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Approach to constipation.pptx
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- 2. Physiology of Defecation ■Defecation is a spinal reflex. ■ Distension of the rectum → reflex contractions of its musculature → desire to defecate Internal Smooth muscle Sympathetic-Excitatory Parasympathetic-Inhibitory External Skeletal muscle Pudendal nerve
- 3. Rectal pressure Response ≥18 mm Hg Urge to defecate ≥ 55 mm Hg defecation 90-100 *Ganong, Guyton and Hall Physiology Straining abdominal muscles puborectalis muscle relaxes pelvic floor descent anorectal angle straight relaxation of the external anal sphincter Defecation
- 4. *Guyton and HallPhysiology 1 2 3 4 5 6 Rectal nerve endings Spinal cord colon sigmoid rectum Parasympathetic nerves ↑ Persistalsis relaxed internal sphincter defecation
- 5. CONSTIPATION ■ Very commonclinical problem all over the world. ■ Serious impact on quality of life of the patients, financial burden. ■ It is said that 2.5 million individuals with constipation undergo evaluation annually. ■ ≥ $500 million is spent on laxatives each year. ■ The traditional definition of constipation has been ≤ 3 bowel movements per week. ■ ACG Task force defines it as “Unsatisfactory defecation characterized by infrequent bowel movements/ difficult to pass stools/ both”. ■ Objectively defined by recent ROME IV criteria.
- 6. ■ These disordersshould be thought of as existing on a continuum, rather than as in isolation.
- 7. *Van Oudenhove etal Gastroenterology 2016;150:1355–1367 Biopsychosocial model for FGID
- 8. Criteria fulfilled forthe last 3 months with symptom onset at least 6 months prior to diagnosis. Any 2 of the below Loose stools rarely present without use of laxatives Not meeting IBS criteria Straining Lumpy/hard stools Incomplete evacuation Sensation of obstruction Manual maneuvers ≤3 spontaneous movements/week 25% of the defecations Patient might be passing stools daily and can still have constipation
- 10. Epidemiology ■ The prevalenceof constipation is estimated to be 14% based on a meta-analysis of 41 studies with over 261,000 subjects throughout the world. STUDY SAMPLE SIZE CRITERIA FOR Dx Prevalence Ghoshal et al. 2008 Complainants: 2785 Non-complainants: 4500 Self-perception 53% Makharia et al 2011 4767 Self perception 11.6% Rajput and Saini 2014 505 ROME II 16.8% Self Perception 24.8% Ghoshal , Singh 2017 2774 ROME III 2.4% Indian studies • Advanced age • Female gender • Low level of education • Low level of physical activity • Low socioeconomic status • Multiracial ethnicity • Use of certain medications
- 11. Types ■ Functional –Most common type – 80% ■ Organic – 20 % Anal stenosis Intestinal stricture Rectocele Sigmoidocele Colorectal cancer Extrinsic compression Diabetes mellitus Heavy metals Hypercalcemia Hypokalemia Hypothyroidism Amyloidosis Multiple sclerosis Parkinsonism dermatomyositis Anti depressants, Anti Parkinson Vinca alkaloids opioids Diuretics Iron
- 12. Functional constipation Normal TransitConstipation Slow Transit Constipation Defecatory Disorders Normal Transit 59% Slow Transit 25% Defecatory disorder 13% Mixed 3% Functional constipation
- 13. NORMAL TRANSIT CONSTIPATION ■Patients report that they have constipation, inspite of normal frequency. ■ Presence of hard stools or a perceived difficulty with evacuation. ■ Stool transit, stool frequency - within the normal range. ■ Bloating and abdominal pain. ■ May exhibit increased psychosocial distress. ■ Respond to therapy with dietary fibre ± osmotic laxative or enterokinetic. ■ Typically will not require a formal transit test. NTC IBS C
- 14. Slow transit constipation ■Slow transport of stool across colon. ■ Infrequent bowel movements (<1 /week) ■ Young Women. ■ Colonic inertia - most severe end of the spectrum. Colonic dysmotility Colonic neuropathy Neuro-hormonal cause Methanogenic bacteria Slow Transit Constipation
- 15. Colonic dysmotility ■ Colonicmotor activity has temporo-spatial variation ■ influenced by sleep, waking, meals , physical and emotional stressors, gender, aging. ■ STC- overall ↓ colonic motor activity. ■ Blunted Gastrocolonic response, no increase in activity after waking up. ■ ↓ frequency, amplitude and duration of HAPCs.
- 16. Colonic Neuropathy ■ Interstitialcells of cajal –evoke basic electrical rythms for intestinal movements, ■ Pacemaker cells for intestinal motility. ■ Pancolonic ↓ in the icc volume across the circular and longitudinal muscle layers and submucosa, ■ ↓ myenteric ganglion cells *GUT- BMJ
- 17. Neuro-hormonal ■ Women>Men. PossibleHormonal cause?? ■ Low levels of ovarian and adrenal steroid hormones has been suggested (not confirmed) ■ Colectomy specimens from women with STC -- ↓ progesterone-dependent contractile G proteins, ↑ inhibitory G proteins in constipated women. Stimulation of mucosa Acetyl choline Substance P NO,VIP Descendin g inhibitory Ascending excitator y Myenteric plexus Mechanical, 5HT,CGRP Relaxation of circular muscle Peristaltic contractions Role of paracrine neurotransmitters ↓ serotonin ↓ receptor density ↓ function of the serotonin reuptake transporter Impaired ascending contractions
- 18. Dyssynergic defecation ■ Inabilityto coordinate the abdominal, rectoanal, and pelvic floor muscles during defecation ■ Symptoms often begin in childhood. Functional constipatio n Abnormal balloon expulsion test Impaired Rectal evacuation Abnormal ARM/Anal surface EMG ≥2 of following Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. STC DD Am J Gastroenterol. 2008;103(3):692-698.
- 19. ■ spasm orinability to relax the external anal sphincter is NOT the sole mechanism. ■ Incoordination or dyssynergia of the muscles, impaired rectal sensation are the primary causes. ■ Three phenotypes have been described ↑ Sphincter pressure Inadequate propulsive force Mixed phenotype 31% 29% 40% childhood post pregnancy/trauma unknown cause J Neurogastroenterol Motil, Vol. 22 No. 3 July, 2016
- 20. Approach to apatient of constipation ■ History Onset – whether it began in childhood Urge, frequency, need for straining, stool consistency, stool size, history of ignoring a call to stool precipitating events, use of any maneuver to assist the defecation. Dietery history- Fiber and fluid intake, number of meals, Breakfast habits Significant past history: Obstetric and Surgical procedures. • Weight loss • Rectal bleeding • Recent change in the caliber of stool • Abdominal pain • Family history of colon cancer Be alert to manifestations of depression, such as insomnia, lack of energy, loss of interest in life, loss of confidence, and a sense of hopelessness. In one study of dyssynergic defecation,22% had a history of sexual abuse, 32% had physical abuse
- 21. 79% 71% 62% 57% 57% 54% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% strainingHard stools discomfort bloating infrequent bowel movemnts Feeling of incomplete evacuation Functional Organic Dyssynergic defecation Long standing symptoms Recent onset Heaviness in perineum No constitutional symptoms Loss of appetite Excess straining No bleeding/mass Loss of weight Feeling of obstruction No symptoms of obstruction Bleeding/mass Digital evacuation/support of perineum Family h/o colonic Can History differentiate between types of constipation?
- 22. Examination ■ Complete GeneralPhysical examination along with neurologic assessment to screen for organic cause ■ Abdominal examination, for distention, hard feces, presence of mass per abdomen. ■ One thing that is very important and is very commonly not performed!??
- 23. sensitivity and specificityof DRE were75% sensitive and 87% specific for identifying dyssynergia. PPV was 97%. paradoxical contraction of the external anal sphincter and puborectalis muscles with fingertip being displaced anteriorly during attempted defecation, suggesting dyssynergic defecation *The American Journal of Gastroenterology
- 24. Investigations ■ Young patientswithout alarm features can be treated empirically after thorough history taking and DRE. ■ Patients with alarm features- mandate work up. ■ Tests for systemic diseases- ESR, CBC, Biochemistry profile, FBS/PPBS/HBA1C Thyroid function tests To exclude systemic/structural disease To detect underlying cause if patient is unresponsive to simple treatment
- 25. Tests for structuraldiseases Plain X ray Abdomen - to complement clinical history and physical examination - Identifies excessive amount of stool in the colon - Not recommended if no alarm features Barium enema - To identify redundant sigmoid colon, megacolon, megarectum, stenosis, extrinsic compression intraluminal masses. - Not recommended if no alarm features C C
- 26. Endoscopic procedures In youngerpatients, a flexible sigmoidoscopy may be sufficient. scop y Bleedin g Age≥ 50 Weight loss Obstructiv e symptoms Recent onset symptoms IDA Recent change in stool calibre *ACG Taskforce recommendation
- 27. Tests for functionalconstipation Colonic Transit studies-- The American and European Neurogastroenterology and Motility Societies recommend 3 methods for assessing colonic transit time. radiopaque markers wireless motility capsule scintigraphy 20% or more retention of markers X rays taken after 120 hours Single capsule swallowed on day 1 STC
- 28. If the markersare retained exclusively in the sigmoid colon and rectum, the patient may have a defecatory disorder. Ghoshal's protocol 20 radio-opaque markers filled in capsules administered at 0, 12, and 24 h, and then abdominal radiographs obtained at 36 and 60 h is found useful. Retention of ≥ 30 radio-opaque markers at 36 h (sensitivity 90%, specificity 82%) and ≥ 14 markers at 60 h (sensitivity 95%, specificity 100%) is quite accurate to detect slow colon transit.
- 29. The wireless motilitycapsule is ingested following a standardized meal and 50 mL of water Patients wear a data receiver on their waists for 5 days, or until the capsule is passed. After the passage of capsule,the data is analysed to assess the transit time. ↑ 𝑇𝑒𝑚𝑝 ↓pH ↑ 𝑝𝐻 ↓Tem p Gastri c Transit Small bowel Transit Coloni c Transit J Neurogastroenterol Motil, 2014 Apr; 20(2): 265–270 Wireless motility capsule 2-5 hr 2-6 hr 10-59 hr
- 30. Scintigraphy ■ Scintigraphy transittests involve the ingestion of radioactive isotopes. ■ There are 2 methods for the delivery of markers in clinical uses: 111In-DTPA labeled water consumed in a standard solid-liquid meal, 111In activated charcoal slurry contained in a capsule. ■ Anterior and posterior images of the colon are obtained using a gamma camera at specified times over 2 to 3 days following ingestion of the meal. ■ Results are expressed as geometric center(GC). It is a Single figure that indicates the region where the median of the radioactivity lies. ■ A GC of 1 would indicate that activity is mostly in region 1 (cecum and ascending colon), and a GC of 5 would indicate that most of the activity is in region 5 (feces). ■ Normal values GC : 1.6–3.8 at 24 h and 3.0– 4.8 at 48 h. ■ Slow colon transit is defined as a GC less than these reference values at 24 and 48 h. ■ A low GC is considered slow transit, high GC center is considered accelerated transit. *THE JOURNAL OF NUCLEAR MEDICINE • vol. 54 • no. 11 • november 2013
- 31. *Evaluation of gastrointestinaltransit in clinical practice: position paper of the American and European Neurogastroenterology and Motility Societies, Rao et al 2010
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- 34. The patient cangenerate an adequate pushing force, (rise in intra abdominal pressure) along with a paradoxical increase in anal sphincter pressure .
- 35. Patient is unableto generate an adequate pushing force (no increase in intrarectal pressure) but can exhibit a paradoxical anal contraction.
- 36. The patient cangenerate an adequate pushing force but, either has absent or incomplete (<20%) sphincter relaxation (i.E. No decrease in anal sphincter pressure) .
- 37. The patient isunable to generate an adequate pushing force and demonstrates an absent or incomplete anal sphincter relaxation
- 38. Balloon expulsion test ■a 4 cm long balloon filled with 50 mL of warm water is placed in the rectum. ■ After placement, the patient is given privacy and asked to expel the balloon. ■ A stop watch is provided to assess the time required for expulsion ■ Useful as Screening test for Dyssynergic defecation. ■ Sensitivity- 50% Specificity- 80-90%
- 39. Defecography ■ Barium defecography-150 mL barium paste into the patient’s rectum--having the subject squeeze, cough, and expel the barium. • radiation exposure • embarrassment • limited availability • interobserver bias • inconsistent methodology
- 40. Indian J RadiolImaging. 2013 Jan-Mar; 23(1): 92–96.
- 41. MR defecography ■ No preparation needed. ■Rectal instillation of Ultrasound jelly. ■ Wears adult diaper ■ Patient in supine position ■ Dynamic T2 Images are taken. ■ 4 Phases. ■ Clear instructions before sending patient on to MRI machine
- 42. Multiple test positivityincluding balloon expulsion test, anorectal manometry, and defecography has better accuracy than a single test for diagnosis of FED.
- 43. History, Physical exam Baselineevaluation Inadequate response To Therapeutic trial Anorectal Manometry Balloon Expulsion Test Normal Abnormal Inconclusive Colonic Transit Defecography Defecatory Disorder Algorithm for chronic constipation AGA.,GASTROENTEROLOGY Vol. 144, No. 1,PAGE 214
- 44. Colonic Transit Defecatory Disorder Defecography Normal Slow Abnormal Normal SlowTransit Constipation Normal Transit constipation Algorithm for chronic constipation AGA.,GASTROENTEROLOGY Vol. 144, No. 1,PAGE 214
- 45. Use of technology Mobileapp – constipation diary
- 46. lwc liu. chronicconstipation: current treatment options. can J gastroenterol 2011;25(suppl B):22B-28B.
- 47. Treatment “Initial treatment ofCC should include lifestyle modification and osmotic laxatives” Timed toilet training Dietery fibers Position of defecation Physical activity Water intake Squatting 1.5-2L Attempt for 5 min,30-60 min after meal, twice a day
- 48. fibre s Dietery fibres Agent Doseremarks Psyllium 4-6g/day Natural,Can cause IgE mediated reaction Methyl cellulose 4-6g/day synthetic Polycarbophil 4-6g/day synthetic Fiber supplement should be avoided if the patient is already on high fiber diet and/or abdominal bloating is a prominent symptom Slow Transit Constipation, Dyssynergic defecation- Recommended dosage – 25-30g/day of soluble fibres – start at 12g/day, slowly increase. (Oats,nuts,barley,beans,lentils,fruits). The benefits of added fiber are not evident for days to weeks. Generous fluid intake along with fiber supplementation. If patients fail to respond to a dietary fiber trial, slow transit constipation and/or a defecatory disorder could be suspected. If results of therapy are inadequate, commercially packaged fiber supplements should be tried.
- 49. Osmotic laxatives Lactulose15-30ml OD/BD Cramps,flatulance PEG 17-34g OD/BD Incontinence Milk of Magnesia 15-30ml OD/BD hypermagnesemia Stimulant laxatives Bisacodyl 5-10 mg H.S. Incontinence,cramps Sod Picosulfate 5-15 mg H.S Senna(anthraquinone) 1-2 7.5-mg Psudomelanosis coli Stool Softners Docusate sodium 100mg bd Enemas Phosphate enema Mineral oil enema Soapsuds enema Rectal mucosa damage, hyperphosphatemia,ele ctrolyte abnormalities Chloride channel activator Lubipristone 8-24𝜇g/day Nausea,headache,d iarrhea Guanyl cyclase C agonist Linaclotide 72-145𝜇g/day diarrhea Plecanatide 3mg OD 5HT4 agonist Tegaserod Prucalopride 2-6mg BD 2mg OD Cardiovascular Headaches,nausea
- 50. Prucalopride, a full5-HT 4 agonist -- benzofuran derivative -- accelerates colonic transit. no cardiovascular side effects have been observed to date with prucalopride. Possible future agents- Chenodeoxycholate Elobixibat Velusetrag Rifaximin* *Intestinal research Journal,2015 Oct Lubiprostone Linaclotide Not recommended in <18years age.
- 51. Yvonne Tse etal. Canadian Journal of Gastroenterology and Hepatology / 2017 / Article
- 52. Biofeedback therapy ■ Principle- any behavior- such as eating or a simple task such as muscle contraction,when reinforced, its likelihood of being repeated and perfected increases several fold. Correct dyssynergia/incoordination of muscles Enhance rectal sensory perception
- 54. Rectoanal coordination ■ Subjectis supine/seated on commode with manometry probe in situ. ■ Asked to take a good diaphragmatic breath and to push as if to defecate. Encouraged to watch the monitor. ■ Visual display of the pressure changes in the rectum and anal canal on the monitor. 10-15 maneuvers are performed. ■ Balloon distended in rectum with 60cc air ■ Subject is asked to attempt defecation while watching the monitor.5-10 attempts Simulated defecation training – To teach the subject to expel an artificial stool in the laboratory using the correct technique. ■ 50ml of water filled balloon in rectum/artificial stool--- ask the patient to expel -– he is taught how to relax the pelvic floor, co-ordinate breathing cycles with the attempt.
- 55. Enhance rectal perception ■progressively inflate the rectal balloon until the subject experiences an urge to defecate. ■ Deflate and repeat the same step 2-3 times. ■ Then with each inflation, balloon volume is decreased by 10% ■ subject is encouraged to observe the monitor and to note the pressure changes and pay close attention to the sensation in their rectum. ■ If patient fails to percieve a particular volume, deflate and again inflate with same volume or to previously perceived volume. ■ By the end of each session, newer thresholds for rectal perception are established. ■ Number of sessions- customised. ■ Every session-1hr, one session every 2 weeks.Avg 4-6 sessions. ■ Reinforcement after 1.5 months,3,6,12 months
- 56. 81% 79% 70% 64% 66% 68% 70% 72% 74% 76% 78% 80% 82% Chiaroni etal Raoet al heyman et al Response to Biofeedback therapy
- 57. Surgical therapy subtotal colectomywith an ileorectal anastomosis. Defecatory Disorders The stapled transanal rectal resection (STARR) procedure has been used with some success, especially for rectocele and intussusception. Slow Transit No PFD No Pseudo obstruction Pain is not a prominent symptom Refractory
- 58. Take Home message ■Thorough history taking is a keystone in constipation. ■ Bristol stool chart is a very useful tool. ■ Red flag signs should mandate relevant work up. ■ Rectal Examination is a must in patients of constipation. ■ Initial treatment of choice is lifestyle and dietary modifications. ■ High Fiber diet will not be helpful in PFD. ■ Biofeedback therapy is the treatment of choice for pelvic floor dyssynergia.
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Editor's Notes
- #3 The sphincter is maintained in a state of tonic contraction, and
- #4 moderate distension of the rectum increases the force of its contraction
- #6 Reports of stool frequency, however, are often inaccurate and correlate poorly with complaints of constipation, 8 and people who complain of constipation frequently have a broader set of symptoms, including hard stools, a feeling of incomplete evacuation, abdominal discomfort, bloating, excessive straining, a sensation of blockage during defecation, and abdominal distention.
- #7 The FBDs are classified into 5 distinct categories: IBS, FC, FDr, FAB/FAB, and unspecified FBD (U-FBD).
- #9 Rome I (14%), Rome II (11%), and Rome III (7%), Rome IV resulted in an even lower prevalence (6.3%)
- #11 prevalence is highest when constipation is self-reported 16 and lowest when the Rome criteria for constipation are applied. The prevalence of self-reported constipation is 2 to 3 times higher in women, 18,26,30,44 particularly women of reproductive age, than men, and infrequent bowel movements The prevalence of self-reported constipation among older adults ranges from 15% to 30%
- #15 The mean colonic transit in healthy volunteers - 34 to 35 hours, with an upper limit - 72 hours. Methanogenic flora, Methanobrevibacter smithii produces methane, which may delay gut transit leading to STC.Needs further authentication.
- #16 Contractile response to Pharmacologic stimuli like bisacodyl is also impaired in cases of STC.
- #17 submucosal border (SMB), circular smooth muscle layer (CM), myenteric plexus region (MPR), and longitudinal muscle layer (LM) in control colonic tissue
- #19 slow colonic transit may be secondary (eg, related to physical obstruction to passage of contents by stool or rectocolonic inhibitory reflexes initiated by rectal distention from retained stool) or the primary manifestation. For example, some patients with DD lack the colonic propagated sequences that normally precede defecation. Perhaps the colonic motor dysfunction occurs first and predisposes to excessive straining, which leads to DD
- #21 Many patients tend to skip breakfast or do not allow time for defecation because of the “early morning rush” to get to work or school. This may prove to be a handicap. A failure to capitalize on these physiological stimulants such as after waking and after a meal may predispose to constipation. caffeinated coffee (150 mg of caffeine) stimulates colonic motility
- #26 Grade A1: Excellent evidence in favor of the test based on high specificity, sensitivity, accuracy, and positive predictive values. Grade B2: Good evidence in favor of the test with some evidence on specificity, sensitivity, accuracy, and predictive values. Grade B3: Fair evidence in favor of the test with some evidence on specificity, sensitivity, accuracy, and predictive values. Grade C: Poor evidence in favor of the test with some evidence on specificity, sensitivity, accuracy, and predictive values.
- #27 In a case series,358 colonoscopy and 205 flexible sigmoidoscopy were done in constipation, the range of neoplasia found and the polyp detection rate were comparable to those expected in asymptomatic historical controls .
- #28 “Metcalf technique”), a capsule containing 24 radiopaque markers is ingested on days 1, 2, and 3. More than 68 remaining markers combined on days 4 and 7 reflect slow colonic transit
- #29 Though stool frequency of up to 3 per week is considered normal in Western population, 99% of Indians pass at least 1 stool per day. Average stool weight in 514 healthy Indians -311 g per day. In contrast, stool weight greater than 200 g per day is diagnostic of diarrhea in Western population. Median mouth to cecum transit time was 65 minutes among 12 healthy Indians and total colonic transit time was 15.8 hours among 25 subjects
- #30 After a standardized meal, a nutrient bar (Smartbar; Given Imaging Corp.) with calorie similar to an egg sandwich and 50 mL H2O, the WMC is ingested, and the subject is not permitted to eat or drink for the next 6 hours in order to assess gastric emptying time (GET). Patient is usually monitored in the lab for 1 hour after WMC ingestion. Subsequently, the patient is allowed to eat and drink as usual and wear the data receiver as shown for the next 3–5 days. Pill 26.8 mm in length and 11.7 mm in diameter. abrupt rise in pH by at least 3 units, abrupt drop in pH by 1 unit that is sustained for at least 10 min (at least 30 min after gastric emptying
- #31 111In-diethylenetriamine pentaacetic acid The GC is expressed as the sum of the multiplication of the proportion of 111In counts in each colonic segment at a given time by that segment's weighting factor: GC = [(%AC × 1) + (%TC × 2) + (%DC × 3) + (%RS × 4) + (%S × 5)]/100 3.7 MBq (0.1 mCi) to 37 MBq (1.0 mCi) Patients are required to fast overnight or minimally for 8 h before the beginning of the procedure. They should discontinue medications that affect motility at least 48–72 h before the start. Patients are instructed not to take laxatives and are told to consume their typical diet for 2 d before the test and for the 4 d of sequential colon imaging.
- #39 normal values range from 4 to 75 seconds in those younger than 50 years of age and from 3 to 15 seconds in those 50 years or older
- #42 150-200ml of Jelly is inserted. The pink line is the “H line” corresponding to the anteroposterior dimension of the hiatus. • The solid black line is the “M line” is the pubococcygeal line. Red line is perpendicular distance between the pubococcygeal line and the posterior anorectal junction
- #51 Linaclotide binds to the guanylate cyclase C (GC-C) receptor on the luminal side of intestinal epithelial cells, causing activation of the intracellular cyclic 3',5'-monophosphate (cGMP) pathway. Elobixibat is a novel investigational, minimally absorbed ileal bile acid–transporter inhibitor that increases the flow of bile into the colon. Velusetrag is a full 5-HT4 agonist. 8 Subsequently, the cGMP-dependent protein kinase II (PKG II) is activated which phosphorylates and activates the cystic brosis transmembrane conductance regulator (CFTR). 9,10 This leads to chloride (Cl − ) and bicar- bonate (HCO − 3 ) secretion from the cell, promoting excretion of sodium (Na + ) from the basolateral cell membrane through tight junctions into the lumen and diffusion of water (H 2 O) out of cells
- #57 he patient was asked to sit on a commode, and attempt 10–15 push maneuvers whilst observing the anal and rectal pressure changes on the hand-held device. When the anal sphincter pressure decreased a greater number of lights would illuminate on the anal panel of the home device. If the patient could not relax then fewer or no lights would be displayed. This provided instant feedback to the patient regarding their anal relaxation effort. Likewise, with an appropriate push effort, more lights would illuminate on the rectal panel providing feedback of their performance. Patients were asked to insert the probe at least twice daily, and practice for 20 minutes
- #58 Preoperative psychological assessment is essential.