Share this article on:

Bear-Down Maneuver Is a Useful Adjunct in the Evaluation of Children With Chronic Constipation

Belkind-Gerson, Jaime*; Surjanhata, Brian; Kuo, Braden; Goldstein, Allan M.

Journal of Pediatric Gastroenterology and Nutrition: December 2013 - Volume 57 - Issue 6 - p 775–779
doi: 10.1097/MPG.0b013e3182a698df
Original Articles: Gastroenterology

Background and Objectives: Chronic constipation is a common problem in pediatrics and often the result of obstructed defecation. The aim of this study was to determine the use of the bear-down maneuver (BDM) in the evaluation of children with chronic constipation and to establish optimal conditions for its performance.

Methods: This retrospective study compares BDM with balloon expulsion testing (BET) during anorectal manometry in 38 children with chronic constipation. BDM was performed with 0-, 20-, 40-, and 60-mL balloon inflation. BET, performed with a 60-mL balloon, was considered normal if the balloon was expelled within 1 minute.

Results: Rectal pressure during BDM was 48% higher in patients able to expel the balloon during BET compared with those who could not (P < 0.05). Anal canal pressure was 46% lower in patients able to expel the balloon (P < 0.05). A rectoanal pressure differential greater than zero during BDM was 90% predictive that the subject would be able to expel the balloon. The optimal balloon inflation volume was 60 mL.

Conclusions: BDM using an inflated balloon provides valuable mechanistic information in the evaluation of children with dyssynergic defecation. We found that patients often had either an insufficient rectal pressure during bear-down or an abnormally high anal canal pressure. This information may be useful in planning further treatment for these children.

*Neurogastroenterology Program and Department of Pediatric Gastroenterology

Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA

Neurogastroenterology Program and Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

Address correspondence and reprint requests to Jaime Belkind-Gerson, MD, MSc, Neurogastroenterology Program, Massachusetts General Hospital for Children, Harvard Medical School, 175 Cambridge St, #575, Boston, MA 02114 (e-mail:

Received 1 November, 2012

Accepted 20 July, 2013

Partial financial support was provided as a grant from the International Foundation for Functional Gastrointestinal Disorders.

The authors report no conflicts of interest.

© 2013 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,