Brain responses to mechanical rectal stimuli in patients with faecal incontinence: an fMRI study

Aim: Continence is dependent on anorectal/brain interactions. Consequently, aberrations of the brain-gut axis may be important in the pathophysiology of faecal incontinence (FI) in certain patients. The aim of this study was to assess the feasibility of recording brain responses to rectal mechanical stimuli in patients with FI using functional Magnetic Resonance Imaging (fMRI). Method: A prospective, cohort pilot study was performed to assess brain responses during rectal stimulation in 14 patients (4 male, mean [SD] age 62 [15] years). Blood oxygen level-dependent (BOLD) signals were measured by fMRI during rest and mechanical distension, involving random repetitions of isobaric phasic rectal distensions at fixed (15 & 45 mmHg) and variable (10% above sensory perception threshold) pressures. Results: Increases in BOLD signals in response to high-pressure rectal distension (45mmHg) and maximum toleration were observed in the cingulate gyrus, thalamus, insular cortex, inferior frontal gyrus, cerebellum, caudate nucleus, supramarginal gyrus, putamen and amygdala. Additionally, activation of the supplementary motor cortex and caudate nucleus with inconsistent activity in the frontal lobe was observed. Conclusions: This study has demonstrated the feasibility of recording brain responses to rectal mechanical stimulation using fMRI in patients with FI, revealing activity in widespread areas of the brain involved in visceral sensory processing. The observed activity in the supplementary motor cortex and caudate nucleus, with relative paucity of activity in the frontal lobes, warrants investigation in future studies to determine whether aberrations in cerebral processing of rectal stimuli play a role in the pathogenesis of FI