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Low recruitment
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The purpose of this study is to determine if Botulinum Toxin-A (Botox) injection will improve symptoms of constipation in obstructed defecation syndrome (ODS).
Constipation represents one of the five most common physician diagnoses for gut disorders. Obstructed defecation syndrome (ODS) is an under-treated condition which accounts for 30%- 50% of all patients with constipation and it is more common as people age. ODS is due to the abnormal contraction of the puborectalis muscle (a muscle around the anus that should relax during defecation).
Biofeedback therapy and medical management are the standards of care for ODS. Typically patients are first managed with dietary modifications (fiber supplementation, increased fluids) and medication (laxatives, enemas). If constipation is not improved, they will undergo biofeedback, which lasts from 3-8 sessions on average. Biofeedback acts on the cause of ODS and it has good short-term success, but around 50%-70% of treated patients re-experience constipation after one year. The main drawbacks of biofeedback for ODS are the facts that it is expensive, time-consuming, available in few select-centers and its success depends very much on the provider. Biofeedback is delivered in multiple 1-hour clinic sessions, so many patients don't finish all recommended sessions and their constipation may recur faster.
Botox also acts on the cause of ODS and was shown to improve constipation within 1-3 weeks after the injection. Botox is delivered as a one-time injection in the puborectalis muscle and external anal sphincter (the muscle right around the anus). The injection can be performed in the clinic under local anesthesia, and the patient goes home afterwards. Currently, Botox is used for treatment of patients who fail biofeedback and medical management, to avoid the options of last resort (resection of the colon with stoma). To this day, no adequately designed study has confirmed that Botox is indeed superior to placebo (normal saline) for the treatment of ODS. The results from this study will provide valuable data on the ability of Botox to improve symptoms of constipation and the duration of its effect. This project has the potential to increase the availability of effective treatments for ODS.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Botulinum Toxin-A | Active Comparator | Patients will receive Botulinum Toxin-A (Botox) injected in the puborectalis muscle and external anal sphincter. We will use 100 units of Botox, a dose with a good safety profile that has been proven to work in previous studies performed in adults. |
|
| Normal saline | Placebo Comparator | Patients will receive normal saline (placebo) injected in the puborectalis muscle and external anal sphincter. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Botulinum Toxin-A | Drug | 100 Units diluted in a 5 cc syringe at a concentration of 20U/mL |
|
| Measure | Description | Time Frame |
|---|---|---|
| Changes in the Altomare Obstructed Defecation Syndrome- Score (ODS-S) and Patient Assessment of Constipation- Quality of Life Score (PAC-QoL) | The primary outcome measure will be the change from baseline in the sum of ODS-S and PAC-QoL at 1 month after the Botox injection. This measures the symptomatic improvement in ODS. ODS (altomare obstructed defecation syndrome score) scores range from 0 (minimum) to 31 (maximum) where 31 is the most severe (worse outcome) and 0 is no symptoms (better outcome). The scale for PAC-QoL (Patient Assessment of Constipation- Quality of life score) is a minimum of 0 and a maximum of 112 where 0 is highest quality of life (better outcome) and 112 is lowest quality of life (worse outcome) Larger number for change would suggest a better outcome | Baseline, 1 month after injection |
| Measure | Description | Time Frame |
|---|---|---|
| Changes in the Altomare ODS Score (ODS-S) | The scale title is obstructed defecation score, the minimum value is 0 and the maximum value is 31 for the ODS score. This measures the symptomatic improvement in ODS. ODS scores range from 0-31 where 31 is the most severe and 0 is no symptoms. A higher score would suggest a better outcome. | Assessed at baseline, 1, 3, 6 and 12 months after injection and value compared from baseline to 12 months |
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Inclusion Criteria:
Males and females 18 years or older of all races and backgrounds
Competent to give informed consent
Meet the Rome III diagnostic criteria for functional constipation
Inability to relax the puborectalis muscle at electromyography
Altomare Obstructed Defecation Syndrome score of 15 points or above
Failure of treatment with 2 conservative measures which may be as follows:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Liliana Bordeianou, M.D. | Massachusetts General Hospital | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Massachusetts General Hospital | Boston | Massachusetts | 02114 | United States |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 16848807 | Background | Shaheen NJ, Hansen RA, Morgan DR, Gangarosa LM, Ringel Y, Thiny MT, Russo MW, Sandler RS. The burden of gastrointestinal and liver diseases, 2006. Am J Gastroenterol. 2006 Sep;101(9):2128-38. doi: 10.1111/j.1572-0241.2006.00723.x. Epub 2006 Jul 18. | |
| 21606976 | Background | Suares NC, Ford AC. Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol. 2011 Sep;106(9):1582-91; quiz 1581, 1592. doi: 10.1038/ajg.2011.164. Epub 2011 May 24. |
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| ID | Title | Description |
|---|---|---|
| FG000 | Botulinum Toxin-A | Patients will receive Botulinum Toxin-A (Botox) injected in the puborectalis muscle and external anal sphincter. We will use 100 units of Botox, a dose with a good safety profile that has been proven to work in previous studies performed in adults. Botulinum Toxin-A: 100 Units diluted in a 5 cc syringe at a concentration of 20U/mL |
| FG001 | Normal Saline | Patients will receive normal saline (placebo) injected in the puborectalis muscle and external anal sphincter. Normal Saline: Dispensed in a 5 cc syringe |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
We were unable to recruit more than one patient to the study so it was closed
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| ID | Title | Description |
|---|---|---|
| BG000 | Botulinum Toxin-A | Patients will receive Botulinum Toxin-A (Botox) injected in the puborectalis muscle and external anal sphincter. We will use 100 units of Botox, a dose with a good safety profile that has been proven to work in previous studies performed in adults. Botulinum Toxin-A: 100 Units diluted in a 5 cc syringe at a concentration of 20U/mL |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Categorical | Count of Participants |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | ||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Changes in the Altomare Obstructed Defecation Syndrome- Score (ODS-S) and Patient Assessment of Constipation- Quality of Life Score (PAC-QoL) | The primary outcome measure will be the change from baseline in the sum of ODS-S and PAC-QoL at 1 month after the Botox injection. This measures the symptomatic improvement in ODS. ODS (altomare obstructed defecation syndrome score) scores range from 0 (minimum) to 31 (maximum) where 31 is the most severe (worse outcome) and 0 is no symptoms (better outcome). The scale for PAC-QoL (Patient Assessment of Constipation- Quality of life score) is a minimum of 0 and a maximum of 112 where 0 is highest quality of life (better outcome) and 112 is lowest quality of life (worse outcome) Larger number for change would suggest a better outcome | since there was only one participant, analysis of the data is limited | Posted | Number | change in score on a scale | Baseline, 1 month after injection |
|
3 months
since there were no patients recruited in the saline arm, there is no risk for serious adverse event or mortality
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Botulinum Toxin-A | Patients will receive Botulinum Toxin-A (Botox) injected in the puborectalis muscle and external anal sphincter. We will use 100 units of Botox, a dose with a good safety profile that has been proven to work in previous studies performed in adults. Botulinum Toxin-A: 100 Units diluted in a 5 cc syringe at a concentration of 20U/mL |
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr Liliana Bordeianou | Massachusetts General Hospital | 6176430541 | lsavitt@mgh.harvard.edu |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP | Yes | Yes | No | Study Protocol and Statistical Analysis Plan | Aug 18, 2015 | Dec 31, 2019 | Prot_SAP_000.pdf |
| ICF | No | No | Yes | Informed Consent Form | Nov 28, 2016 | Dec 31, 2019 | ICF_001.pdf |
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| ID | Term |
|---|---|
| D019274 | Botulinum Toxins, Type A |
| D000077330 | Saline Solution |
| D012965 | Sodium Chloride |
| ID | Term |
|---|---|
| D001905 | Botulinum Toxins |
| D008666 | Metalloendopeptidases |
| D010450 | Endopeptidases |
| D010447 | Peptide Hydrolases |
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| Normal Saline | Drug | Dispensed in a 5 cc syringe |
|
|
| Changes in the Patient Assessment of Constipation- Quality of Life Score (PAC-QoL) | PAC-QoL is Patient Assessment of Constipation- Quality of Life Score. The scale for PAC-QoL is 0 minimum score to 112 maximum score where 0 is highest quality of life (better outcome) and 112 is lowest quality of life (worse outcome). Since we are looking for a change in score, the minimum change would be 0 and the maximum change would be 112. A higher change would suggest a better outcome. | Assessed at baseline, 1, 3, 6 and 12 months after injection and value compared from baseline to 12 months |
| Changes in Health-Related Quality of Life | Medical outcomes survey short form (SF-36 version 1) will be used to measure changes in the health-related quality of life.This is a measure of efficacy. The score ranges from 0-100 where 0 is maximum impact on health and 100 is no impact on health | Baseline, 1, 3, 6 and 12 months after injection and value compared from baseline to 12 months |
| Changes in Cleveland Clinic Fecal Incontinence Score (CCFI) | This is a measure of Botox-specific adverse events. The score is a total of answers of questions. The score range is 0-20 where 0 is perfect incontinence and 20 is complete incontinence. | Assessed at baseline, 1, 3, 6 and 12 months after injection and value compared from baseline to 12 months |
| Changes in Fecal Incontinence Quality of Life Scale (FIQoL) | This is a measure of Botox-specific adverse events. This fecal incontinence quality of life scale (FIQoL) scale ranges from 4 as the minimum and 20 as maximum. lower score indicates lower quality of life (worse outcome) and higher score has better quality of life (better outcome). | Assessed at baseline, 1, 3, 6 and 12 months after injection and value compared from baseline to 12 months |
| Relaxation of Puborectalis With Push Measured by EMG | This is a measure of efficacy. | Baseline, 1 month follow-up visit |
| Success of Balloon Expulsion Test | This is a measure of efficacy. | Baseline, 1 month follow-up visit |
| Change in Anal Sphincter Function | The changes in anal sphincter function will be assessed by anorectal manometry. This test will measure the resting sphincter pressure, maximal resting anal pressure, maximum squeeze pressure. The change in anal sphincter function is a measure of treatment efficacy. The minimum score for resting sphincter pressure is 0 and the maximum is 200. The minimum squeeze pressure is 10 and the maximum is 200. The lower score is suggested of decreased tone and worse outcome, where high scores may suggest worse outcome in terms of sphincter function. | Baseline, 1 month follow-up visit |
| Change in Defecation Index | The defecation index=maximum rectal pressure during attempted defecation/minimum anal residual pressure during attempted defecation. This is calculated based on measurements obtained from anorectal manometry and is a measure of treatment efficacy. Scores can change from 0 (meaning no change- least effective) to 1 meaning that the change shows complete relaxation with defecation. | Baseline, 1 month follow-up visit |
| 23261064 | Background | American Gastroenterological Association; Bharucha AE, Dorn SD, Lembo A, Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013 Jan;144(1):211-7. doi: 10.1053/j.gastro.2012.10.029. No abstract available. |
| 17029615 | Background | Maria G, Cadeddu F, Brandara F, Marniga G, Brisinda G. Experience with type A botulinum toxin for treatment of outlet-type constipation. Am J Gastroenterol. 2006 Nov;101(11):2570-5. doi: 10.1111/j.1572-0241.2006.00791.x. Epub 2006 Oct 4. |
| BG001 |
| Normal Saline |
Patients will receive normal saline (placebo) injected in the puborectalis muscle and external anal sphincter. Normal Saline: Dispensed in a 5 cc syringe |
| BG002 | Total | Total of all reporting groups |
| Participants |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| Race and Ethnicity Not Collected | Race and Ethnicity were not collected from any participant. | Count of Participants | Participants |
|
| Region of Enrollment | Count of Participants | Participants |
|
| ODS score | Number | units on a scale |
|
Patients will receive Botulinum Toxin-A (Botox) injected in the puborectalis muscle and external anal sphincter. We will use 100 units of Botox, a dose with a good safety profile that has been proven to work in previous studies performed in adults. Botulinum Toxin-A: 100 Units diluted in a 5 cc syringe at a concentration of 20U/mL |
| OG001 | Normal Saline | Patients will receive normal saline (placebo) injected in the puborectalis muscle and external anal sphincter. Normal Saline: Dispensed in a 5 cc syringe |
|
|
| Secondary | Changes in the Altomare ODS Score (ODS-S) | The scale title is obstructed defecation score, the minimum value is 0 and the maximum value is 31 for the ODS score. This measures the symptomatic improvement in ODS. ODS scores range from 0-31 where 31 is the most severe and 0 is no symptoms. A higher score would suggest a better outcome. | since there was only one participant, analysis of the data is limited | Posted | Number | score on a scale | Assessed at baseline, 1, 3, 6 and 12 months after injection and value compared from baseline to 12 months |
|
|
|
| Secondary | Changes in the Patient Assessment of Constipation- Quality of Life Score (PAC-QoL) | PAC-QoL is Patient Assessment of Constipation- Quality of Life Score. The scale for PAC-QoL is 0 minimum score to 112 maximum score where 0 is highest quality of life (better outcome) and 112 is lowest quality of life (worse outcome). Since we are looking for a change in score, the minimum change would be 0 and the maximum change would be 112. A higher change would suggest a better outcome. | since there was only one participant, analysis of the data is limited | Posted | Number | change in score on a scale | Assessed at baseline, 1, 3, 6 and 12 months after injection and value compared from baseline to 12 months |
|
|
|
| Secondary | Changes in Health-Related Quality of Life | Medical outcomes survey short form (SF-36 version 1) will be used to measure changes in the health-related quality of life.This is a measure of efficacy. The score ranges from 0-100 where 0 is maximum impact on health and 100 is no impact on health | since there was only one participant, analysis of the data is limited | Posted | Number | change in score on a scale | Baseline, 1, 3, 6 and 12 months after injection and value compared from baseline to 12 months |
|
|
|
| Secondary | Changes in Cleveland Clinic Fecal Incontinence Score (CCFI) | This is a measure of Botox-specific adverse events. The score is a total of answers of questions. The score range is 0-20 where 0 is perfect incontinence and 20 is complete incontinence. | since there was only one participant, analysis of the data is limited | Posted | Number | change in score on a scale | Assessed at baseline, 1, 3, 6 and 12 months after injection and value compared from baseline to 12 months |
|
|
|
| Secondary | Changes in Fecal Incontinence Quality of Life Scale (FIQoL) | This is a measure of Botox-specific adverse events. This fecal incontinence quality of life scale (FIQoL) scale ranges from 4 as the minimum and 20 as maximum. lower score indicates lower quality of life (worse outcome) and higher score has better quality of life (better outcome). | since there was only one participant, analysis of the data is limited | Posted | Number | change in score on a scale | Assessed at baseline, 1, 3, 6 and 12 months after injection and value compared from baseline to 12 months |
|
|
|
| Secondary | Relaxation of Puborectalis With Push Measured by EMG | This is a measure of efficacy. | since there was only one participant, analysis of the data is limited | Posted | Number | participants | Baseline, 1 month follow-up visit |
|
|
|
| Secondary | Success of Balloon Expulsion Test | This is a measure of efficacy. | since there was only one participant, analysis of the data is limited | Posted | Count of Participants | Participants | Baseline, 1 month follow-up visit |
|
|
|
| Secondary | Change in Anal Sphincter Function | The changes in anal sphincter function will be assessed by anorectal manometry. This test will measure the resting sphincter pressure, maximal resting anal pressure, maximum squeeze pressure. The change in anal sphincter function is a measure of treatment efficacy. The minimum score for resting sphincter pressure is 0 and the maximum is 200. The minimum squeeze pressure is 10 and the maximum is 200. The lower score is suggested of decreased tone and worse outcome, where high scores may suggest worse outcome in terms of sphincter function. | since there was only one participant, analysis of the data is limited | Posted | Number | change of score | Baseline, 1 month follow-up visit |
|
|
|
| Secondary | Change in Defecation Index | The defecation index=maximum rectal pressure during attempted defecation/minimum anal residual pressure during attempted defecation. This is calculated based on measurements obtained from anorectal manometry and is a measure of treatment efficacy. Scores can change from 0 (meaning no change- least effective) to 1 meaning that the change shows complete relaxation with defecation. | since there was only one participant, analysis of the data is limited | Posted | Number | change in score on a scale | Baseline, 1 month follow-up visit |
|
|
|
| 0 |
| 1 |
| 0 |
| 1 |
| 0 |
| 1 |
| EG001 | Normal Saline | Patients will receive normal saline (placebo) injected in the puborectalis muscle and external anal sphincter. Normal Saline: Dispensed in a 5 cc syringe | 0 | 0 | 0 | 0 | 0 | 0 |
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| D006867 |
| Hydrolases |
| D004798 | Enzymes |
| D045762 | Enzymes and Coenzymes |
| D045726 | Metalloproteases |
| D001426 | Bacterial Proteins |
| D011506 | Proteins |
| D000602 | Amino Acids, Peptides, and Proteins |
| D001427 | Bacterial Toxins |
| D014118 | Toxins, Biological |
| D001685 | Biological Factors |
| D000077324 | Crystalloid Solutions |
| D007552 | Isotonic Solutions |
| D012996 | Solutions |
| D004364 | Pharmaceutical Preparations |
| D002712 | Chlorides |
| D006851 | Hydrochloric Acid |
| D017606 | Chlorine Compounds |
| D007287 | Inorganic Chemicals |
| D017670 | Sodium Compounds |