Anismus and biofeedback: who benefits?

BACKGROUND: Biofeedback is the main treatment for dyschezia in patients with anismus, but retraining may fail because of the frequent association of pelvirectal disorders with anismus. We set out to identify indices of biofeedback failure in the treatment of anismus. PATIENTS AND METHODS: From May 1990 to May 1993, 27 patients (20 women and seven men; median age 46 years) with anismus in which dyschezia was not improved by laxative agents were enrolled in a biofeedback retraining programme. All patients underwent proctologic examination, anal manometry and defecography. Anismus was defined as an increase in anal pressure during attempted defecation in conjunction with an impairment of rectal emptying as assessed using an objective test (barium paste expulsion). Associated disorders were encountered frequently. These included abnormal perineal descent (22 cases), large rectocoele (12 cases), high-grade rectal prolapse (six cases), abnormally high anal canal pressures at rest (seven cases) and abnormal rectal response to inflation (20 cases). Anismus was the sole abnormality in 12 patients when perineal descent, low-grade prolapse and abnormal rectal sensations were not taken into account. RESULTS: Biofeedback retraining did not suppress dyschezia in 13 out of 27 patients. Neither associated disorders (rectocoele, rectal prolapse, abnormal perineal descent, anal pressure and abnormalities of rectal sensation) nor a relevant past history (hysterectomy, laxative abuse, use of antidepressive agents) were encountered more frequently in these 13 patients than in the other 14. The duration of symptoms before treatment was significantly longer in the group unresponsive to biofeedback retraining (81 +/- 61 compared with 33 +/- 34 months for the responsive group, P < 0.01), but the total duration of symptoms and the number of retraining sessions attended did not differ significantly between the two groups. CONCLUSIONS: (1) Extensive examination (defecography and manometry) before biofeedback retraining of anismus is not mandatory because the failure of retraining (48%) is not related to the presence of associated pelvirectal disorders. (2) A long past history of dyschezia seems to provide an index of the failure of biofeedback retraining.

[Does manometric megarectum have a symptomatic role in patients complaining of dyschezia?]. / Le mégarectum manométrique a-t-il une responsabilité symptomatique chez les patients se plaignant d'une dyschésie?

UNLABELLED: Adults with dyschezia are occasionally diagnosed as having megarectum when anorectal manometry identifies rectal sensory disturbances. It remains difficult however to ascertain whether this state represents a part of the pathophysiological process responsible for symptoms, or just an associated phenomenon. The aim of this study was to highlight the symptomatic and functional features encountered in patients with dyschezia and megarectum, and to compare them with those obtained in an asymptomatic group and in a group of patients complaining of dyschezia without manometric megarectum. PATIENTS AND METHODS: The maximum tolerable volume (MTV) was defined as the highest tolerable volume which induced painful and irrepressible repletion upon inflation of the rectum with air. The upper normal range of MTV (330 mL) was obtained from rectal manometry performed in a group of 18 healthy volunteers and asymptomatic patients (mean age: 37.8 +/- 14 years, 12 F, 6 M). Between February 90 and February 92, 27 consecutive adults (48 ans +/- 15 years, 26 F, 1 M) suffering from dyschezia were found to have abnormally increased MTV, and were compared to a group of 35 patients (47 +/- 15.3 years, 34 F, 1 M) with dyschezia with MTV within normal ranges. Symptomatic patients underwent detailed interrogation, clinical examination, anorectal manometry, and evacuation proctography. RESULTS: Parity, prevalence of hysterectomy, symptoms and natural history did not differ between the two groups except for increased use of antidepressive agents in the megarectum group.(ABSTRACT TRUNCATED AT 250 WORDS)