Dyssynergic patterns of defecation in constipated adolescents and young adults with anorectal malformations

Abstract

We aimed to evaluate the etiologies of constipation in patients with anorectal malformations having a good prognosis for bowel control but a high risk of constipation. We included twenty-five patients from the Odense university hospital in Denmark. Patients were subjected to colon transit time examination and high resolution anorectal manometry (HRAM). The median age was 18 (14-24) and 48% (12/25) were females. Fifty-two % (13/25) of patients were diagnosed with constipation. Types of anorectal malformation were perineal fistula (9/25), rectovestibular fistula (8/25), rectourethral bulbar fistula (5/25) and no fistula (3/25). No difference in neither total colon transit time nor segmental colon transit times were found based on the presence of constipation. Only four of the constipated patients fulfilled criteria for dyssynergic defecation with a dyssynergic pattern at HRAM and prolonged colon transit time. A Type I dyssynergic pattern was dominant in constipated patients (7/13). A Dyssynergic defecation pattern was due to isolated contraction of puborectalis muscle in 9 out of 13constipated patients. We found a dyssynergic pattern during attempted defecation in patients with anorectal malformations disregarded the presence of constipation. In the majority of constipated patients an isolated contraction of the puborectalis muscle was visualized with HRAM.

Trial registration: ClinicalTrials.gov NCT02624232.

Figure 1

Pressure profile obtained by HRAM showing a lambda pattern during squeeze maneuver. On the right a normal characteristic λ-pattern after 2D opening of the 3D pressure cylinder on the left. Numbers indicates distance in length from anal verge in centimeters. Ant anterior, Post posterior, L left, H right. Numbers indicates length in centimeters.

Figure 2

Dyssynergic patterns from HRAM during attempted defecation. Tracings from high resolution anorectal manometry, revealing four different patterns during attempted defecation in study patients. In type I dyssynergia the patient generates an adequate propulsive force (rise in intra-rectal pressure > 40 mm Hg) accompanied by a paradoxical increase in the anal sphincter pressure. In type II dyssynergia the patient is unable to generate an adequate compulsive force with a paradoxical small increase in anal sphincter pressure. In type III dyssynergia the propulsive rectal force is adequate but no relaxation of the anal sphincter. In type IV dyssynergia generated propulsive force is insufficient with inadequate relaxation of the anal sphincter.

Figure 3

Individual muscle involvement during attempted defecation. High resolution anorectal manometry results in two constipated patient during attempted defecation. High pressure areas are seen with “warm” colors (red/purple) and low pressure areas with “cold” color (blue/green/yellow). On the left is presented a three-dimensional cylindrical pressure-distribution during attempted defecation. A two-dimensional landscape plot of the cylindrical presentation is presented on the right. In the upper picture a high pressure area is located in the posterior and proximal part of the anal canal indicative of paradoxical activation of the puborectalis muscle. In the lower picture a high pressure zone is observed in lower part of the anal canal interpreted as external anal sphincter contraction. Numbers indicates length in centimeters. Ant anterior, Post posterior, L left, H right.

Figure 4

Abdominal frontal x-ray with colonic segments. In this frontal x-ray containing radio-opaque markers, the imaginary white lines mark the areas for segmental colon transit times. From the center of vertebrae L5, one line runs cranially along the vertebrae. The two other strait lines run towards the left iliac crest and the right pelvic outlet. The formed upper right area, the upper left and the lower left areas represents the right colon, the left colon and the recto-sigmoid colon respectively.