Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 36-year-old woman is evaluated for a 12-year history of refractory constipation. Her symptoms began after a difficult childbirth. She has constipation marked by straining, bloating, and a constant sensation of incomplete emptying. She sometimes has 4 or more days between bowel movements. When she does have a bowel movement, the stool is soft-formed. Trials of several fiber supplements, lactulose, milk of magnesia, docusate, bisacodyl, polyethylene glycol, and lubiprostone have provided only transient relief for no more than 4 weeks before the gradual return of symptoms. There is no family history of gastrointestinal malignancies or inflammatory bowel disease. Medications are polyethylene glycol, psyllium, and bisacodyl.
On physical examination, vital signs are normal. BMI is 17. Tenderness to palpation is noted in the lower abdomen. No masses are noted. Rectal examination reveals normal resting tone, an increase in external anal sphincter tone, and poor relaxation of the pelvic floor when bearing down. Soft stool is noted in the rectal vault.
Anorectal manometry confirms paradoxical muscle contraction during the Valsalva maneuver consistent with pelvic floor dyssynergia.
Which of the following is the most appropriate management?
A. Increase polyethylene glycol
B. Increase psyllium
C. Start biofeedback therapy
D. Start enema therapy.
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