home. For some people, the onset
of dysmotility relates to surgical procedures particularly within the pelvis.
A third group of people with constipation are those whose bowel transit is
satisfactory, there is a desire to defecate but then an inability to satisfactorily
evacuate. This usually follows childbirth and can be compounded by gyneco-
logical procedures. Patients may or may not be aware of perineal descent and
a rectocele. They very often manipulate themselves in order to defecate and
frequently feel they have not fi nished. Sometimes this is real, with stool left in
the rectum or the rectocele, but sometimes this is not real, with the sensation
coming from an intussuscepting rectum.
To complicate the issue, there are patients who have a mixture of both
dysmotility and diffi culty of evacuation. Indeed, it would be surprising if peo-
ple with longstanding dysmotility and straining at stool did not eventually get
a diffi culty of evacuation due to stretching of tissues. A history of childbirth,
particularly a diffi cult vaginal delivery, and especially a woman with lax tis-
sues (hypermobile joint for instance), should alert you to the possibility of
some degree of prolapse accounting for the diffi culty with defecation.
With regard to investigations, ensure that you are not missing disease
within the bowel. Cancers can happen even in young women.
Transit studies can give you a clue about small and large bowel motility, the
former being done with a hydrogen breath test and the latter with a shape study.
These are snapshots of a moment in time and need interpretation. If a patient’s
bowels only move once every 3 weeks then inevitably the transit is slow.
A defecating proctogram is a useful investigation in this group to look for
prolapse, intussusception, and rectocele in particular. Patients fi nd it useful to
observe what happens when they are trying to defecate. However, beware of over
interpretation; intussusception of the rectum to a degree is probably normal, it
just depends how hard you strain. Always treat people, never treat X-rays.
Anorectal physiology studies can be a useful measure of sphincter activity.
Voluntary contraction of the external sphincter is frequently toward the lower
end of the normal range in a constipated woman. It is worth confi rming the
presence of the rectoanal refl ex to exclude Hirschsprung’s disease. Physiology
studies do not tell you what to do, but it is a comfort to know where you
started from should you be contemplating embarking on surgery.
366
P.J. Mitchell and E.S. Kiff
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