Original article—alimentary tract
Digital Rectal Examination Is a Useful Tool for Identifying Patients With Dyssynergia

https://doi.org/10.1016/j.cgh.2010.06.031Get rights and content

Background & Aims

Dyssynergic defecation is a common cause of chronic constipation; its diagnosis requires anorectal physiological tests that are not widely available. It is not known whether digital rectal examination (DRE) can be used to identify dyssynergia. We examined the diagnostic yield of DRE in patients with dyssynergic defecation.

Methods

Consecutive patients with chronic constipation (Rome III criteria, n = 209) underwent DREs, anorectal manometry analyses, balloon expulsion tests, and colonic transit studies. In the DRE, dyssynergia was identified by 2 or more of the following features: impaired perineal descent, paradoxic anal contraction, or impaired push effort; diagnostic yields were compared with physiological test results.

Results

Of the patients included in the study, 187 (87%) had dyssynergic defecation, based on standard criteria; 134 (73%) of these were identified to have features of dyssynergia, based on DREs. The sensitivity and specificity of DRE for identifying dyssynergia in patients with chronic constipation were 75% and 87%, respectively; the positive predictive value was 97%. DRE was able to identify normal resting and normal squeeze pressure in 86% and 82% of dyssynergic patients, respectively.

Conclusions

DRE appears to be a reliable tool for identifying dyssynergia in patients with chronic constipation and detecting normal, but not abnormal, sphincter tone. DREs could facilitate the selection of appropriate patients for further physiologic testing and treatment.

Section snippets

Materials and Methods

Patients referred to a tertiary care center with symptoms of chronic constipation and difficult defecation, and who fulfilled the Rome III criteria for functional constipation,16, 17 were enrolled in this study. They were asked to complete a constipation symptom questionnaire that assessed the prevalence of common bowel symptoms. Their clinical assessment included a detailed DRE (as described later), performed by a single investigator (S.S.C.R.). Subsequently, all patients underwent anorectal

Demographics and Symptoms

A total of 209 patients (men/women, 191/18) with a mean age (± standard deviation) of 41 ± 15.3 years, and with a diagnosis of chronic constipation (ROME III), were enrolled. The mean duration (± standard deviation) of constipation symptoms was 17 ± 15.1 years. The symptom patterns reported by these patients are shown in Figure 1.

Anorectal Manometry

A total of 183 patients (87%) had a dyssynergic pattern of defecation based on established criteria.19 The anal resting sphincter pressure was normal in 101 patients

Discussion

Because the prevalence of dyssynergia in the community is not known and the diagnosis of dyssynergic defecation requires both symptomatic and objective physiologic criteria,6, 8, 9 we examined a consecutive group of patients presenting with chronic constipation and difficulty with defecation to a specialized defecation disorders clinic. Although previous studies have examined the correlation between DRE and anorectal manometry findings in subgroups of patients with anorectal disorders,14, 26, 27

Acknowledgments

The authors sincerely acknowledge the excellent statistical advice and help of M. Bridget Zimmerman, PhD.

References (38)

  • D.M. Preston et al.

    Anismus in chronic constipation

    Dig Dis Sci

    (1985)
  • W.E. Whitehead et al.

    Functional disorders of the anorectum

    Gut

    (1999)
  • B.M. Kawimbe et al.

    Outlet obstruction constipation (anismus) managed by biofeedback

    Gut

    (1991)
  • A.E. Bharucha

    Update of tests of colon and rectal structure and functionAlimentary tract: clinical review

    J Clin Gastroenterol

    (2006)
  • S.S. Rao et al.

    Clinical utility of diagnostic tests for constipation in adults: a systematic review

    Am J Gastroenterol

    (2005)
  • J. Hill et al.

    History and examination in the assessment of patients with idiopathic fecal incontinence

    Dis Colon Rectum

    (1994)
  • A. Wald

    CON: anorectal manometry and imaging are not necessary in patients with fecal incontinence

    Am J Gastroenterol

    (2006)
  • S.S. Rao

    A balancing view: fecal incontinence: test or treat empirically—which strategy is best?

    Am J Gastroenterol

    (2006)
  • R.I. Hallan et al.

    Comparison of digital and manometric assessment of anal sphincter function

    Br J Surg

    (1989)
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    This article has an accompanying continuing medical education activity on page e116. Learning Objectives—At the end of this activity, the learner should be able to recognize the diagnostic criteria for dyssynergic defecation, appreciate the utility of rectal examination in suggesting the diagnosis, and recognize the prevalence of pelvic floor dysfunction as a cause of chronic constipation.

    Conflicts of interest The authors disclose no conflicts.

    Funding Dr Rao was supported by National Institutes of Health grant 2R01 KD57100-05A2; and Dr Tantiphlachiva was supported by a research fellowship grant from Chulalongkorn University, Bangkok, Thailand.

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