Evidence for increased tone or overactivity of pelvic floor muscles in pelvic health conditions: a systematic review.

OBJECTIVE: Pelvic floor muscle tone, which includes active and passive components, is argued to be increased in many pelvic health conditions, including those involving pain. This study systematically reviewed evidence for increased pelvic floor muscle tone in pelvic health conditions. DATA SOURCES: Electronic databases (PubMed, CINAHL, and Embase) were searched up to May 31, 2021. The search strategy included variants of pelvic and/or floor, muscle, and tone using keywords and Medical Subject Headings (MeSH) terms. STUDY ELIGIBILITY CRITERIA: Studies were included if they investigated increased tone of the pelvic floor muscle and reported measures of active or mechanical properties of the pelvic floor muscle in humans with any pelvic health condition, including pain, bowel, urogenital, or sexual dysfunctions. Studies of any design were included, except systematic and narrative reviews. Reference lists of studies, reviews, and book chapters were searched for additional studies. METHODS: Data were extracted using a standardized form, including measurement tool and outcome measure. Risk of bias was analyzed using a modified ROBINS-I (Risk of Bias In Non-randomized Studies - of Interventions) tool, and a score was allocated to determine whether the study provided "convincing" interpretation (comparison with condition-free control group, valid measure, no application issues). RESULTS: In total, 151 studies were included, reporting 8 different tools (electromyography, dynamometry, manometry, digital palpation, defecography, ultrasound, magnetic resonance imaging, other). The most common pelvic health condition was pelvic pain (n=16 conditions), followed by bowel and urogenital conditions. Most studies (57%) were cross-sectional. A healthy control group was infrequently included for comparison (27%). Unvalidated methods or methods applied in a manner that precluded convincing interpretation were common (94%). Of the 15 measurement tools that provided convincing evidence, 10 demonstrated greater tone in a pelvic health condition (all pain) compared with controls, and 5 showed no difference. CONCLUSION: Despite the large literature, few studies provide convincing evidence for increased tone/overactivity of pelvic floor muscles in pelvic health conditions. Interpretation is hampered by design and measurement issues. Terminology was often inaccurate. Few studies investigate male, transgender, and pediatric groups.

A modified myotomy of the puborectalis for anismus.

Anismus or non-relaxing puborectalis muscle (PRM) on straining may affect over 40% of patients with obstructed defecation (OD). Management is usually with biofeedback, or botulin toxin injection or partial puborectalis muscle myotomy. Such a procedure can be difficult technically. Bleeding and rectal injury may occur when detaching the PRM from the rectum. A partial modification of surgical technique may avoid these complications. The diagnosis should be confirmed with exclusion of sphincter compromise. Through two cutaneous incisions, an Ellis forceps is advanced through the ischio-rectal space, whilst finger pressure per rectum allows the puborectalis to be visualized and grasped by the forceps. Removal of some ischiorectal fat may be necessary to allow division of half the PRM under direct view. From October 2020 to October 2021, 5 patients underwent the modified technique in our department (4 males, median age 43 years [range 34-58 years], median follow-up 6 months [range 2-12 months]). No patients suffered from injury of the rectum or bleeding during or after surgery. Operative time was 30 min less than conventional PRM division, as the time-consuming "blind dissection" of PRM was avoided. Four patients regained appropriate relaxation of the PRM on straining. One male patient had temporary minor anal incontinence for 2 weeks. One male patient with severe mental distress continued to have with anismus and OD after surgery and refused psychiatric support. This modified procedure is feasible and safe and quicker than our conventional technique. More cases with longer follow-up are needed to confirm its efficacy.

Systematic review and meta-analysis of the outcome of puborectalis division in the treatment of anismus.

AIM: Anismus is a common cause of obstructed defaecation syndrome (ODS). The aim of the present review is to assess the efficacy and safety of puborectalis muscle (PRM) division in the treatment of anismus. METHOD: PubMed, Scopus, Web of Science and the Cochrane Library were searched for studies that assessed the outcome of PRM division in the treatment of anismus. The main outcome measures were subjective improvement in ODS, decrease in the Wexner constipation score and ODS score, and complications, namely faecal incontinence (FI). RESULTS: Ten studies (204 patients, 63.7% male) were included. The weighted mean rate of initial subjective improvement across randomized trials was 97.6% (95% CI 94%-100%) and across nonrandomized studies it was 63.1 (95% CI 39.3%-87%). The weighted mean rate of 12-month improvement across randomized trials was 64.9% (95% CI 53.3%-76.4%) and across nonrandomized studies it was 55.9% (95% CI 30.8%-81%). The weighted mean rate of FI across randomized trials was 12.1% (95% CI 4.2%-20%) and across nonrandomized studies it was 10.4% (95% CI 1.6%-19.3%). Male sex and unilateral PRM division were significantly associated with recurrence of symptoms after PRM division. Bilateral PRM division, posterior division, complete division and concomitant sphincterotomy were significantly associated with FI after PRM division. CONCLUSIONS: The use of PRM division for treatment of anismus was followed by some initial improvement in ODS symptoms which decreased to <60% 12 months after PRM division. The mean rate of FI after PRM division, namely 10%-12%, is a limitation of the technique. Further well-designed trials are needed to verify the outcome of PRM division in the treatment of anismus.

Magnetic resonance defecography findings of dyssynergic defecation.

Dyssynergic defecation (DD) is defined as paradoxical contraction or inadequate relaxation of the pelvic floor muscles during defecation, which causes functional constipation. Along with the anal manometry and balloon expulsion tests, magnetic resonance (MR) defecography is widely used to diagnose or rule out pelvic dyssynergia. Besides the functional abnormality, structural pathologies like rectocele, rectal intussusception, or rectal prolapse accompanying DD can also be well demonstrated by MR defecography. This examination can be an uncomfortable experience for the patient, so the imaging method and the importance of patient cooperation must be explained in detail. The defecatory phase of the examination is indispensable for evaluation, and inadequate effort should be ruled out before diagnosing DD. MR defecography provides important data for the diagnosis of DD, but optimal imaging criteria should be applied. Further tests can be suggested if patient co-operation is not sufficient or MR defecography findings are irrelevant.

Obstructed defecation syndrome associated with paradoxical puborectalis contraction: osteopathic treatment versus anal biofeedback. Results of a pilot study.

BACKGROUND: Biofeedback is the most widespread rehabilitative therapy for the treatment of anismus after failed conservative treatment. Osteopathy represents an alternative therapy for constipation. The aim of this study was to evaluate short- and long-term results of osteopathic treatment as compared to biofeedback in patients with dyssynergic defecation. METHODS: This was a prospective cohort pilot study on 30 patients with dyssynergic defecation enrolled at the Colorectal Clinic of the University Hospital of Ferrara, Italy, from May 2015 to May 2016 and followed until May 2020. Dyssynergic defecation was defined as the inappropriate contraction of the pelvic floor or less than 20% relaxation of basal resting sphincter pressure (on anal manometry) with adequate propulsive forces during attempted defecation. Dyssynergic patients were divide into 2 treatment groups: 15 patients had osteopathy and 15 patients had biofeedback. Before and 3 months after rehabilitation treatment, all patients had anorectal manometry, defecography, and ultrasound, and were evaluated with the Cleveland Clinic Florida (CCF) constipation score, obstructed defecation syndrome (ODS) score, Colo-rectal-anal Distress Inventory (CRADI-8), Colo-rectal-anal Impact Questionnaire (CRAIQ-7), and the Brusciano Score (BS). To evaluate the efficacy of osteopathy and biofeedback in the long-term, all patients completed the above-mentioned questionnaires 5 years later via a telephone interview. RESULTS: The two treatments were similarly effective in the short term with reduction in questionnaires scores, and increase in the percentage of anal sphincter release at straining at anorectal manometry in both groups. The ODS score was significantly reduced in biofeedback group (p = 0.021). The 3-month post-treatment BS was lower in the osteopathy group, but this just failed to reach statistical significance (p = 0.050). Periodic rehabilitation reinforcements were provided. The CCF constipation score decreased significantly in the osteopathy group (p = 0.023) after 5 years. CONCLUSIONS: Osteopathy is a promising treatment for dyssynergic defecation, and it can be associated with biofeedback.

Pelvic Floor Nonrelaxation: Approach to Evaluation and Treatment.

Dyssynergic defecation can be a complex, burdensome condition. A multidisciplinary approach to these patients is often indicated based on concomitant pathology or symptomatology across the pelvic organs. Escalating treatment options should be based on shared decision making and include medical and lifestyle optimization, pelvic floor physical therapy with biofeedback, Botox injection, sacral neuromodulation, rectal irrigation, and surgical diversion.

Biofeedback for Pelvic Floor Disorders.

Defecatory disorders can include structural, neurological, and functional disorders in addition to concomitant symptoms of fecal incontinence, functional anorectal pain, and pelvic floor dyssynergia. These disorders greatly affect quality of life and healthcare costs. Treatment for pelvic floor disorders can include medications, botulinum toxin, surgery, physical therapy, and biofeedback. Pelvic floor muscle training for pelvic floor disorders aims to enhance strength, speed, and/or endurance or coordination of voluntary anal sphincter and pelvic floor muscle contractions. Biofeedback therapy builds on physical therapy by incorporating the use of equipment to record or amplify activities of the body and feed the information back to the patients. Biofeedback has demonstrated efficacy in the treatment of chronic constipation with dyssynergic defecation, fecal incontinence, and low anterior resection syndrome. Evidence for the use of biofeedback in levator ani syndrome is conflicting. In comparing biofeedback to pelvic floor muscle training alone, studies suggest that biofeedback is superior therapy.

Persistent levator co-activation is not associated with symptoms or bother of obstructed defecation.

INTRODUCTION AND HYPOTHESIS: The objective was to determine whether levator contraction during Valsalva (i.e. levator co-activation), as visualised on four-dimensional translabial ultrasound (4D-TLUS), is associated with obstructed defecation (OD). METHODS: This was a retrospective study including patients attending a tertiary urogynecological unit. All underwent an interview, clinical examination and 4D-TLUS. Frequent straining at stool, digitation or sensation of incomplete emptying during defecation were considered symptoms of OD. Archived 4D-TLUS volumes were evaluated, blinded to all other data. Hiatal anteroposterior (AP) diameter (cm) and hiatal area (cm2) were measured at rest and on maximal Valsalva. Patients with anatomical explanations for OD (rectocele, enterocele and/or rectal intussusception) were excluded. Reduction of hiatal AP diameter and hiatal area on Valsalva were tested for association with symptoms of OD. RESULTS: Overall, 1,383 women attended the unit from May 2013 to July 2016. Seven hundred and eight were excluded because of rectocele (n = 645), enterocele (n = 116) or rectal intussusception (n = 41) and 10 owing to missing data, leaving 665. Mean age was 53 years (16-89), mean body mass index (BMI) 27.3 kg/m2 (15.7-64.4). OD symptoms were reported by 368 (55.3%) patients. On imaging, a reduction in hiatal AP diameter on Valsalva was seen in 11.7% cases (78 out of 665) with a mean reduction of 3.5 mm (0.2-17). A mean reduction in hiatal area of 1.9cm2 (0.03-14.8) on Valsalva was seen in 9.8% cases (65 out of 665). These sonographic measures of levator co-activation were not associated with OD symptoms or bother caused by them (p > 0.05). CONCLUSIONS: Levator co-activation seen on TLUS is not associated with obstructed defecation.

Impact of TRREMS on symptoms of obstructed defecation due to rectocele: predictive factors and outcomes.

BACKGROUND: The aim of this study was to evaluate the impact of the transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS) on the treatment of obstructed defecation due to rectocele and to identify the predictive factors for unsuccessful results. METHODS: Consecutive patients with obstructed defecation symptoms (ODS) associated with rectocele who had the TRREMS procedure were included. Each patient was assessed by echodefecography, manometry, and colonic transit time as well as the Cleveland Clinic constipation score (CCS) before therapy and at follow-up after 6 months. Reduction in the CCS score was calculated as a ratio. Factors correlated with a decrease in the CCS were analyzed in a univariate analysis. RESULTS: A total of 81 patients were included. Nineteen patients had postoperative complications that were not severe: 7 (8.6%) had tenesmus, 6 (7.4%) stenosis (4 treated with digital dilatation and 2 with endoscopic stricturectomy), 4 (4.9%) residual mucosal prolapse treated with rubber band ligation, 1 (1.2%) early bleeding, and 1(1.2%) thrombosis. Seventy-nine (97.5%) patients had a significant clinical response with significant reduction of the CCS constipation score from median 13 (range 17-10) to 4 (range, 8-2) (p = 0.0001); only 2 patients (2.5%) had an unsatisfactory response, complaining of straining and vaginal digitation during the evacuatory effort. Patients with anismus previously treated with biofeedback had a lower reduction ratio of the CCS score compared with patients without anismus (61.2 ± 2.8% versus 70.9% ± 1.5, p = 0.0006). There were no significant differences in the reduction of the CCS according to age, parity, type of delivery, previous hysterectomy, post-menopausal status, rectal mucosal prolapse and/or associated rectal intussusception, grade of rectocele and presence of complications. CONCLUSIONS: The TRREMS procedure significantly improved evacuation disorders in this study. Appropriate selection of patients is key for the success of this approach. Anismus even if previously treated with biofeedback, was the main predictive factor of unsuccessful treatment.

Effects of Alfuzosin, an α1-Adrenergic Antagonist, on Anal Pressures and Bowel Habits in Women With and Without Defecatory Disorders.

BACKGROUND & AIMS: Some patients with defecatory disorders (DD) have high anal pressures that may impede rectal evacuation. Alpha-1 adrenoreceptors mediate as much as 50% of anal resting pressure in humans. We performed a randomized, placebo-controlled study of the effects of alfuzosin, an alpha1-adrenergic receptor antagonist, on anal pressures alone in healthy women and also on bowel symptoms in women with DD. METHODS: In a double-blind study performed from March 2013 through March 2017, anal pressures were evaluated before and after 36 women with DD (constipation for at least 1 year) and 36 healthy women (controls) were randomly assigned (1:1) to groups given oral alfuzosin (2.5 mg immediate release) or placebo. Thereafter, patients were randomly assigned (1:1) to groups given oral alfuzosin (10 mg extended release) or placebo each day for 2 weeks. Participants kept daily diaries of bowel symptoms for 2 weeks before (baseline) and during administration of the test articles (treatment). Weekly questionnaires recorded the overall severity of constipation symptoms, bloating, abdominal pain, nausea, and vomiting; overall satisfaction with treatment of constipation was evaluated at weeks 2 and 4. The primary endpoint was the change in the number of spontaneous (SBMs) and complete SBMs (CSBMs) between the treatment and baseline periods. We evaluated relationships between stool form, passage, and complete evacuation. RESULTS: Alfuzosin reduced anal resting pressure by 32 ± 3 mm Hg versus 16 ± 3 mm Hg for placebo (P = .0001) and anal pressure during evacuation by 26 ± 3 mm Hg versus 16 ± 3 mm Hg for placebo, (P = .03). However, alfuzosin did not significantly increase the rectoanal gradient, SBMs or CSBMs compared with placebo. Both formulations of alfuzosin were well tolerated. Hard stools and the ease of passage during defecation accounted for 72% and 76% of the variance in the satisfaction after defecation, respectively, during baseline and treatment periods. CONCLUSIONS: In a randomized trial, alfuzosin reduced anal pressure at rest and during simulated evacuation in healthy and constipated women, compared with placebo, but did not improve bowel symptoms in constipated women. This could be because the drug does not improve stool form or dyssynergia, which also contribute to DD. ClinicalTrials.gov number, NCT 01834729.

High-resolution Anorectal Manometry for Identifying Defecatory Disorders and Rectal Structural Abnormalities in Women.

BACKGROUND & AIMS: Contrary to conventional wisdom, the rectoanal gradient during evacuation is negative in many healthy people, undermining the utility of anorectal high-resolution manometry (HRM) for diagnosing defecatory disorders. We aimed to compare HRM and magnetic resonance imaging (MRI) for assessing rectal evacuation and structural abnormalities. METHODS: We performed a retrospective analysis of 118 patients (all female; 51 with constipation, 48 with fecal incontinence, and 19 with rectal prolapse; age, 53 ± 1 years) assessed by HRM, the rectal balloon expulsion test (BET), and MRI at Mayo Clinic, Rochester, Minnesota, from February 2011 through March 2013. Thirty healthy asymptomatic women (age, 37 ± 2 years) served as controls. We used principal components analysis of HRM variables to identify rectoanal pressure patterns associated with rectal prolapse and phenotypes of patients with prolapse. RESULTS: Compared with patients with normal findings from the rectal BET, patients with an abnormal BET had lower median rectal pressure (36 vs 22 mm Hg, P = .002), a more negative median rectoanal gradient (-6 vs -29 mm Hg, P = .006) during evacuation, and a lower proportion of evacuation on the basis of MRI analysis (median of 40% vs 80%, P < .0001). A score derived from rectal pressure and anorectal descent during evacuation and a patulous anal canal was associated (P = .005) with large rectoceles (3 cm or larger). A principal component (PC) logistic model discriminated between patients with and without prolapse with 96% accuracy. Among patients with prolapse, there were 2 phenotypes, which were characterized by high (PC1) or low (PC2) anal pressures at rest and squeeze along with higher rectal and anal pressures (PC1) or a higher rectoanal gradient during evacuation (PC2). CONCLUSIONS: In a retrospective analysis of patients assessed by HRM, measurements of rectal evacuation by anorectal HRM, BET, and MRI were correlated. HRM alone and together with anorectal descent during evacuation may identify rectal prolapse and large rectoceles, respectively, and also identify unique phenotypes of rectal prolapse.

Semi-closed bilateral partial miotomy of the puborectalis for anismus: a pilot study: Partial miotomy of the puborectalis for anismus.

BACKGROUND: Anismus or non relaxing puborectalis muscle (PRM) may cause obstructed defecation (OD). Reported surgical treatment is partial miotomy, followed by sepsis, bleeding, and incontinence. The aim of the present study was to investigate on the feasibility and outcome of a modified mini-invasive operation. PATIENTS AND METHODS: Consecutive patients with anismus and OD not responding to medical therapy, excluding multiparous females, patients with anal incontinence, recto-rectal intussusception, and disordered psychological pattern. Semi-closed bilateral partial division of PRM, pulled down through 1-cm perianal incisions, was performed. Concomitant significant rectal mucosal prolapse and rectocele, when present, were treated. OD was evaluated using a validated score and anal/vaginal ultrasound (US) was performed pre -and postoperatively. A control group of seven patients with normal bowel habit was also investigated. RESULTS: Eight patients (seven females), median age 48 years (range 29-71) were operated. Six also had significant mucosal prolapse and rectocele. All were followed up for a median of 12 months (range 2-40). None of them had postoperative sepsis or bleeding. One had just one occasional episode of mild anal incontinence. Symptoms improved in 6 or 75 % and, OD score decreased from 19.6 ± 1.0 to 9.2 ± 2.0 (mean ± s.e.m.), P = 0.007. No patient had anismus after surgery and PRM relaxation changed from 0 to 5.9 ± 0.8 mm being 6.6 ± 1.5 mm in controls. CONCLUSION: Semi-closed bilateral partial division of PRM achieves muscle's relaxation on straining in all patients without any significant postoperative complication. Further studies are needed prior to consider it a validated procedure.

Anismus-A Very Unusual Extrapyramidal Side Effect of Paliperidone Palmitate in an Adolescent with Schizo-Affective Disorder.

Here, authors report on an interesting case of an adolescent with a diagnosis of schizo-affective disorder, maintained on LAI paliperidone palmitate that developed an unusual dystonic reaction in form of anismus that masquerade as constipation and faecal impaction. To our knowledge, this is one of the earliest reports of antipsychotic-induced anismus notably in adolescent population. Clinicians should be mindful of unusual forms of dyskinesias that might be associated with high-potency antipsychotic use.

Functional Constipation and Obstructed Defecation.

Constipation encompasses symptoms of decreased colonic motility or difficulty with the defecation process. As a broad definition, this can be inclusive of functional constipation (FC) or colonic inertia, obstructed defecation (OD), and irritable bowel syndrome-constipation type (IBS-CS). After excluding IBS-C, FC and OD diagnosis and management require a multidisciplinary approach often involving nutritionists, pelvic floor therapists, urogynecologists, and colon and rectal surgeons. Differentiating the presence or absence of each can direct therapy and prognosticate chances for improvement in this often complex combination of disorders.

[Childhood sexual abuse: how important is the diagnosis to understand and manage sexual, anorectal and lower urinary tract symptoms]. / Abus sexuels dans l'enfance: intérêt de leur diagnostic pour la compréhension et la prise en charge des troubles sexuels, ano-rectaux et vésico-sphinctériens.

OBJECTIVE: To understand and manage the sequels of childhood sexual abuse on sexual, anorectal and lower urinary tract functions. MATERIAL AND METHODS: Review of articles published in the Medline database, selected according to their scientific relevance and published guidelines on this subject together with our own experience. RESULTS: A history of sexual abuse is frequently found when assessing dysfunction or symptoms of the lower urinary tract. In this context, urinary stress incontinence is rarely involved but it can be linked by epidemiological factors. Dysuria with urgency is the most frequent expressed symptom. When associated with anorectal disorders and pelvic pain or a sexual disorder in particular dyspareunia, a sexual abuse should be evoked and specific questions asked to the patient. Although these symptoms are frequently encountered in 12 to 33% of women, and 8 to 16% of men, few practitioners, whatever their speciality ask about them as routine. It is important that the physician diagnose the existence of sexual abuse, in particular when the symptoms mentioned by the patient are not conclusive, in spite of thorough urological assessment. Patients finding the initial examination difficult and painful and the failure of the initial treatment should lead to questions concerning abuse, if neglected by the initial medical inquiry. CONCLUSIONS: Clinicians involved in perineal functional pathology are able to acquire standardized modalities of inquiry about child sexual abuse for a better time management and efficacy in the therapeutic approach. The interest of a multidisciplinary diagnostic and therapeutic approach is primordial, associating psychological therapy and if necessary perineal re-education. This can avoid unnecessary tests and out-patient visits. Directing patients towards a multidisciplinary approach is highly advisable.

Diagnostic performance of dynamic MR defecography in assessment of dyssynergic defecation.

PURPOSE: To assess diagnostic performance of MR defecographic findings in diagnosis of dyssynergic defecation (DD). METHODS: This retrospective study included 46 patients with chronic constipation who met the Rome IV criteria for diagnosis of present or absent DD and underwent MRI between Jan 2015 and June 2020. Patients were divided into DD group (n = 24) and non-DD group (n = 22). Nine parameters were analyzed by two radiologists: anorectal angle (ARA) and M line at rest, defecation, and change between 2 phases; anal canal width; prominent puborectalis muscle; abnormal evacuation. Receiver operating characteristic (ROC) curves were plotted to extract the optimal cut-offs and area under the curve (AUC). Multivariate analysis was performed. RESULTS: Seven findings showed statistically significant difference between DD and non-DD groups. M line at defecation had highest odds ratio, followed by ARA change, ARA at defecation, M line change, prominent puborectalis muscle, abnormal evacuation and anal canal width, respectively. ARA change and prominent puborectalis muscle had highest specificity (95.5% and 100%, respectively). The optimal cut-offs of ARA at defecation, ARA change, M line at defecation, M line change and anal canal width were 122°, 1.5°, 3.25 cm, 1.9 cm and 8.5 mm, respectively. Multivariate logistic regression revealed two significant findings in differentiating between DD and non-DD, including M line at defecation (OR 23.31, 95% CI 3.10-175.32) and ARA at defecation (OR 13.63, 95% CI 1.94-95.53) with sensitivity, specificity, PPV, NPV and AUC of 79.2%, 95.5%, 95%, 80.8% and 0.87(95% CI 0.78-0.97), respectively. CONCLUSION: MR defecography has high diagnostic performance in diagnosis of DD. Although M line and ARA at defecation are two significant findings on multivariate analysis, ARA change less than 1.5 degrees and prominent puborectalis muscle have good specificity in DD diagnosis.

Assessment of defecation disorders using high-resolution MRI-defecography.

AIMS: The aim of this retrospective study was to try to find correlations between different diagnoses established by clinical examination, anorectal manometry and MRI-defecography and, the association with psychiatric disorders. METHODS: 44 patients (median age 53.81 years) presenting with intestinal motility disorders and who underwent clinical, biological and psychiatric examination, dynamic defecographic-MRI (resting, squeezing, straining, defecation and evacuation phases), anorectal manometry, colonoscopy. MRI was performed using the 1,5 T. RESULTS: MRI-defecography revealed the following changes: anismus (16), rectocele (12), pelvic floor dysfunction (6), peritoneocele (2), cervical-cystic-ptosis (1), rectal prolapse (6), and in 1 case the examination was normal. Hypertonic anal sphincter (16) and lack of defecation reflex (12) at anorectal manometry correlated with anismus in all patients at MRI-defecography. Lack of inhibitor anal reflex (6) was associated with rectocele (4), cervix-cysto-ptosis (1) and peritoneocele (2). Anxiety (11), depression (6) and anxiety-depressive disorders (10) were found in 27/44, somatization disorders in 9/44 and no psychiatric changes in 8/44 cases. CONCLUSION: As multiparous women are at risk for outlet obstruction constipation, MRI-defecography is suggested in this category. There is good correlation between diagnosis using anorectal manometry and MRI-defecography in patients with terminal constipation and anismus. Lower defecation dysfunction is often associated with psychiatric disorders.

Disorders of anorectal motility: Functional defecation disorders and fecal incontinence.

Functional defecation disorders (FDDs) and fecal incontinence (FI) are common anorectal disorders often distressing and significantly add to the healthcare burden. They present with multiple, overlapping symptoms that can often obscure the underlying pathophysiology and can pose significant management dilemmas. A detailed history, stool diaries and visual scales of stool form, a careful digital rectal examination are needed to guide anorectal physiology tests. With high-resolution (3-D) anorectal manometry, anal ultrasonography, (magnetic resonance) defecography and imaging, and neurophysiological tests, it is possible to define and characterize the underlying structural and functional abnormalities more accurately. In this review, we present a succinct update on the latest knowledge with regards to the pathophysiology, diagnosis and management of FDDS, fecal incontinence and abnormalities of rectal capacity (i.e., megarectum, microrectum).

Anismus, Physiology, Radiology: Is It Time for Some Pragmatism? A Comparative Study of Radiological and Anorectal Physiology Findings in Patients With Anismus.

PURPOSE: Anismus is a functional disorder featuring obstructive symptoms and paradoxical contractions of the pelvic floor. This study aims to establish diagnosis agreement between physiology and radiology, associate anismus with morphological outlet obstruction, and explore the role of sphincteric pressure and rectal volumes in the radiological diagnosis of anismus. METHODS: Consecutive patients were evaluated by using magnetic resonance imaging proctography/fluoroscopic defecography and anorectal physiology. Morphological radiological features were associated with physiology tests. A categorical analysis was performed using the chi-square test, and agreement was assessed via the kappa coefficient. A Mann-Whitney test was used to assess rectal volumes and sphincterial pressure distributions between groups of patients. A P-value of <0.05 was significant. RESULTS: Forty-three patients (42 female patients) underwent anorectal physiology and radiology imaging. The median age was 54 years (interquartile range, 41.5-60 years). Anismus was seen radiologically and physiologically in 18 (41.8%) and 12 patients (27.9%), respectively. The agreement between modalities was 0.298 (P = 0.04). Using physiology as a reference, radiology had positive and negative predictive values of 44% and 84%, respectively. Rectoceles, cystoceles, enteroceles and pathological pelvic floor descent were not physiologically predictive of animus (P > 0.05). The sphincterial straining pressure was 71 mmHg in the anismus group versus 12 mmHg. Radiology was likely to identify anismus when the straining pressure exceeded 50% of the resting pressure (P = 0.08). CONCLUSION: Radiological techniques detect pelvic morphological abnormalities, but lead to overdiagnoses of anismus. No proctographic pathological feature predicts anismus reliably. A stronger pelvic floor paradoxical contraction is associated with a greater likelihood of detection by proctography.