Rome Constipation Symptoms Augmented by Painful Defecation Predicts Specific Subtypes of Refractory Constipation.

Introduction: Functional defecation disorders (FDD) are a prevalent etiology of refractory constipation. The diagnosis of FDD requires specific physiology testing, including anorectal manometry (ARM) and balloon expulsion test (BET). The aims of our study were to evaluate whether the complaint of painful defecation added to the Rome III symptoms questionnaire could help to differentiate subtypes of refractory chronic constipation.

Materials and methods: One hundred and ninety-eight constipated patients (Rome III Criteria) who had failed a 30-day fiber/laxative trial were enrolled. Before entering the study (T0) the patients underwent a digital rectal examination, including the assessment of tenderness elicited by traction of the puborectalis muscles (DRE-tenderness). Patients reporting painful defecation (occurring at least once per week) were specifically assessed at T0. Thirty days after T0, the patients underwent: DRE with DRE-tenderness evaluation. ARM + BET. Barium defecography (when ARM and BET were discordant). Colonic transit time evaluation with radiopaque markers. Based on these tests, the patients were classified into five subgroups: dyssynergic defecation (DD), inadequate defecatory propulsion (IDP), isolated structural outlet obstruction (mostly large rectocele), isolated slow transit constipation, and normal transit constipation. The association between symptoms and diagnostic outcomes was assessed using multivariate analysis based on binary logistic regression.

Results: Eighty-one patients (40.9%) reported weekly episodes of painful defecation, while 86 patients (43.3%) reported DRE-tenderness. Ninety-six patients (48.5%) showed features of FDD: 70 DD and 26 IDP; 25 (12.6%) showed isolated structural outlet obstruction, and 23 (11.6%) showed isolated slow transit constipation. No predictors were found for IDP.

Conclusions: The subjective complaint of painful defecation added to the Rome III criteria is critical to improve the identification of specific subtypes of refractory chronic constipation, thus improving care and potentially decreasing the need for physiology testing.