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Anismus 

Anismus (also known as spastic pelvic floor syndrome,[1] anal sphincter dyssynergia,[2] pelvic floor dyssynergia[3] and dyssynergic defecation[4]) is a malfunction of the external anal sphincter and puborectalis muscle during defecation. Normal defecation involves relaxation of both of these muscles. Malfunction involves their failure to relax or their paradoxical increased contraction.[5] Anismus is a form of obstructed defecation and can cause constipation[6]. It is more common in women than in men, and sometimes is associated with sexual abuse.[7] It occurs also in children, sometimes from birth.

Paradoxical contraction of the anal sphincter is fairly common and in many people it does not cause anismus.[8]

Contents

Diagnosis

Physical examination can rule out anismus (by identifying another cause) but is not sufficient to diagnose anismus. Anismus needs to be distinguished from rectal inertia, another cause of obstructed defecation and constipation. Techniques proposed to do this include the rectal cooling test.[9] Other techniques include manometry, balloon expulsion test, evacuation proctography, and MRI defecography.[3] Diagnostic criteria are: fulfillment of criteria for functional constipation, manometric and/or EMG and/or radiological evidence (2 out of 3), evidence of adequate expulsion force, and evidence of incomplete evacuation.[3]

Anismus can be classified by type:[4]

  • Type I: paradoxical anal contraction
  • Type II: impaired propulsion
  • Type III: impaired anal relaxation with adequate propulsion


Complications

Complications of anismus may include fecal impaction and megarectum.[10]

Treatment

Biofeedback is used to treat anismus, and for this purpose it is highly effective.[11][12][13] However, when anismus occurs in the context of intractable encopresis (as it often does), resolution of anismus may be insufficient to resolve encopresis.[11] For this reason, and because biofeedback training is invasive, expensive, and labor intensive, biofeedback training is not recommended for treatment of encopresis with anismus.

Other therapies, such as botulin toxin type-A[14] injections into the affected muscles have been considered. Historically, the standard treatment was surgical resection of the puborectalis muscle, but this has been found to be of no value.

References

  1. ^ Bleijenberg G, Kuijpers HC: Treatment of the spastic pelvic floor syndrome with biofeedback. Dis Colon Rectum 1987, 30:108-111
  2. ^ Help for Constipation
  3. ^ a b c Berman L, Aversa J, Abir F, Longo WE (July 2005). "Management of disorders of the posterior pelvic floor". Yale J Biol Med 78 (4): 211–21. PMID 16720016. PMC:2259151. 
  4. ^ a b Rao SS, Mudipalli RS, Stessman M, Zimmerman B (October 2004). "Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus)". Neurogastroenterol. Motil. 16 (5): 589–96. doi:10.1111/j.1365-2982.2004.00526.x. PMID 15500515. 
  5. ^ Anismus - WrongDiagnosis.com
  6. ^ Papachrysostomou, Maria C.; Smith, Adam N. * Functional obstructive defaecation: what is anismus?. European Journal of Gastroenterology & Hepatology. 6(11):975-982, November 1994.
  7. ^ LEROI A.-M. ; BERKELMANS I. ; DENIS P. ; HEMOND M. ; DEVROEDE G. Anismus as marker of sexual abuse : consequences of abuse on anorectal motility. Digestive diseases and sciences. ISSN 0163-2116. vol. 40, no7, pp. 1411-1416, 1995.
  8. ^ Voderholzer WA, Neuhaus DA, Klauser AG, Tzavella K, Müller-Lissner SA, Schindlbeck NE (August 1997). "Paradoxical sphincter contraction is rarely indicative of anismus". Gut 41 (2): 258–62. PMID 9301508. PMC:1891465. 
  9. ^ Shafik A, Shafik I, El Sibai O, Shafik AA (March 2007). "Rectal cooling test in the differentiation between constipation due to rectal inertia and anismus". Tech Coloproctol 11 (1): 39–43. doi:10.1007/s10151-007-0323-4. PMID 17357865. 
  10. ^ Real Martínez Y, Ibáñez Moya M, Pérez Mota A (June 2007). "[Megarectum and anismus: a cause of constipation" (in Spanish; Castilian). Rev Esp Enferm Dig 99 (6): 352–3. PMID 17883300. 
  11. ^ a b Nolan T, Catto-Smith T, Coffey C, Wells J (August 1998). "Randomised controlled trial of biofeedback training in persistent encopresis with anismus". Arch. Dis. Child. 79 (2): 131–5. PMID 9797593. PMC:1717674. 
  12. ^ Chiarioni G, Salandini L, Whitehead WE (July 2005). "Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation". Gastroenterology 129 (1): 86–97. PMID 16012938. 
  13. ^ Rao SS, Seaton K, Miller M, et al (March 2007). "Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation". Clin. Gastroenterol. Hepatol. 5 (3): 331–8. doi:10.1016/j.cgh.2006.12.023. PMID 17368232. 
  14. ^ Botulinum toxin type-a in therapy of patients with anismus. Journal Diseases of the Colon & Rectum. Publisher Springer New York. ISSN 0012-3706 (Print) 1530-0358 (Online).Issue Volume 44, Number 12: 1821-1826. December, 2001
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