Pelvic Floor and Anorectal Disorders

• Audio chapter
  Attending-narrated, listen on the commute.
• ABIM-format MCQs
  5-option vignettes with full wrong-answer teaching.
• Study guide
  Tables, decision trees, primary sources.
• AI tutor
  Chapter-grounded, answers the question you're stuck on.

What this chapter covers

• Section 16.1: Chronic constipation: definitions and empiric management

  Chronic constipation is a diagnosis the candidate must build on symptoms rather than on stool frequency alone, because the population that complains of constipation is dominated by patients who pass stool more than three times a week and still report straining, hard stools, incomplete evacuation, and dependence on manual maneuvers.

• Section 16.2: Prescription therapies for refractory CIC

  Prescription therapy in chronic idiopathic constipation begins when fiber, polyethylene glycol, and stimulant laxatives have failed to produce a satisfactory response, and the choice among the available drugs is mechanism-driven.

• Section 16.3: Defecation disorders and biofeedback

  Defecatory disorders are the diagnoses the candidate must consider when a constipation patient has failed empiric therapy, because the mechanism is mechanical rather than transit-related and the right intervention is biofeedback rather than additional laxatives.

• Section 16.4: Slow-transit constipation

  Slow transit constipation is the diagnosis that emerges after a defecatory disorder has been excluded and the patient still has infrequent bowel movements and refractory symptoms.

• Section 16.5: Opioid-induced constipation and PAMORA

  Opioid-induced constipation is mechanistically distinct from chronic idiopathic constipation, and the candidate must recognize that distinction because the right drug class differs.

• Section 16.6: Fecal incontinence

  Fecal incontinence is the involuntary loss of solid or liquid stool, distinct from anal incontinence (which includes flatus) and from seepage (passage of small amounts of stool residue, typically in patients with internal sphincter dysfunction or perianal soiling).

• Section 16.7: Hemorrhoids, anal fissure, and pruritus ani

  The benign anorectal disorders that bring patients to clinic are anatomically distinguished by their relationship to the dentate line, and the candidate should anchor the differential to that anatomic landmark before reaching for a diagnosis.

Podcast episodes

1. 01

   Chronic Constipation Pharmacology and OIC

   Chronic constipation pharmacology and opioid-induced constipation: the empiric laxative sequence, the prescription secretagogues and prokinetics for refractory chronic idiopathic constipation, and the peripherally acting opioid antagonists that treat opioid-induced constipation without crossing into the brain.

2. 02

   Transit Constipation

   The constipation phenotypes that need more than pharmacology: defecation disorders diagnosed on anorectal manometry and balloon expulsion and treated with biofeedback, and slow-transit constipation documented on a marker or capsule study, where colectomy is considered only after outlet disease is excluded.

3. 03

   Fecal Incontinence and Benign Anorectal Disorders

   Fecal incontinence managed in a fixed sequence from medical optimization through biofeedback to sacral neuromodulation, and the benign anorectal disorders (hemorrhoids, anal fissure, and pruritus ani) each with a focused algorithm.