Clinical Impact of Rectal Hyposensitivity: A Cross-Sectional Study of 2,876 Patients With Refractory Functional Constipation

Abstract

INTRODUCTION: Normal bowel function requires intact sensory pathways. Diminished rectal sensation (rectal hyposensitivity [RH]) is associated with constipation, although its clinical importance remains unclear. METHODS: Consecutive patients (aged 18–80) attending a tertiary center (2004–2016) for investigation of refractory functional constipation (Rome IV core criteria defined, applied post hoc) were included. Patients completed a clinical symptom questionnaire and underwent anorectal physiologic investigations, including rectal sensory testing (balloon distension) to determine 3 well-established sensory thresholds. Multivariate regression analyses were performed to evaluate associations between RH, symptomology, and allied physiologic investigations. RESULTS: Of 2,876 patients meeting inclusion criteria, 722 (25%) had RH based on ≥1 elevated sensory thresholds (0: n = 2,154 [74.9%]; 1: n = 327 [11.4%]; 2: n = 209 [7.3%]; and 3: n = 186 [6.5%]). A linear relationship existed between increasing number of elevated sensory thresholds and constipation severity (Cleveland Clinic constipation score: mean difference per threshold [95% confidence interval] 0.69 [0.48–0.90]; P < 0.001). Several symptoms were significantly (P < 0.05) associated with RH including: infrequent defecation (odds ratio 1.29 [1.17–1.42]), painful evacuation (1.15 [1.05–1.27]), prolonged toileting (1.14 [1.05–1.24]), and digitation or enema use (1.18 [1.08–1.30]). On defecography, a “functional” evacuation disorder was also associated with RH (1.37 [1.25–1.50], P < 0.001), as was megarectum (2.52 [2.08–3.05], P < 0.001). DISCUSSION: RH occurs in 25% of patients with refractory functional constipation. Increased number of elevated sensory thresholds is associated with more severe constipation phenotype. These data, in the largest study to date, provide for the first time evidence to show that RH is a major pathophysiologic mechanism in constipation, with recognized clinical impact (http://links.lww.com/AJG/B765). JOURNAL/ajgast/04.03/00000434-202104000-00029/inline-graphic1/v/2023-07-18T070751Z/r/image-tiff

Gastrointestinal transit and contractility in diabetic constipation: A wireless motility capsule study on diabetes patients and healthy controls

“…We therefore emphasise the need for a thorough investigation before initiating treatment, which should be individualised based on diagnostic findings. Prokinetic agents may still have a place in treatment but other causes like rectal evacuation disorders and psychiatric comorbidities should be ruled out first, as these require an entirely different approach to treatment than slow‐transit constipation 25,30 . When performing gastrointestinal motility testing, our findings also underline the relevance of evaluating more than just colonic transit, as diabetes patients regularly show concurrent affection of multiple gastrointestinal segments 33 .…”

“…Without sensing this stimulation, the urge to defecate may be attenuated, leading to accumulation of faeces 21 . In patients with refractory functional constipation, 25% had rectal hyposensitivity 25 . Given the potential of diabetic neuropathy for disrupting anorectal sensory pathways, we consider it likely that rectal hyposensitivity is a main mechanism also in diabetic constipation.…”

Transcutaneous Electrical Acustimulation Improves Constipation by Enhancing Rectal Sensation in Patients With Functional Constipation and Lack of Rectal Sensation

“…Rectal sensory dysfunction involves in the development of functional bowel diseases ( 22 ), and rectal hyposensitivity was reported in patients with functional constipation ( 38 , 39 ). In addition, diminished awareness of rectal distension has been shown in metabolic diseases, neurological diseases, and postanorectal surgery.…”

Non-drug therapies for the management of chronic constipation in adults: the CapaCiTY research programme including three RCTs

“…This focus was pragmatic, given the concentration of expertise, diagnostics and biofeedback equipment in hospital settings. Based on well-established epidemiological data 28,29 (see SYNOPSIS, Background), the main target population was women of mean age 50 years.…”

“…Christine Norton is chief investigator on another programme grant on symptom management in inflammatory bowel disease. 2 Overall PAC-QoL score by randomised group and mean differences between HT and HTBF groups and no-INVEST and INVEST groups for those included in the final analysis model TABLE 3 The CapaCiTY trial 2 primary outcome: PAC-QoL score, low-volume TAI vs. high-volume TAI TABLE 4 Total PAC-QoL and PAC-SYM scores at baseline and follow-up points post surgery, with 95% CI and p-value for change from baseline to each follow-up point 7 The CapaCiTY trial 1 outcome measures at baseline TABLE 8 Mean PAC-QoL score by randomised group at 6 months and mean differences between HT and HTBF and between no-INVEST and INVEST groups for those included in the final analysis model TABLE 9 Binary PAC-QoL score at 3, 6 and 12 months by randomised group and ORs for HT and HTBF and no-INVEST and INVEST groups for those included in the final analysis model TABLE 10 Overall PAC-QoL score for individual domains at 3, 6 and 12 months by randomised group and mean differences between HT and HTBF and between no-INVEST and INVEST groups for those included in each analysis model at the relevant time point TABLE 11 Other continuous secondary outcomes at 3, 6 and 12 months by randomised group and mean differences between HT and HTBF and between no-INVEST and INVEST groups for those included in each of the final analysis models at the relevant time point TABLE 12 Binary secondary outcomes (EQ-5D-5L) at 3, 6 and 12 months by randomised group and mean differences between HT and HTBF and no-INVEST and INVEST groups for those included in each of the final analysis models at the relevant time point TABLE 13 The CapaCiTY trial 1 AEs and SAEs TABLE 14 The CapaCiTY trial 1 economic analysis variables (£, 2018) TABLE 15 The CapaCiTY trial 1 cost-effectiveness analysis (£, 2018) TABLE 16 The CapaCiTY trial 2 baseline data TABLE 17 The CapaCiTY trial 2 outcome measure data at baseline TABLE 18 The CapaCiTY trial 2 primary outcome: PAC-QoL score, low-volume vs. high-volume TAI and difference in means at 3 months TABLE 19 The CapaCiTY trial 2 continuous secondary outcomes at baseline and follow-up for participants with data collected at 3, 6 and 12 months by randomised treatment group TABLE 20 The CapaCiTY trial 2 binary secondary outcomes (EQ-5D-5L score) at baseline and follow-up for patients with data collected at 3, 6 and 12 months by randomised treatment group 25 The CapaCiTY trial 2 cost-effectiveness analysis (£, 2018) TABLE 26 The CapaCiTY trial 3 baseline data TABLE 27 The CapaCiTY trial 3 outcome measure data at baseline TABLE 28 ...…”