title: Dyssynergic defecation: a treatable cause of persistent symptoms when inflammatory bowel disease is in remission.
abstract: BACKGROUND
  Introduction of biologic agents in inflammatory bowel disease (IBD) has increased the likelihood of disease remission. Despite resolution of active inflammation, a subset of IBD patients report persistent defecatory symptoms.
  
  
  OBJECTIVE
  To evaluate a group of patients with inflammatory bowel disease with suspected functional defecatory disorders, by use of anorectal manometric testing and subsequent biofeedback therapy.
  
  
  METHODS
  A group of IBD patients with persistent defecatory problems despite clinical improvement were included in this study. These patients had no evidence of left-sided disease. Endoscopic and radiographic study findings and timing in relation to the manometry study were recorded. Anorectal manometry was performed by the standard protocol and included rectal sensory assessment, ability to expel a balloon, and pressure dynamics with simulated defecation.
  
  
  RESULTS
  Thirty IBD patients (Crohn's 23 patients; ulcerative colitis six patients) presented with defecatory disorders including constipation (67%) increased stooling (10%), and rectal urgency and/or incontinence and rectal pain (6%). All but one patient had anorectal manometric criteria of dyssynergia (presence of anismus motor pattern and inability to expel the balloon). Of the patients who completed biofeedback therapy, 30% had a clinically significant (≥7-point) improvement in SIBDQ score, with a reduction in health-care utilization after a six-month period (p=0.02).
  
  
  CONCLUSIONS
  Despite remission, some inflammatory bowel disease patients have persistent defecatory symptoms. Defecatory symptoms may not be predictive of an underlying inflammatory disorder. Lack of inflammatory activity and absence of left-sided disease should prompt investigation of functional disorders. Anorectal manometric testing and biofeedback therapy for patients with a diagnosis of dyssynergia may be a useful therapy.
authors.affiliation: Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI, 53226, USA, lperera@mcw.edu.
authors.forename: Lilani P
authors.initials: LP
authors.lastname: Perera
authors.forename: Ashwin N
authors.initials: AN
authors.lastname: Ananthakrishnan
authors.forename: Corinne
authors.initials: C
authors.lastname: Guilday
authors.forename: Kristin
authors.initials: K
authors.lastname: Remshak
authors.forename: Yelena
authors.initials: Y
authors.lastname: Zadvornova
authors.forename: Amar S
authors.initials: AS
authors.lastname: Naik
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Stein
authors.forename: Benson T
authors.initials: BT
authors.lastname: Massey
mesh_terms: D000328:Adult; D001676:Biofeedback, Psychology; D003248:Constipation / Q000209:etiology* / Q000628:therapy; D003672:Defecation; D005260:Female; D006296:Health Services / Q000706:statistics & numerical data; D006801:Humans; D015212:Inflammatory Bowel Diseases / Q000150:complications / Q000503:physiopathology* / Q000628:therapy; D008297:Male; D008365:Manometry; D008875:Middle Aged; D011788:Quality of Life; D012189:Retrospective Studies
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