EVALUATION OF MANOMETRY AND DEFECOGRAPHY ASSESSMENT FOR CONSTIPATION AND INCONTINENCE By SUSAN ISOBEl SHANNON M.Sc A Thesis Submitted to the School of Graduate Studies in Partial Fulfilment of the Requirements for the Degree Doctor of Philosophy McMaster University March,1996
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EVALUATION OF MANOMETRY AND DEFECOGRAPHY
ASSESSMENT
FOR CONSTIPATION AND INCONTINENCE
By
SUSAN ISOBEl SHANNON M.Sc
A ThesisSubmitted to the School of Graduate Studies
in Partial Fulfilment of the Requirementsfor the Degree
Doctor of PhilosophyMcMaster University
March,1996
EVALUATION OF (\MNOMETRY AND DEFECOGRAPHY
ASSESSMENT FOR CONSTIPATION AND INCONTINENCE
DOCTOR OF PHILOSOPHY (1996)(Biomedical Sciences)
McMASTER UNIVERSITYHamilton t Ontario
TITLE:
AUTHOR:
SUPERVISOR:
EVALUATION OF MANOMETRY ANDDEFECOGRAPHY ASSESSMENT FORCONSTIPATION AND INCONTINENCE
Susan Isobel Shannon M.Sc. (McMasterUniversity)
Dr. J. Huizinga
NUMBER OF PAGES: iii, 125
II
ABSTRACT
This thesis examines the sensitivity and specificity of manometry and defecography
assessments; the rE-lationship bemeen function and symptoms; and the relationship between
age and parity and patient assessments.
The manometry assessments of 72 incontinent and 50 constipated female patients
were compared to 86 healthy volunteers using discriminant function and classification analysis
(DFA). The defecC'graphy c.3sessments of a subset of these patients, 21 i:1continent and 25
constipated, were compared to 22 healthy female volunteers. These data were used to
examine the factors age, parity, severity of symp~omsand rectal wall morphology on function.
The results show that the variables of total squeeze pressure and resting pressure
have a sensitivity of 79% for the incontinent patients and 32% for the constipated patients.
The spedficity was 87%. The manometry variables resting pressure, squeeze pressures,
volume to urgency were significantly different in the patient groups. Aging was a significant
ta~tl')r for lower resting pressures and increased parity was a significant factor for lower
squeeze pressures in the patient groups.
The sensitivity of the combination of the defecography variables, lift and strain angles
and junction levdls, was 90% for the incontinent patients and 88% for the constipated patients.
The specificity was 95%. The defecography variables were not significantly different in the
patient groups. Rest and lift angles were significantly wider with increased age and parity.
Neither the defecography and manometry variables nor rectal wall morphology
changes were associated with varying severity of either constipation or incontinence.
The manometry and defecography assessments are presented in graphs, which may
enhance the dinical usefulness of the assessments by demonstrating the difference between
patient values and healthy controls. The manometry data are also presented in an index
which makes areas of specific impairment more obvious.
iii
DFA of the manomeby and defecography variables provides probability rates which
may be useful in predicting patient outcomes. The discriminant scores from the analysis of
the defecography and manometry variables can be used to develop a continuum from health
to incontinence.
iv
ACKNOWLEDGEMENTS
I wsh to express my appreciation for the gLidance a:-td support provided by my thesis
supervisor, Dr. Jan Huizinga. As weh, as being my mentor. his broad interdisciplinary
knowledge, insight and patience have been invaluable to this thesis.
I wish to thank the members of my thesis committee: Drs. Nick Diamant, Steve
Collins, Dugal Cal":'lpbell and Ellen Ryan for their criticism, gl!idance and advice.
Iv.;sh to reco~rlze Drs Bill Waterfall, Sat Somers and Meman Anvari who were very
generous in giving their time and support to this research.
I am grateful to the Faculty of Health Sciences, the Departments of Gastroenterology,
Radiology and Psychiatry, as well as the R Samuel McLaughlin Centre for Gerontological
Health Research for providing me the opportunity to complete the work for this thesis.
I am thankful to my family, friends and colleagues for their optimism and
encouragement throughout the course of these studies.
A special thank you to all the patients for being so open and willing to participate in
this research.
v
CONTENTS
PAGE
CHAPTER I Introduction 1
CHAPTER II Anorectal physiology and pathophYsiology 4
CHAPTER III Methods of assessment 11
CHAPTER IV Manometry assessment of anorectal function 28
CHAPTER V Sensitivity and specificity of manometry assessment 49
CHAPTER VI Defecography in the diagnosis of pelvic floor dy~function 66
CHAPTER VII Cumbination of manometry and defecography assessments 80
CHAPTER VIII The relationship of defecography and manometryvariables to rectal wall morphology 95
APPENDIX 1 Anorectal manometry report 114
APPENDIX 2 Defecography report 115
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CHAP'fER IIITABLE I.TABLE II.
CHAPTER IVTABLE I.TABLE II.TABLE "I.
TABLE IV.
TABLEV.
TABLE VI.
TABLE VII.
CHAPTER VTABLE I.
TABLE I!.
TABLE III.
TABLE IV.
TABLEV.
TABLE VI.
LIST OF TABLES
Patient history manometry studiesPatient history defecography studies
Manometry patients and controlsManometry variablesPercent distribution of controls inManometry indexPercent distribution of constipatedPatients in manometry indexPercent distribution of incontinentPatients in manometry indexDescription of all patients by indexCategoryManometry variables for categoryHigh resting-low squeeze pressure
Discriminant function classification results Controls and incontinent patientsDiscriminant function classisifcation results Controls and constipated patientsDiscriminant function classification results Incontinent and constipated patientsDistribution of discriminant scores for allPatients in the manometry indexDistribution of discriminant scores ofIncontinent patients in the manometry indexDistribution of discriminant scores ofConstipated patients in the manometry index
. PAGE
2627
4142
43
44
45
46
47
61
61
62
63
64
65
CHAPTER VITABLE I. Anorectal junction levelsTABLE II. Movement of the pelvic floorTABLE III. Anorectal anglesTABLE IV. Rdiographic featuresTABLE V. Classification results controls and
Incontinent patients
VII
75767677
78
:1
PAGE
CHAPTER VI (Continued...)TABLE VI. Classification results controls and
Constipated patients 78
TABLE VII. Classification results_constipated andIncontinent patients . 79
CHAPTERVlITABLE I. Manometry and defecography results 90TABLE II. Description of all patients by index category 91TABLE 111. Distribution of patients in manometry index 92TABLE IV. Manometry and defl!cography discriminant
Function classification results 93TABLE V. Discriminant scores and manometry index 93
CHAPTER VIIITABLE I. Incontinent and constipatc:d patients and
Rectal wall morphology grade 105TABLE II. Correlation of defecography and manometry
Variables and rectal wall morphology grade 106
VIII
UST OF FIGURES
PAGECHAPTER IV
FIGURE 1. Resting and squeeze pressures 48
CHAPTER VFIGURE 2. Histogram of discriminant function scores 60
CHAPTER VIFIGURE 1. Anorectal junction levels at rest lift and
strain referenced from the i~chial tuberosities 75FIGURE 2. Anorectal angles at lift, rest and ~train 76
CHAPTER VIIFIGURE 1. Histogram of discriminant function scores 94
CHAPTER VIIIFIGURE 1. Resting and squeeze pressures and rectal