Is Dyssynergic Defecation an Unrecognized Cause of Chronic Constipation in Patients Using Opioids?

Abstract

OBJECTIVES: The impact of opioids on anorectal function is poorly understood but potentially relevant to the pathogenesis of opioid-induced constipation (OIC). To evaluate anorectal function testing (AFT) characteristics, symptom burden, and quality of life in chronically constipated patients prescribed an opioid (OIC) in comparison with constipated patients who are not on an opioid (NOIC). METHODS: Retrospective analysis of prospectively collected data on 3,452 (OIC = 588 and NOIC = 2,864) chronically constipated patients (Rome 3) who completed AFT. AFT variables included anal sphincter pressure and response during simulated defecation, balloon expulsion test (BET), and rectal sensation. Dyssynergic defecation (DD) was defined as an inability to relax the anal sphincter during simulated defecation and an abnormal BET. Patients completed Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires. RESULTS: The mean age of the study cohort was 49 years. Most patients were women (82%) and whites (83%). Patients with OIC were older than NOIC patients (50.7 vs 48.3, P = 0.001). OIC patients were significantly more likely to have DD (28.6% vs 21.4%, P < 0.001), an abnormal simulated defecation response on anorectal manometry (59% vs 43.8%, P < 0.001), and an abnormal BET (48% vs 42.5%, P = 0.02) than NOIC patients. OIC patients reported more severe constipation symptoms (P < 0.02) and worse quality of life (P < 0.05) than NOIC patients. DISCUSSION: Chronically constipated patients who use opioids are more likely to have DD and more severe constipation symptoms than NOIC.

Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology and investigation

“…The Rome IV criteria define OIC as a change in bowel habit or defecatory patterns, in comparison with normal following initiation, alteration, or an escalation in opioid therapy, see Table 1 20 . Two recent cross‐sectional studies comparing symptoms and results of diagnostic testing in constipated patients either currently taking or not taking opioids have shown that opioid use is associated with increased symptom severity, diminution in quality of life, and a greater incidence of rectal hyposensitivity, functional EDs/dyssynergic defecation, and delayed whole‐gut transit 112,113 …”

Letter: opioid usage is associated with rectal hyposensitivity in patients with opioid‐induced constipation

“…In 3,452 patients with chronic constipation, Nojkov et al showed that opioid users (n = 588) had a significantly higher mean defaecatory desire volume (DDV) than non-users. 4 In another study of 424 patients, recent opioid use (but not distant use) was independently associated with higher thresholds of first constant sensation volume, DDV and maximum tolerable volume in a multivariable regression analysis. 5 We also demonstrated, in 2,754 patients referred for specialist investigation for chronic constipation, that opioid use for moderate-to-severe pain (n = 238 patients) was associated with rectal hyposensitivity (defined as ≥2 out of 3 rectal sensory thresholds above normal limits).…”

Efficacy and Safety of Naloxegol in Patients with Chronic Non-Cancer Pain Who Experience Opioid-Induced Constipation: A Pooled Analysis of Two Global, Randomized Controlled Studies

“…[7][8][9] OIC results from the binding of opioids to μ-opioid receptors located in the enteric nervous system leading to decreased gastrointestinal motility, reduced intestinal fluid and electrolyte secretion and increased reabsorption, and sphincter dysfunction. [10][11][12] OIC commonly persists with chronic opioid use, whereas other adverse effects such as nausea and vomiting lessen over time. [13][14][15] Gastrointestinal symptoms associated with OIC include decreased stool frequency, straining, hard stools, and a sense of incomplete evacuation.…”