Anorectal physiology in health: A randomized trial to determine the optimum catheter for the balloon expulsion test

112

Background: High-resolution manometry (HRM) is used to measure rectoanal pressures in defecatory disorders and fecal incontinence. This study sought to define normal values for rectoanal HRM, ascertain the effects of age and BMI on rectoanal pressures, and compare pressures in asymptomatic women with normal and prolonged balloon expulsion time (BET). Methods:High-resolution manometry pressures and BET were measured in 163 asymptomatic healthy participants. Women (96) and men (47) with normal BET were used to estimate normal values and the effects of age/BMI on pressures using a Medtronic 4.2-mm-diameter rectoanal catheter.Key Results: Age is associated with lower resting pressure, higher rectal pressure during evacuation, and a higher rectoanal gradient during evacuation in women and men. In women, the BET is also inversely correlated with age while the BMI is correlated with a higher threshold volume for discomfort and a longer BET. The anal squeeze pressure increment, squeeze duration, and HPZ length are higher in men than women. The rectoanal gradient during evacuation is also lower (ie, more negative) in asymptomatic women with an abnormal than a normal BET. Conclusions & Inferences:These findings provide an expanded database of normal values for anorectal HRM in men and women. Age and sex affect anal resting and squeeze pressures, respectively; rectal pressure during evacuation is also higher in older people. Less than 15% of asymptomatic people have BET >60 seconds, which is associated with manometry features of impaired evacuation. K E Y W O R D Sanorectal manometry, balloon expulsion test, constipation, defecatory disorders, pelvic floor dysfunction

Section: Discussionsupporting

confidence: 74%

Section: Discussionmentioning

confidence: 89%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Anorectal pressures measured with high‐resolution manometry in healthy people—Normal values and asymptomatic pelvic floor dysfunction

Oblizajek

Gandhi

Sharma

et al. 2019

112

“…Normal values for the BET depend on the type of balloon. 23,24 With a Foley catheter, the upper limit of normal BET (nBET) is 2 minutes. Consistent with data from our and other centers with balloons similar to that used in this study, a BET greater than 60 seconds was considered to be prolonged (ie, abnormal) for the analysis.…”

Section: Rectal Balloon Expulsion Timementioning

confidence: 99%

Improving the utility of high‐resolution manometry for the diagnosis of defecatory disorders in women with chronic constipation

Sharma

Muthyala

Feuerhak

et al. 2020

Background We compared the utility of existing and modified versions of high‐resolution manometry for diagnosing defecatory disorders (DD). Methods In 64 healthy and 136 constipated women, we compared left lateral (LL) and seated manometry, and analyzed with existing (ManoView™) and new methods, for discriminating between constipated patients with normal and prolonged rectal balloon expulsion time (BET). In both positions, the rectoanal gradient (RAG) and, for the new analysis, the pressure topography pattern during evacuation were used to discriminate between constipated patients without and with DD. Key Results The BET was prolonged, suggestive of a DD, in 52 patients (38%). During evacuation, rectoanal pressures and the RAG were greater in the seated than the LL position (P≤.001). The new analysis identified 4 rectoanal pressure patterns. In the seated position, the BET was associated with the pattern (P=.0001), being prolonged in, respectively, 45%, 15%, 53%, and 0% of patients with minimal change, anal relaxation, paradoxical contraction, and transmission. Within each pattern, the RAG was greater (ie, less negative, P<.0001) in patients with a normal than a prolonged BET. Compared to the ManoView™ RAG in the LL position, the integrated analysis (ie, pattern and new RAG) in the LL position (P<.01) and the seated ManoView™ gradient (P=.02) were more effective for discriminating between constipated patients without and with DD. Conclusions & Inferences Anorectal HRM ideally should be performed in the more physiological seated position and analyzed by a two‐tier approach, which incorporates the overall pattern followed by the rectoanal gradient. These findings reinforce the utility of manometry for diagnosing DD.

“…

…”

mentioning

confidence: 99%

Reply to letter: Anorectal physiology in health: A randomized trial to determine the optimum catheter for the balloon expulsion test

Mazor

Kellow

Malcolm

2019

Self Cite

We thank Chiarioni and Whitehead for their insightful comments on our recently published manuscript. 1 In their own landmark study, Chiarioni et al 2 reported the results of balloon expulsion testing (BET) using a Foley catheter in 40 healthy subjects and 286 patients with constipation. All healthy subjects expelled the Foley catheter in under 120 seconds, and this was highly reproducible on two separate testing days. By way of contrast, in our study, 25% of healthy subjects could not expel the Foley catheter within this time frame. This is in spite of (a) the older average age of our cohort (56 vs 38 years), where age has been shown previously to be inversely related to balloon expulsion time, 3 (b) the very thorough screening we performed to define healthy subjects, (c) the great care taken to replicate the methods used by Chiarioni et al, (d) the very short (<20 seconds) balloon expulsion time with other balloon catheters in almost all of our subjects, in line with recent publications 4 , and (e) the lack of other anorectal physiology differences, such as the prevalence of inadequate rectal pressure on push maneuver, between subjects who expelled the Foley catheter and those who did not.In their letter, Chiarioni and Whitehead propose that factors other than the type of balloon may influence balloon expulsion time such as patient instructions, environment, and balloon consistency.We agree with this statement; however, we used the patients as their own controls, each expelling the three different balloons in randomized order, with the same instructions, same nurse, and same test environment (private toilet). We believe that balloon consistency or deformability is the most notable difference between the catheters, and we demonstrated a very high intra-balloon pressure upon inflation of the Foley catheter balloon. Our observation is that a Foley catheter produces a very firm Bristol type 1 like balloon whereas both a party balloon and the commercial balloon have a more Bristol type 4 consistency. This, in turn, may be due to overinflation of the Foley catheter balloon, as this technique requires the Foley catheter to be filled with 50 mL of water, which is over the manufacturer-recommended limit of 30 mL. Reasons for the differing results between our study and that of Chiarioni et al may include effects due to gender, ethnicity, or cultural differences. Some of the subjects reported by Chiarioni et al were male, and all were of Italian descent, whereas our study included only females, and 86% were Caucasians, mainly first-or second-generation Australian.Our study highlights the importance of using methodology-specific normal values for BET, and we agree that replicating these data in other centers is of importance. However, as mentioned above, the off-label use of the Foley catheter with 50 mls of water might limit the further use of this specific BET protocol. O RCI D Yoav Mazor