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Chapter 040. Diarrhea and Constipation (Part 16)

ANORECTAL AND PELVIC FLOOR TESTS Pelvic floor dysfunction is suggested by the inability to evacuate the rectum, a feeling of persistent rectal fullness, rectal pain, the need to extract stool from the rectum digitally, application of pressure on the posterior wall of the vagina, support of the perineum during straining, and excessive straining. These significant symptoms should be contrasted with the sense of incomplete rectal evacuation, which is common in IBS. Formal psychological evaluation may identify eating disorders, "control issues," depression, or post-trauma stress disorders that may respond to cognitive or other intervention and may be important in restoring quality of. | Chapter 040. Diarrhea and Constipation Part 16 ANORECTAL AND PELVIC FLOOR TESTS Pelvic floor dysfunction is suggested by the inability to evacuate the rectum a feeling of persistent rectal fullness rectal pain the need to extract stool from the rectum digitally application of pressure on the posterior wall of the vagina support of the perineum during straining and excessive straining. These significant symptoms should be contrasted with the sense of incomplete rectal evacuation which is common in IBS. Formal psychological evaluation may identify eating disorders control issues depression or post-trauma stress disorders that may respond to cognitive or other intervention and may be important in restoring quality of life to patients who might present with chronic constipation. A simple clinical test in the office to document a nonrelaxing puborectalis muscle is to have the patient strain to expel the index finger during a digital rectal examination. Motion of the puborectalis posteriorly during straining indicates proper coordination of the pelvic floor muscles. Measurement of perineal descent is relatively easy to gauge clinically by placing the patient in the left decubitus position and watching the perineum to detect inadequate descent 1.5 cm a sign of pelvic floor dysfunction or perineal ballooning during straining relative to bony landmarks 4 cm suggesting excessive perineal descent . A useful overall test of evacuation is the balloon expulsion test. A balloontipped urinary catheter is placed and inflated with 50 mL of water. Normally a patient can expel it while seated on a toilet or in the left lateral decubitus position. In the lateral position the weight needed to facilitate expulsion of the balloon is determined normally expulsion occurs with 200 g added. Anorectal manometry when used in the evaluation of patients with severe constipation may find an excessively high resting 80 mmHg or squeeze anal sphincter tone suggesting anismus anal sphincter spasm . .