Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic ﬂoor) f.
2.
Loose stools are rarely present without the use of laxatives, and there are insufficient criteria for IBS.
3.
a Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. From Drossman DA, Corazziari E, Talley NJ, et al., eds. Rome III: the functional gastrointestinal disorders. 3nd ed. McLean, VA: Degnon Associates, 2006:885–897, Appendix A, with permission.
Table 28.6 Functional Defecation Disorders 1.
The patient must satisfy diagnostic criteria for functional constipation (Table 28.5) 2.
During repeated attempts to defecate must have at least two of the following: a.
Evidence of impaired evacuation, based on balloon expulsion test or imaging b.
Inappropriate contraction of the pelvic ﬂoor muscles (i.e., anal sphincter or puborectalis) or less than 20% relaxation of basal resting sphincter pressure by manometry, imaging, or EMG c.
aCriteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. From Drossman DA, Corazziari E, Talley NJ, et al., eds. Rome III: the functional gastrointestinal disorders. 3nd ed. McLean, VA: Degnon Associates, 2006:885–897, Appendix A, with permission.
is defined as the delayed passage of radiopaque markers through the proximal colon without retropulsion of markers from the left colon and in the absence of systemic or obstructive disorders. The cause remains unclear. Patients with this disorder have impaired phasic colonic motor activity and diminished gastrocolic reﬂexes (48,49). Studies on the role of laxatives, absorption, hormones, psychological abnormalities, and endogenous opioids have been inconclusive. Current literature suggests a possible neurologic or smooth muscle disorder (49,50).
In young women, obstetric injury is the most common cause of fecal incontinence. The mechanism of injury can be from anatomic disruption of the anal sphincter complex, pelvic ﬂoor denervation, or a combination of the two conditions. The risk factors for anal sphincter laceration are primiparity, high birth weight, forceps delivery, and episiotomy (51–53). Recent work suggests that women with anal sphincter injuries have slower labor, without the normal deceleration phase, and with late descent of the fetal head (54). Although there are limited long-term prospective studies demonstrating the natural history of anal sphincter injury, pelvic ﬂoor neuropathy, and the progression of these conditions to fecal incontinence, current literature supports the relationship of early-onset symptoms to sphincter damage and delayed-onset symptoms to neuropathy (55). This relationship would account for the large discrepancy in the prevalence of fecal incontinence between younger men and women that decreases as the population ages (56).