So we're going to have Dr. Hall speak on treatment for constipation from the colorectal viewpoint. These are my disclosures. Thank you very much for the opportunity to come and talk about what the lowly colorectal surgeon has to say about pelvic constipation. So what I'm going to highlight is the difference between pelvic and abdominal, which I think was very elegantly done. But I'm just going to talk about it from my standpoint. The gold standard treatments and the complexity of pelvic constipation, because I think that's what we all really don't understand. So I'm going to assume in my talk that these patients have failed good non-surgical therapy. And this is how, when a patient comes to me with constipation, this is my first decision point. Do they have abdominal or do they have pelvic constipation? So let's briefly talk about abdominal, which was discussed before. We rely on the chronic transit study as many of you who might order this test know. The company has been sold. The pills are no longer available. Currently, we are in negotiations with another company to try to get these pills made. The SmartPill is another test that's utilized, although I'm not in love with the SmartPill because this was mentioned before. If your rectum doesn't empty, your colon is going to get backed up. And the SmartPill will be read as colonic source, and it's really a pelvic source. So I would never operate based on a SmartPill. And the most common operation we do is a laparoscopic colectomy and iliorectal anastomosis. So how do we do? Well, when we look at our data, and I updated it, patients, I usually tell them you're going to have about four bowel movements a day. About 18% end up needing to use still some type of laxative, although the majority, it's much less. And about 83% are satisfied. The most common dissatisfaction is before where they move their bowels maybe once a month, now they move them four times a day. And that to them is not as positive. So now I'm going to get into the more complex situation, which is pelvic evacutory constipation. So we use these tests. I rely on video defecography. Dynamic MRI in our hands is not as good. Most of them are done laying down. How many of us poop laying down? Probably nobody here. The other thing about it that I don't particularly like is you can see a lot of things, but I don't know what to do with it. The dynamic, I feel like I have a better handle on what to do with it, the dynamic defecography. We use anal physiology. And then in selected patients, I do a transit study. If somebody comes in and they're moving their bowels a couple of times a week, a transit study to me is not necessary. You know, those patients that move their bowels once a month when they menstruate, those are the patients that you're going to be doing the transit study on. So I just want to get Hirschsprung's disease out of the way. There is a small segment of patients that have constipation that come to us in their late teens and early 20s that have short segment Hirschsprung's that has been missed all their life. They have a big rectum. They've had testing done that they've had biopsies, but it's very difficult to make this diagnosis in some individuals just on the biopsies. I think you have to do a strip biopsy and orient it from the posterior aspect of the anal rectum. And these people do very, very well with a proctectomy and a coloanal anastomosis. I'm not going to talk about rectoceles. I am in the mecca of people that know how to deal with rectoceles much better than I do. And in our practice, we very, very lovingly send all the rectoceles to the urogynecologist. But I'll talk about the other celes. So you have a patient that says, I start to move my bowels and then something happens and I can't keep going. Think about an eneroseal or a sigmoidoseal. I examine all the patients on their left side, which obviously is not the best. But I can a lot of times put a finger in the vagina and a finger in the anus and I can feel something when I have them strain come down in the rectovaginal septum. So then I communicate with my radiologist and say, hey, I'm concerned this patient may have something coming down in their rectovaginal septum when they do their DEFO. And a lot of times you'll see the results. And the other thing when you do a DEFO for a patient, you have to really coach them. Patients are very, I would be shy. You know, you're pooping and you're behind, granted you're behind a screen, but somebody is really watching you poop. I tell them, this test is very embarrassing, but you have to poop and you have to strain when they tell you to, like your eyes are gonna pop out. Because we wanna see what really happens. And you have to really give them a lot of coaching. It's kinda like the informed consent with the video that we were listening to before. The more coaching, the better tests you're gonna get. So what about these patients that have these seals? Well, most of them have a very deep pouch of Douglas. And we work with our yoga oncologist and we do, usually they end up getting a sacrocopalpexy plus minus a sigmoid resection. And we really try to completely close off the pelvis so particularly this bowel can't migrate down in there in the rectovaginal septum. To me, the non-relaxation from whatever area of the pelvis is the hardest and most vexing to treat. It leads to rectal dysfunction. So over time, the rectum can generate enough pressure to overcome this pelvic floor spasticity or non-relaxation. But with time, the rectum will enlarge and it will become more hyposensitive. You'll have backup into the sigmoid. We always try medical treatment first. We try physical therapy. But what we really rely on now for most of these patients is Botox and then physical therapy because a lot of them, they can't even figure out anything about how to relax if you just try physical therapy first. A lot of them have had this habit, it's changed in their brain. So they've had neuroplasticity in their brain and they are in this habit of contracting. Sometimes SNS, but these will be in places in Europe unless the patient's very rich because it's not approved by the FDA. I'll show you a video in a second of how we do the Botox injection. So there's been some studies done on this in our study and overall, Botox is effective, but it's very hard, the objective criteria to see how effective is not nearly as scientific as the studies that were presented this morning. But if you have a patient that has this, they're miserable and trying so many different things and anything to try to improve their quality of life is what we strive for. So we start out with, we usually use long-acting marcaine because this is painful and we inject it in the subcutaneous tissue on each side of the anus. Then what we're gonna do is we're gonna inject the Botox in usually the levator plate in those six positions of the arrows that are closest to the anus. We use 200 units of Botox, we divide it up into six tuberculin syringes with needles. We use a different needle, we're very worried always about infection. We prep the anal rectal area and you have a finger in the anus because it's very difficult to get the right spot. So with a finger in the anus, you can feel where the levator plate is and then you inject this syringe with the needle in, this is the tuberculin syringe. And we end up flooding the muscle in the six areas that I demonstrated on the schematic diagram. And so, and that's the technique that I described before when I described that we use that for the pre-limb for physical therapy in patients that have very poor relaxation. So the last type of constipation I wanna talk about is hyposensitivity. So on anal physiology, you put the balloon in, you fill the balloon as high as it goes and the patient never senses it. That's the patient with hyposensitivity and treating this is very difficult. There's been a lot of studies that have highlighted sacral nerve stimulation, particularly in Europe. One thing that I'm very disappointed in is people that do these studies, they group all constipation together and I hope as you figured out, there's many different types of constipation. You can't group them all together. And some of the studies have had these teased out and the hyposensitivity seems to be the group of constipation that works the best on. So if you tease that out from these non-US studies, you can see that they have improvement in many different domains. I'm not sure that this is ever gonna be available in the United States, but for this group of patients, to me, this is the best type of therapy. And as a last resort, they do a stoma. We do a stoma. Any patient that comes in and I figure out they have pelvic constipation, I start that seed in their head right away. And some of them say, I am so miserable, I'll take a stoma right now. That is how debilitating pelvic constipation can be. Unfortunately, there are a lot of patients that we can't help and a stoma can give them some quality of life back. So my last thoughts, conservative therapy is always the first line, except if you have short-segment Hirschsprung, those patients need surgery first off. I hope you think about colonic versus the pelvic sources of constipation. And I think with proper preoperative evaluation and patient selections, we can be successful in a large number of these patients. Thank you very much. Thank you for having me. And a special thanks to my colleagues in San Diego or from San Diego, UCSD, UC Irvine, and Kaiser. Thanks for asking me to speak on behalf of the pelvic PTs of the world. But I do have a small confession. I'm an Augs virgin, it's my first time here and I'm already talking about poop. So I'm not sure what that says about me or my colleagues that recommended me. My only disclosure is that I own a small PT clinic in San Diego called CTF. So if you refer a patient to me, we might make a little teeny bit of money. But by all means, feel free to refer patients. San Diego is a great place to visit and we're barely breaking even. So here's a short list of defecatory and rectal issues physical therapy can help treat. For the sake of time, we're focusing on two ends of the spectrum, fecal incontinence and constipation. But please remember that we treat everything in between, especially pain, which can be a part of both syndromes. Here's a generalized PT treatment plan that we'll go over in more detail. As you can see, we simply use the same modalities for both extremes. We simply adjust our focus and our techniques. When we begin our treatments, we first start with the history of everything and I mean everything. And ideally, we would also like to see a seven day food, fluid, bowel and bladder diary. And then we get into this crazy physical exam. We screen the lumbar spine, sacroiliac joints and hips for contributing factors, especially looking for weakness or other dysfunctions. We also look at functional strategies for breathing and toileting. Both can make a difference. And then we get to a detailed pelvic exam. We test both superficial and deep layers, the anterior urogenital triangle versus more of the posterior structure in the levator ani and external anal sphincter. We're looking for squeeze, lift, bear down and of course, relax. We observe externally and we feel internally. We see patterns on surface EMG and we can even visualize on real time ultrasound. Can you play the video with this please? We test various hold times, one second, 10 seconds, 30 seconds and 60 seconds. Not sure that video is working. We look for dysfunction and deficiencies everywhere. We're on the hunt for them. We might even take the exam further by looking into a variety of positions including what these muscles do in squatting and sitting to mimic toileting. Multiple levels of control and multiple factors are involved in maintaining bowel regularity. We have strength, sensation, rectal capacity, GI motility and reflexes. They're all key components for regularity, control and complete evacuation. Capitalizing on reflexes helps manage bowel regularity to stimulate or to quiet, that's the question. For instance, that gastrocolic reflex may stimulate an urge 30 seconds to 30 minutes after a meal, especially warm food and warm drinks, Starbucks coffee. Constipated patients need to take every advantage of this reflex while our fecal incontinence patients need to be very wary of the consequences of these actions. And then there's the parasympathetic defecation reflex which stimulates total bowel evacuation, otherwise known as the nervous poop. Patients often require coaching to calm their systems and mindful meditation and diaphragmatic breathing can also help. This is what I was doing this morning. As far as muscle control goes and treatment focus, we're focused on the level of the levator ani and the external anal sphincter. If it's weak, of course we're gonna strengthen. If it's overactive, we work to coordinate these muscles mostly for relaxation. This is where a lot of biofeedback comes into play and I mean a lot. And then there's the puborectalis. It seems to be the biggest troublemaker. Ideally, we want to have enough tone in the puborectalis to hold stool in the rectum but be flexible enough for complete emptying. If the puborectalis is overactive, the anal rectal angle might increase leading to constipation and if that worsens further, then to overflow fecal incontinence. But if it's underactive, hypotonic or weak, it may result in urgency, fecal incontinence and puts the burden on the external anal sphincter which is often disrupted especially with those nasty fourth degree tears. We educate our patients a lot. We spend a lot of time looking at every detail of their diet and hydration habits. We want to promote consistency with fiber and water and teach patient consequences of other bowel stimulants and irritants. Here's a short list of the medications our patients come in with and supplements. We just want to get them off the crazy rollercoaster because what we hear from our patients is that they take one medication a day and what we hear from our patients is that they take one medication that was prescribed by them but they didn't like the consequences so then they took another one and then they get on and off this crazy rollercoaster and go back and forth between constipation or incontinence. We're neither promoting nor prescribing, we just want to educate our patients. And then there's toileting mechanics. We are really looking at posture. We want wide knees and wide elbows, knees higher than hips mimicking a squat, the back and neck are fairly straight and the heels are up, think stilettos or even better, think squatty potty. I was asked by a colleague to make sure I address the squatty potty which clinically we see works really hard and honestly it's something I wish I would have invented because I recommend it every single day. There's not a whole lot of great information on this but it's coming because someone's doing current research on squatty potty. So there's more research to come on that and I think it's gonna be good news. A deal, I'll talk about that later. We're looking at actual technique. We really want to see what they're doing. So we get them on a commode and we assess via biofeedback or now real-time ultrasound. We're looking at how they actually bear down. We often describe it as belly big, belly hard or blow as you go, both cues, to just make sure they're not bearing down too much or tightening that pelvic floor as they bear down. The gut's also a slow learner so establishing a schedule and regular routine is paramount for our success. Scheduling also reduces anxiety for both our fecal incontinence and constipation patients. And here's a new look at an old modality. All different types of electrical stimulation. Neuromuscular electrical stim is used primarily for strengthening the external anal sphincter and levator ani for fecal incontinence. More recently, TENS, which we primarily in the old school used for pain, now is being found to decrease constipation and abdominal pain and increase evacuation frequency. There's not a whole lot of research on it. The sample sizes seem pretty small but it's something easy that people can try, especially if they already have TENS for low back pain, you might as well put it over their colon and see if it works. Interferential current is also another form of electrical stimulation. It's a medium frequency and again, on either side of the colon, anterior and posterior, we've seen some success, especially in a pediatric client. So biofeedback can come in many forms. We can simply use our manual skills and palpate musculature or use mirrors to educate our patients but these other devices and modalities can really be helpful. Many studies show various biofeedback training in conjunction with home exercise programs and pelvic floor exercises to be superior to exercise alone so we use these a lot. And I don't know if you know who this gentleman is but it's one of the most famous people in the world. But it's Walter Cronkite and he's said many great things including America's healthcare system is neither healthy, caring, nor a system. He also said when asked about aging, he was doing just fine. Don't ever trust a fart. Surface EMG is something that's been studied a lot. We've seen, it's been reported 70 to 80% success rates when treating constipation, especially for dysnergia. Other studies show some success with fecal incontinence as well but just remember, humans tend to cheat. They breath hold, they contract their glutes, they contract their abs. They'll do anything to see those little lines move so it takes an expert to coach them out of it. And again, combined therapies appear to work best. And then there's rectal balloon therapy. We want our FI patients to recognize the slightest sense of anything in the rectum. The don't ever trust a fart patients. We also want to train compliance and flexibility of the rectum. We can also use rectal balloons filled with either air or water to simulate expulsion coordination. Oh, my videos are working. Our friends from down under, our Australian friends have been using real-time ultrasound regularly as a biofeedback tool, especially in stress incontinence but we're just getting started with it here in the United States. Again, it's primarily been studied for stress incontinence but we can see the potential benefits, especially for fecal incontinence patients and streamline conditions for constipation. It really helps us define which exercises and which verbal cues work best with exercises. And then there's the magic poopy rub. It's fairly effective for facilitating movement in the constipated client. It's not a standalone modality but by all means it can really help. It's used to decrease discomfort associated with gas, bloating and constipation. There are many variations in the technique including depth, pressure, meridian and organ specificity. There's various small settings shows improvement with massage versus education alone for constipation, especially in the pediatric case client, post-CBA and the MS populations. So think those neuro and neurodevelopmental issues. Each study is small so we need more studies to prove its effectiveness but remember it's not a standalone treatment, it's just in conjunction with other treatments as well. But by all means you should try it. Patients, friends and neighbors, have me on speed dial for this magic poopy rub. It actually works. Uh-oh, now there's two videos going. Can we move to the next video? The diaphragm is a huge muscle with close relationships to the spine, abdomen, vascular and GI systems. So when your patient comes to you and says, well, my PT told me just to breathe, we're prescribing more than just breathing, we're prescribing different types of exercises to either re-educate posture, improve coordination or calm the nervous system and promote GI movement. Mary Mastry, who's a mentor of mine here from Chicago, uses a variety of breathing exercises including resistive breathing to improve constipation, in stress urinary incontinence, pelvic organ prolapse and even back pain. So there's a whole bunch of variations of this. We start in a non-functional supine position but it's because it's just easier for the patients to learn but then we get them into more functional postures. And finally, we just want our patients to move. We heard earlier this morning that as we age in the geriatric population, our musculoskeletal system can really decline as far as muscle strength and function. So we really do want our constipated patients especially need to move and walk or even run because it's good for them and good for their GI system. Our endocrinologists, our cardiologists, because it's good for them and good for their GI system. RFI patients need to gain strength and coordination as well as confidence first to get back to regular exercise and improve their quality of life. We may also use a variety of different exercises including yoga and Pilates to help both populations. But just remember, combined therapies work best and thanks for having me. Thank you. Thank you very much, that's a remarkable meeting and a befitting introduction to a group of poop doctors. What I'd like to do to cut to the chase is to start with the case, a 19-year-old lady who had been constipated for the past two years. She had infrequent bowel movements and hard stool. The Bristol Stool Form Scale is the most sophisticated tool a gastroenterologist uses. She denied the urge to defecate. She had abdominal discomfort and bloating unrelated to eating. A normal colonoscopy, the test was unnecessary. Abdominal tenderness and the diagnosis, if I asked you all, would you say she had irritable bowel syndrome? But I've omitted a few key features in her history. That is several symptoms that are suggestive of anorectal dysfunction and are critical to ask patients about. You see them listed on this slide. And on a rectal exam, she had stool in the waltz, high anal resting tone, reduced perineal descent during evacuation. And to all the fellows, it's important to emphasize that anal resting tone can be gauged by the resistance to insertion of the finger in the rectal waltz. Thereafter, when patients squeezed, the puborectalis lifts the index finger upwards and anteriorly towards the umbilicus. Conversely, when you ask patients to try and expel your finger, the perineum should descend by two to four centimeters and normally the puborectalis should contract. By contrast to that normal pattern, patients with defecatory disorders have impaired relaxation or paradoxical contraction of the puborectalis. What I find much more useful is the patients who have a frozen pelvic floor. It just doesn't move. That's virtually diagnostic of a defecatory disorder. At the other extreme, as I'll show you in a minute, you have patients with excess perineal descent. And in addition, some patients may have an isthmus, that is the increased resting tone. Others fail to contract their pelvic floor muscles. And then you have these ancillary findings. And as I read through all this, I think they should have a separate ICD-9 code for the rectal exam. But suffice to say, one cannot differentiate between pelvic floor dysfunction and other causes of constipation based on the clinical exam alone, which is why anorectal tests are necessary, as you'll hear in a minute. So for someone like this, I think it's important to start by verifying medications. And if they're on opiates or anticholinergic agents, I push very strongly to try and adjust them. The only test you really need is a complete blood count. Many people do a serum calcium or sensitive TSH, but that's unnecessary, unless there are other reasons to do this. And you only need to do screen for colon cancer when it's necessary based on the age. So then using anorectal tests and colonic transit, these patients can be categorized into normal transit constipation, isolated slow transit constipation, and defecatory disorders. And patients with defecatory disorders may have either normal or slow transit. So remember, because of this, just because you have someone with slow transit, it doesn't mean that they have isolated slow transit constipation. The slow transit may well be secondary to a defecatory disorder. So moving on, I'd like to briefly review the physiology of colonic motor functions and defecation, touch on the diagnosis of defecatory disorders. Cindy will talk about biofeedback therapy, and then go on to normal and slow transit constipation. Dr. Hull will cover surgical therapy. The colon is essentially a scavenger. It extracts water and electrolytes, and breaks down fiber to short-chain fatty acids, and eliminates stool. And because these functions take time, the colon works relatively slowly, taking approximately 36 hours to move contents from the cecum to the rectosigmoid colon. And while it's regarded as a single organ, remember that there's several differences in the anatomy, nerve and blood supply, lymphatic drainage, and even functions between the right colon, which serves primarily as a reservoir to mix contents, absorb water and electrolytes, the left colon, which normally functions as a conduit, and the rectosigmoid, which is involved in defecation. The colon is asleep at night, wakes up in the morning, and its activity is very irregular, probably because it facilitates mixing. But against that background of irregular motor activity, there are four key features of colonic motor activity that you should probably remember for the rest of your lives. First, is the colon contracts within a second to a few minutes after a meal. We call this the gastrocolic reflex, as you see here. And that probably explains why many patients with diarrhea-predominant IBS have abdominal cramps. This patient, it was accompanied by these very powerful, high-amplitude propagated contractions that moved from the descending to sigmoid colon, and not surprisingly, resulted in defecation. So when you have a patient with diarrhea-predominant IBS who says, doctor, I eat after rush to the toilet, give them a tablet or two of loperamide half an hour before eating, and they'll bless you. These HAPCs often precede defecation. They're induced by bisacodylene glycerol, which is how these drugs work, and constipated patients have fewer HAPCs. The colon is also exquisitely sensitive to its inter-ruminal content, and fat, short-chain fatty acids, and osmotic laxatives all accelerate proximal colonic emptying. Conversely, opiates and alpha-2-adrenergic agonists relax the colon, which is why they predispose to O'Keele-Weiss syndrome after surgery. When the rectum is distended by a stool, it induces involuntary relaxation of the internal sphincter. This reflex is absent in patients with Hirschsprung's disease and thereafter, defecation is accomplished by increased rectal pressure, shown here in yellow, coordinated with relaxation, not only of the external sphincter, but also the puborectalis, thereby establishing the gradient between the rectum and the anal canal necessary for fecal expulsion. By contrast to that normal pattern, patients with defecatory disorders either have this synergia, that is, not only rectal, but also anal pressure increase, shown here in orange, so you don't have that gradient, whereas others fail to increase the rectal pressure during evacuation. And you can see this nicely with these clips, which are acquired with dynamic MRI. In this healthy person, notice the perineal descent, relaxation of the puborectalis, opening of the anal canal, and expulsion of the ultrasound gel, whilst the anterior pelvic floor was well-supported. By contrast, the second clip, the one in the middle, is from a constipated patient who tried hard, but was unable to relax the pelvic floor. This is the frozen pelvic floor that I was alluding to earlier. If you see this on a physical exam, you don't need the MRI. The third clip is from a lady also with long-standing constipation. She'd had a hysterectomy. She expelled the gel, but at a price, the price being the marked perineal descent and the pelvic organ prolapse. When John Gebart, the urogynecologist at Mayo sees this, he says, Adil, this one needed a hysterectomy by a urogynecologist. That's why God created them. We study rectoanal pressures with high-resolution manometry. We have several catheters in the anal canal and the lower rectum, and then two sensors in the rectal balloon. Pressures are shown here in color with the lowest pressures in blue and the highest pressures in red. In this tracing from a constipated patient, notice the red reflecting contraction of the muscle during squeeze. During defecation, there was increased rectal pressure. The color changed from a dark blue to a lighter blue with nice anal relaxation, thereby establishing the gradient necessary for evacuation. Here, you can also see with rectal distension, you can see the progressively increasing relaxation of the anal sphincter reflecting the rectoanal inhibitory reflex. By contrast to that normal pattern in a constipated patient, this is a healthy person, and when she tried to defecate here, clearly the rectal pressure is lower than the anal pressure. The rectoanal gradient is negative, as it often is in healthy women shown here, which is why manometry is less useful than a balloon expulsion test for diagnosing defecatory disorders. So how do we put this together? When the clinical index of suspicion is low and the tests are normal, you're home free, as you probably are when the clinical index of suspicion is higher and the tests are abnormal. On the other hand, when there is a discrepancy between the index of suspicion and the tests, or particularly if you suspect a rectocele or pelvic organ prolapse, then a defecography is necessary to break the tie, in particular because many patients with pelvic organ prolapse and excessive perineal descent will have a normal balloon expulsion test and you might miss the diagnosis of a defecation disorder. So to summarize, a rectal balloon expulsion test is useful. Approximately 50% of patients with defecatory disorders have slow transit, and biofeedback therapy is better than laxatives for patients with defecatory disorders, which is why we're discussing this topic today. Moving on to normal and slow transit constipation, don't overlook the utility of a plain abdominal X-ray. It may disclose not only a lot of stool, but also in patients these days who chew gum and drink through a straw, a lot of air in the stomach. This was a patient who had a defecatory disorder and underwent pelvic floor retraining. Moving on to the center panel, that is when anorectal tests are normal, one assesses colonic transit, which can be either normal or slow. Regardless, we treat these patients with laxatives or secretagogues, as shown on this slide. You can start out with dietary fiber supplement, which is very useful as a first-line approach. The osmotic laxatives include polyethylene glycol, for which there is the most evidence, and magnesium salts. The stimulant laxatives you know are bisacodyl and glycerin. The secretagogues essentially increase the secretion of fluids and electrolytes. They soften the stool, also accelerate colonic transit, and then there's bucaloprite, which I'll mention in a moment. How do I do this in my practice? I always consider medication-induced constipation, and I try hard to stop opioid use alternative measures for managing pain. Start with a dietary fiber supplement, increase very gradually over several weeks, up to 20 grams a day, and encourage patients to be patient. Whilst I do this, the effect's not going to be as pronounced as it is with the laxatives. We've talked about the osmotic agents. I use the suppositories as rescue agents if patients don't have a bowel movement every two to three days, and if they don't work, then I move on to the secretagogues, which cost of the order of $350 to $400 a month, compared to pennies every day for the cheaper agents. And bucaloprite is useful, it's safe, it's not FDA-approved, but you can import it legally and it's available in Canada. This table summarizes the number needed to treat, and as you know, a lower number means it's better for chronic constipation, and then constipation-predominant IBS, shown on the right. The endpoints vary slightly amongst the studies, so it's not an apples-to-apples comparison, but it puts things in perspective. And the first point I just wanted to highlight is that for fiber, for polyethylene glycol and bisacodyl, the NNT is much lower than it is for linaclotide, placenotide, and bucaloprite, which is why we start with these agents. For constipation-predominant IBS, we have less evidence. For Lubiprostone, notice that the NNT is 13 versus four here, because for IBS, you have to hit it on two endpoints, not only bowel disturbances, but also the abdominal pain. For linaclotide, the NNT is comparable. For placenotide, we don't have any data. But we don't really know the efficacy of these agents in patients who have not responded to simple laxatives, which is the way we use these agents in our practice, because the trial included all comers, not just patients who didn't respond to laxatives. We don't know if the response is influenced by the pathophysiology of constipation, because these trials did not assess for defecatory disorders or assess colonic transit. And we don't have a good idea if these responses are sustained over a period of time. So for patients who don't respond to these agents, it's over to the colorectal surgeon, provided they don't have pelvic floor dysfunction. So to summarize, we talked about the key aspects of colonic motor functions. Remember the gastrocolic response to a meal, high-amplitude propagated contractions. This is how bisacodyl and glycerin work. The symptoms exam and tests are very useful for categorizing patients as normal transit, isolated slow transit, or pelvic floor dysfunction. Remember that even asymptomatic people may have abnormal anorectal tests, so one has to interpret the test results in the clinical context, and that slow colon transit may be secondary to pelvic floor dysfunction. And we've talked about biofeedback therapy for pelvic floor dysfunction, other measures for the rest, and subtotal colectomy for refractory slow transit constipation. Thank you very much.

constipation

colorectal viewpoint

laparoscopic colectomy

pelvic evacutory constipation

Hirschsprung's disease

sacro-culpoplexy

biofeedback therapy