7-5 Irritable Bowel-Anismus Wael Solh and Eric G.Weiss The causes of constipation and altered defecation are mul- found in patients with solitary ulcer syndrome and idio- tifactorial, and the manifestations are varied. Etiologies of pathic perineal pain.3 Therefore, the diagnosis of NRPS must constipation or altered defecation can be divided into two be made based on the patient’s clinical findings, supported categories – slow transit constipation, and pelvic outlet by more than one physiologic investigation. obstruction. Pelvic outlet obstruction includes etiologies such as paradoxical or nonrelaxation of the puborectalis muscle or anismus (nonrelaxation of the “anal canal”), Treatment rectal prolapse or intussusception, and nonemptying rec- toceles. Associated findings may include perineal descent Because NRPS is a behavioral rather than an anatomic and solitary rectal ulcer syndrome. abnormality, biofeedback is the standard therapy. In In normal defecation, the pelvic floor muscles and exter- biofeedback training, patients are allowed to view their nal anal sphincter are voluntarily inhibited resulting in an own EMG or manometric tracings on a video monitor increase in the anorectal angle with increasing intraab- while attempting to relax the pelvic floor and sphincter dominal pressure. Patients with nonrelaxing puborectalis muscles. Numerous reports have demonstrated success syndrome (NRPS) or anismus are unable to voluntarily rates ranging from 37% to 100%.4 In the largest series to inhibit contraction of the pelvic floor. When inappropriate date, Gilliland and Wexner5 found only one variable to be function of the puborectalis muscle (inappropriate con- predictive of a successful outcome: patients who self- traction or failure to relax) results in the inability to evac- discharged from therapy had a success rate of only uate the rectum, the condition is termed anismus. Unlike 29%, whereas patients who remained in therapy until dis- levator syndrome, anismus is painless. charged by the therapist had a success rate of 63%. Where biofeedback therapy has failed to relieve a patient’s symptoms, botulinum toxin type A injection Diagnosis under EMG guidance can be offered in selected cases. We found high initial success rates with moderate long-term The diagnosis of NRPS is confirmed with a combination results.6 Another therapeutic modality available is electro- of anorectal manometry, electromyography (EMG), and galvanic stimulation (EGS). Hull et al.7 reported poor long- cinedefecography. Cinedefecographic findings that suggest term outcome (19% had their symptoms relieved, 24% had NRPS include obstructed defecation, a long and persistently partial relief at 28 months follow-up) for the treatment of closed anal canal, and the presence of a rectocele. Elec- levator syndrome. More recently, Chiarioni et al.8 reported tromyography studies can confirm persistent contraction a 50% success rate when they treated 30 patients with pelvic during defecation and straining. The balloon expulsion test floor “dyssynergia” with EGS. Overall, we believe EGS may is another modality that can be used. This simple and inex- represent a useful adjunct in the treatment options for these pensive test has shown high reliability in diagnosing pelvic patients because of its simplicity and low morbidity. outlet obstruction resulting from nonrelaxation of the puborectalis muscle.1 However, these diagnostics should be interpreted with caution.In a prospective study,we found the Surgical Approaches sensitivity and specificity of EMG and cinedefecography to be suboptimal if applied individually to diagnose anismus.2 Surgery has been universally unsuccessful in the treatment Others argue that paradoxical contraction of the puborec- of NRPS. A review of the literature provides numerous talis muscle on EMG analysis is not a specific finding, being examples of failures to surgically alleviate these patients’ 189 190 Urgency/Frequency Syndromes Therapy symptoms. These futile attempts have included division of to non-relaxing puborectalis muscle. Dis Colon Rectum 1992;35: the puborectalis muscle either posteriorly or laterally, 1019–1025. anorectal myectomy, rectopexy, and progressive anal dila- 2. Jorge JM,Wexner SD,Ger GC,Salanga VD,Nogueras JJ,Jagelman DG. Cinedefecography and electromyography in the diagnosis of nonre- tion. Not only were these attempts unsuccessful, but some laxing puborectalis syndrome. Dis Colon Rectum 1993;36:668–676. resulted in unacceptable levels of temporary or permanent 3. Jones PN, Lubowski DZ, Swash M, Henry MM. Is paradoxical con- incontinence. Another dilemma the clinician may be con- traction of puborectalis muscle of functional importance? Dis Colon fronted with is how to approach the constipated patient Rectum 1987;30:667–670. with both slow colonic transit and pelvic outlet obstruc- 4. Corman ML. Colon and Rectal Surgery. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 1998:383–385. tion. In short, the key to success in this population is appro- 5. Gilliland R, Wexner SD. Outcome and predictors of success of priate patient selection. In fact, a significant proportion of biofeedback for constipation. Br J Surg 1997;84:1123–1126. constipated patients have NRPS.9 It is imperative to accu- 6. Joo JS, Wolff B, Wexner SD. Initial North American experience with rately identify these patients using a combination of transit botulinum toxin type A for treatment of anismus. Dis Colon Rectum studies and pelvic floor function tests, before proceeding 1996;39:1107–1111. 7. Hull TL, Milsom JW, Church J, Oakley J, Lavery I, Fazio V. Electro- with colectomy and ileorectal anastomosis. The use of such galvanic stimulation for levator syndrome: how effective in the long comprehensive preoperative investigations resulted in a run? Dis Colon Rectum 1993;36(8):731–733. 97% success rate in those patients who underwent surgical 8. Chiarioni G, Chistolini F, Menegotti M, et al. One year follow-up therapy.10 It is our practice to recommend biofeedback study on the effects of electrogalvanic stimulation in chronic idio- therapy before any surgical intervention in those patients pathic constipation with pelvic floor dyssynergia. Dis Colon Rectum 2004;47(3):346–353. with concomitant slow transit and NRPS. In severe cases of 9. Wexner SD, Nogueras JJ, Jagelman DG. Physiologic assessment of refractory pelvic outlet obstruction, we perform a divert- colorectal functional disorders: use or abuse of technology? Dis ing stoma (loop ileostomy or sigmoid colostomy depend- Colon Rectum 1992;35:10–11. ing on colonic function). It is our preference to use the 10. Nyam DC, Pemberton JH, Ilstrup DM, Rath DM. Long term results laparoscopic approach to divert patients with benign of surgery for chronic constipation. Dis Colon Rectum 1997;40: 273–279. pathology. References 1. Fleshman JW,Dreznik Z, Cohen E, Fry RD, Kodner IJ. Balloon expul- sion test facilitates diagnosis of pelvic floor outlet obstruction due.