| Background:Functional constipation (FC) is a kind of common gastrointestinal disease. The prevalence of FC is in the range of 12%-19% of the North American population and 3.0%-25.9% of Chinese population. The prevalence of FC is varied in different areas and age groups. Further investigations indicate that the prevalence of FC is significantly related to the anorectal pressure and rectal sensory function. As a result of the complexity of the causes, the therapeutic results of functional constipation were not really consistent, besides the Routine Medication, the researchers at home and abroad explore a number of new therapies, such as bio-feedback therapy, botulinus toxin A injection, surgical therapy and so on. Bio-feedback therapy has become the first-line treatment of functionality constipation overseas. But the bio-feedback machine is expensive and complicated to operate and requires a lot of manpower and time. Therefore, bio-feedback therapy only carries on a few hospitals and research centers. In addition, the high medical expenses, the slow onset and the long course of treatment, lead to patients' suspicion of treatment, poor compliance and high lost rates of follow-up, which directly affect the bio-feedback therapy's efficacy and promotion. Based on the present research and demand, we begin to study an instrument of bowel training, which may help the patients with FC to establish the normal defecation reflex as early as possible, and effectively improve the patients' clinical symptoms and anorectal function.Purposes:The aim of the present study is to develop an instrument of bowel training, which can measure anorectal pressure and rectal sensory function of patients with FC. It may also be a tool of auxiliary diagnoses and bio-feedback training evaluation of FC. Moreover, as a tool of carrying on manometry feedback training and rectum sensory training, it may improve the subjective and objective symptoms of patients with FC without pain and injuries.Methods:1. Study on an instrument of bowel training:The instrument was designed according to the anal canal and rectal structure of the adults'and the simple pressure-measuring principle of Gunal's. The bowel training instrument is composed of a disposable latex tube, two sphygmomanometers, two three-way valves and two disposable sterilized syringes (capacity of 50 milliliters)。2. Appraisal of the performance and security of bowel training instrument:The anorectal pressure and rectal sensory volume were investigated in 10 healthy adults by the instrument of bowel training. Measure items include anal canal resting pressure, maximum anal squeeze pressure, residual anal pressure, rectal squeeze pressure, first sensation of distention, sensation of defecation, sensation of urgency and maximum tolerable volume. Each item was measured three times to investigate the differences from three groups.3. The study on anorectal motility in patients with FC:Anorectal pressure and rectal sensory volume were examined in 28 perceptive patients with FC and in 24 healthy adults as controls by the bowel training instrument to investigate the differences of anorectal motility between the patients with FC and healthy controls.4. The influence of bowel training therapy on patients with FC:The training plan was made according to the results of anorectal motility in patients with FC. The training plan can be divided into two stages, one is the strengthened training stage which lasted for 2 weeks with practice once a day or every other day, another stage is the consolidated training stage which lasted for 2-3 weeks with practice every third day. According the situation of patients with FC, the training plan lasted for 1-2 courses, usually 10 to 15 times as one course of treatment. The clinical symptoms and anorectal motility of patients with FC were evaluated 3 months after the treatment.5. The life style and defecation appraisal table have been formulated according to Rome III criteria, risk factors of functional constipation and the symptom questionnaire. Use this appraisal table to assess patients with FC before the treatment, then the health promotion plan was made according to the appraisal results of patients with FC and the researcher taught them in detail. The researchers assessed them again with the appraisal table 3 months after the treatment.Results:1. Appraisal of the performance and security of bowel training instrument: Results showed that the result of anal canal resting pressure, maximum anal squeeze pressure, rectal squeeze pressure and residual anal pressure were similar to the study in China and there were no significant differences among the three groups that derived from repetitive anorectal motility measurement of ten healthy controls. The result also showed that there were no significant differences among the three groups that derived from repetitive measurement of ten healthy controls regarding the volume of first sensation of distention and defecation. And there were significant differences among the three groups that derived from repetitive measurement of ten healthy controls regarding the threshold of sensation of urgency and maximum tolerable volume. There were no cases showing adverse reaction.2. Comparison of anorectal pressure between patients with FC and healthy controls:There were no significant differences between the patients with FC and healthy controls about the gender and age and that means comparable. Patients with FC had significantly higher residual anal pressure (P<0.01) and significantly lower defecation index than those of controls (P<0.05). No differences of anal canal resting pressure, maximum anal squeeze pressure, rectal squeeze pressure and minimum relaxation volume was found between patients with FC and controls(P> 0.05). The first sensation of distention, sensation of defecation, sensation of urgency and maximum tolerable volume of patients with FC were significantly higher than those of controls (P<0.01).3. Effects of bowel training therapy on clinical symptom and anorectal motility of patients with FC:(1) Effects of bowel training therapy on anorectal pressure of patients with FC:①Anal canal resting pressure:The anal canal resting pressure of patients with FC before and 3 months after treatment was significantly higher than that of controls (P <0.05). And there was no significant differences between patients with FC before and 3 months after treatment regarding the anal canal resting pressure.②Maximum anal squeeze pressure:No differences of maximum anal squeeze pressure was found among the controls and patients with FC before and 3 months after treatment (P> 0.05).③Residual anal pressure:The residual anal pressure of patients with FC before treatment was significantly higher than that of the controls(P<0.01). And there was no significant difference between patients with FC 3 months after treatment and healthy controls regarding the residual anal pressure(P>0.05). The residual anal pressure of patients with FC 3 months after treatment was significantly lower than that of patients with FC before treatment(P<0.01).④Rectal squeeze pressure:No differences of rectal squeeze pressure was found between patients with FC before treatment and the controls (P>0.05). The rectal squeeze pressure of patients with FC 3 months after treatment was significantly higher than that of patients with FC before treatment and that of the controls(P<0.05).⑤Defecation index:And there was no significant difference between patients with FC before treatment and health controls regarding the defecation index(P>0.05), and the same as patients with FC 3 months after treatment and healthy controls (P>0.05). The defecation index of patients with FC 3 months after treatment was significantly higher than that of patients with FC before treatment(P< 0.01).(2) Effects of bowel training therapy on rectal sensory function of patients with FC:①First sensation of distention:The first sensation of distention of patients with FC before treatment was significantly higher than that of the controls(P<0.01). And no differences of first sensation of distention was found between patients with FC 3 months after treatment and the controls (P>0.05). The first sensation of distention of patients with FC 3 months after treatment was significantly lower than that of patients with FC before treatment(P<0.01).②Sensation of defecation:The sensation of defecation of patients with FC before treatment was significantly higher than that of the controls(P<0.01). And no differences of sensation of defecation was found between patients with FC 3 months after treatment and the controls (P>0.05). The sensation of defecation of patients with FC 3 months after treatment was significantly lower than that of patients with FC before treatment(P<0.01).③Sensation of urgency:The sensation of urgency of patients with FC before treatment was significantly higher than that of the controls(P<0.05). And no differences of sensation of urgency was found between patients with FC 3 months after treatment and the controls (P>0.05). The sensation of urgency of patients with FC 3 months after treatment was significantly lower than that of patients with FC before treatment(P<0.01).④Maximum tolerable volume:The maximum tolerable volume of patients with FC before treatment was significantly higher than that of the controls(P<0.05). And no difference of maximum tolerable volume, was found between patients with FC 3 months after treatment and the controls (P>0.05). The maximum tolerable volume of patients with FC 3 months after treatment was significantly lower than that of patients with FC before treatment(P<0.01).(3) Effects of bowel training therapy on clinical symptoms of patients with FC: The frequency of defecation, Bristol form of stool and stool volume of patients with FC 3 months after the treatment were significantly improved than those of patients with FC before treatment(P<0.01). At the end of treatment after 3 months, patients with FC showed significant improvement in straining, sensation of incomplete evacuation and anorectal obstruction compared with those before treatment (P< 0.01). And no improvement in anus pain and anus bloat of patients with FC 3 months after treatment was showed compared with those before treatment. (P>0.05). The total score of symptoms of patients with FC 3 months after treatment was significantly lower than that of patients with FC before treatment. The satisfaction of patients with FC 3 months after treatment was significantly higher than that of patients with FC before treatment.4. Effects of the health education on life style of patients with FC:At the end of treatment after 3 months, patients with FC showed higher daily fiber and water intake compared with those before treatment(P<0.05), and also had remarkable improvement in the situation of suppressing the bowel movement and not defecating daily. Conclusions:1. The bowel training instrument can assess anorectal pressure and rectal sensory volume of patients with FC accurately and repeatedly. Moreover, it was characterized for its portability, stability, practical and non-invasive.2. The abnormalities of anorectal pressure and visceral perception may be involved in the pathogenesis of constipation.3. Training for recto-anal coordination with the bowel training instrument can re-train the puborectal muscle and external sphincter, reshape the pelvic floor muscles and improve the recto-anal coordination. And to make the patient acquired the capability of relaxing the sphincter completely during defecation. The function of abdominal respiration is to strengthen the abdominal muscles that are one of the propulsive factors for defecation. Education to improve sensory perception is carried out for patients with impaired rectal sensation, and rectal sensation can be improved with this training procedure so as to establish the normal defecation reflex again.4. The clinical symptoms of patients with FC can also be improved with bowel training therapy. The frequency of defecation, Bristol form of stool and stool volume of patients with FC were improved with bowel training therapy. Three months after treatment, the associated symptoms of patients with FC including straining, sensation of incomplete evacuation and anorectal obstruction were also significantly relieved by bowel training therapy.5. The bowel training instrument can serve as a manometry system to provide an effective way of treatment on FC. Moreover it was characterized for its portability, non-invasive, economy and practicality and has a greater promotional value in hospital and community.6. The healthy promotion intervention could help patients with FC establish the healthy life style. Therefore, it was conducive to prevent the occurrence and the development of functional constipation. |
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