Background-Many patients with idiopathic constipation do not respond to conventional medical treatments. Recently biofeedback has been proposed as an alternative treatment but the long term results, and which patients benefit, are unknown. Treatment has usually been restricted to patients with normal colonic transit and impaired pelvic floor coordination on straining. Aims-To determine the eYcacy and long term outcome of biofeedback treatment in idiopathic constipation. Methods-One hundred consecutive contactable patients who had completed a course of biofeedback more than 12 months previously were identified. Pretreatment details of bowel function and symptoms, whole gut transit time, and anorectal physiological testing, which had been previously prospectively collected, were collated. Follow up consisted of structured interview. Sixty five per cent had slow transit and 59% had paradoxical pelvic floor contraction on straining. Results-Median follow up was 23 months (range 12-44). On long term follow up 55% felt that biofeedback had helped and 57% felt their constipation was improved. There was a significant reduction in need to strain, abdominal pain, bloating, and oral laxative use. Spontaneous bowel frequency was significantly improved by treatment. Patients with slow and normal transit, males and females, and those with and without paradoxical contraction of the anal sphincter on straining, benefited equally from treatment. Anorectal testing did not predict outcome. Conclusion-This study suggests that biofeedback is an eVective long term treatment for the majority of patients with idiopathic constipation unresponsive to traditional treatments. Pelvic floor abnormalities and transit time should not form selection criteria for treatment. (Gut 1998;42:517-521)

There is a marked, unequivocal improvement in symptoms of fecal incontinence with sacral nerve stimulation shown in this double-blind crossover trial. Sacral nerve stimulation improves the quality of life in selected patients with fecal incontinence.

SUMMARYBackground: Laxatives are frequently ineffective in treating constipation. An alternative therapeutic approach is to target serotonin-4 receptors, which are involved in initiating peristalsis. Aim: In a double-blind, placebo-controlled trial, to assess the efficacy and safety of a systemically active serotonin-4 agonist, prucalopride. Methods: Seventy-four women with constipation were stratified into slow or normal transit groups, and each group was randomized to receive either placebo or 1 mg prucalopride daily for 4 weeks. A bowel function diary was maintained. Whole-gut and orocaecal transit, visceral sensitivity, quality of life and psychological state were assessed before and after treatment. Results: Prucalopride, not placebo, increased spontaneous stool frequency (P ¼ 0.008) and reduced time to

Background-Stronger prokinetic agents which specifically enhance transit in different parts of the gut are required. R093877 is a novel 5-HT 4 agonist prokinetic compound which is chemically related to cisapride but believed to have greater eVect on colonic activity. Aims-To evaluate the eVects of R093877 on bowel function, upper and lower gut transit, visceral sensitivity, and sphincter function in healthy volunteers in a double blind, placebo controlled, crossover study. Methods-The study consisted of five consecutive one week periods: no drug treatment; active drug treatment with either 1 or 2 mg daily or placebo; washout; active drug or placebo; no treatment. Seventeen male subjects maintained a detailed diary of bowel function for the entire study. Orocaecal transit (breath hydrogen), whole gut transit (radio-opaque markers), and anorectal function were assessed at the end of each of the two treatment periods. Blood testing was performed to confirm compliance and for safety analysis. Results-One subject withdrew from the study due to side eVects while on placebo. Eight subjects completed the study on 1 mg and a further eight on 2 mg. Blood testing showed non-compliance in one subject on the 2 mg dose, and he was excluded from analysis of all diary and physiological data. Treatment increased the number of stools per week (placebo versus 1 mg, 7.8 versus 13.6, p=0.003; placebo versus 2 mg, 8.9 versus 11.3, p=0.15) and the percentage of loose or watery stools (24.2% versus 61.5%, p<0.04; 9.9% versus 40.0%, p<0.02). Stool frequency and consistency reverted to normal immediately after treatment. Treatment shortened orocaecal and whole gut transit in all subjects on both doses. Treatment accelerated orocaecal (76 versus 51 minutes, p=0.007; 63 versus 47 minutes, p=0.07) and whole gut (38.2 versus 27.0 hours, p=0.05; 44.8 versus 24.0 hours, p<0.04) transit, and decreased the number of retained markers ingested 36 hours previously (4.8 versus 1.8, p=0.016; 7.0 versus 4.3, p=0.033). Gut sensitivity to distension and electrical stimulation, and anal manometry, were unchanged. Transient headache occurred in seven subjects on R093877 and one subject had mild elevation of liver aminotransferases which resolved on drug cessation.Conclusions-R093877 is well tolerated by healthy subjects and has a marked and consistent eVect on stool frequency and consistency, and upper gut and colonic transit. It does not aVect visceral sensitivity or sphincter function. It holds promise for patients with large bowel symptoms or slow gut transit. (Gut 1998;42:511-516)