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Zinovy Khokhlov
Zinovy Khokhlov

Anal Mature



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Trans-anal irrigation (TAI) is used widely to treat bowel dysfunction, although evidence for its use in adult chronic functional constipation remains unclear. Long-term outcome data are lacking, and the effectiveness of therapy in this patient group is not definitively known.


Evidence for effectiveness and safety was reviewed and the quality of studies was assessed. Primary research articles of patients with chronic functional constipation, treated with TAI as outpatients and published in English in indexed journals were eligible. Searching included major bibliographical databases and search terms: bowel dysfunction, defecation, constipation and irrigation. Fixed- and random-effect meta-analyses were performed.


Primary research articles that include patients with chronic functional constipation as defined above, treated with retrograde trans-anal irrigation at home as outpatients, and published in English in indexed journals were eligible. The following were not eligible for inclusion: articles solely studying patients with a known cause for their constipation (e.g., neurogenic constipation, opioid-induced constipation, other organic cause); conference abstracts, audits, letters and commentaries; articles studying antegrade irrigation (Table 1). Reviews were not included but relevant review articles [8, 10] were screened for further relevant studies, as were citations of retrieved studies. No protocol was registered, however the review was reported in accordance with the PRISMA statement (2009) [11].


Both qualitative review of study results and quantitative analysis was performed. Rates of complications are reported and statistical pooling of proportion estimates was explored using fixed and random effect models within StatsDirect Version 3. Both Q and I2 statistics were calculated to assess study heterogeneity. An Egger test was performed to assess risk of publication bias.


Therefore, whilst one or more side effects were experienced by a large proportion of patients undergoing anal irrigation, the risk of major life-threatening, life-limiting or irreversible complications was very low.


There is insufficient evidence to state with any certainty how best to tailor therapy to patient symptoms. A recent review based on expert consensus [24] has proposed a number of regimes to overcome problems with irrigation and so improve outcomes, but experimental trial evidence is lacking, especially for functional constipation patients. In spinal cord injured patients, it has been found that emptying the rectosigmoid using irrigation stimulates colonic transit [24] however it is not clear whether this is transferable to patients with slow colonic transit and functional constipation. Scintigraphic studies have suggested that these patients have a different response to irrigation, with reduced colonic clearance compared with spinal cord injured patients [20]. In addition, none of the studies assess outcomes of low-volume anal irrigation systems.


Two previous systematic reviews examining trans-anal irrigation were found [8, 10]. These reviews, while valuable, have several limitations: They focus on irrigation as a therapy for several conditions including neurogenic constipation, faecal incontinence, idiopathic constipation and mixed symptoms; also, one review [10] incorporates studies of inpatient pulsed irrigation which is a very different therapy from home irrigation described in this review. The findings of this review are similar to the previous studies with respect to the weak nature of current evidence and the heterogeneity of the studies included. Subsequent to these reviews further studies have been identified and this review is the first to address irrigation therapy in idiopathic constipation only. This is also the first systematic review on this topic to be conducted in accordance with the PRISMA statement. Additionally, this is the first meta-analysis of the effectiveness of irrigation in chronic functional constipation.


This review suggests that trans-anal irrigation may be an effective therapy for chronic constipation, and may be considered in patients who have not responded to medical management. Irrigation is safe and its effectiveness is at least comparable with pharmacological therapies. However, the evidence to guide its use in chronic functional constipation is weak, and its long-term benefits are unclear. There are no reported data on cost-effectiveness of irrigation: whether treatment provides good value for money from scarce health service resources. There is a clear need for well-designed prospective trials to evaluate the effectiveness, duration, and adverse consequences of treatment, as well as to assess how best to tailor therapy to individual patients. Future studies should have defined outcome measures, for example improvement in validated quality-of-life questionnaires within a defined time point. More evidence about the comparative effectiveness and cost-effectiveness of low-volume and high-volume irrigation systems would also be valuable.


CDE; study design, literature search, data collection and analysis, manuscript drafting. HJC; study design, literature search, checking accuracy of data collection, review of the manuscript. JYY: Study design, review of the manuscript. JMM; study design, statistical analysis, review of manuscript. All authors read and approved the final manuscript.


An adult pinworm generally is 1/4 to 1/2 inch (about 6 to 13 millimeters) in length. The most common symptom of infection is anal itching, particularly at night, as worms migrate to the host's anal area to lay their eggs.


While the infected person sleeps, female pinworms lay thousands of eggs in the folds of skin surrounding the anus. Most people infected with pinworms have no symptoms, but some people experience anal itching and restless sleep.


Accidentally swallowing or breathing in pinworm eggs causes a pinworm infection. The tiny (microscopic) eggs can be carried to your mouth by contaminated food, drink or your fingers. Once swallowed, the eggs hatch in the intestines and mature into adult worms within a few weeks.


Female pinworms move to the anal area to lay their eggs, which often results in anal itching. When you scratch the itchy area, the eggs cling to your fingers and get under your fingernails. The eggs then get transferred to other surfaces, such as toys, bedding or toilet seats. The eggs can also be transferred from contaminated fingers to food, liquids, clothes or other people.


The parasite can travel from the anal area up the vagina to the uterus, fallopian tubes and around the pelvic organs. This can cause problems such as inflammation of the vagina (vaginitis) and inflammation of the inner lining of the uterus (endometritis).


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Background The quadrivalent human papillomavirus (HPV) vaccine (qHPV; types 6, 11, 16, 18) is indicated for men and women aged 9 to 26 years to prevent HPV associated anogenital high-grade squamous intraepithelial lesions (HSIL) and cancer. ACTG 5298 was a randomized placebo controlled Phase 3 study in human immunodeficiency virus (HIV)-infected men who have sex with men, and women of qHPV to prevent persistent anal HPV infection. Baseline data are presented here. Methods Human immunodeficiency virus-infected men who have sex with men, and women 27 years or older without previous anogenital or oral cancer were enrolled. Baseline anal cytology, high-resolution anoscopy and collection of anal, oral, and vaginal specimens for HPV genotyping were performed and acceptability assessed. Results Five hundred seventy-five (575) participants were enrolled (82% men and 18% women). Median age was 47 years. Race/ethnicity was 46% white, 31% black, and 20% Hispanic. Plasma HIV-1 RNA was less than 50 copies/mL in 83% and median CD4 T count was 602 cells/μL. Abnormal anal cytology was detected in 62%, with corresponding HSIL on biopsy (bHSIL) in 33%. Anal HPV 6, 11, 16, and 18 were detected in 25%, 13%, 32%, and 18% of the participants, respectively. Prevalence of 0, 1, 2, 3, and 4 qHPV types was 40%, 38%, 17%, 4%, and 1%, respectively. Oral infection with 1 or more qHPV type was detected in 10% of the participants. Study procedures were generally acceptable. Conclusions At study baseline, there was a high prevalence of abnormal anal cytology, bHSIL, and HPV infection. Sixty percent of the participants had anal infection with preventable qHPV types. 041b061a72


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