The spastic pelvic floor syndrome

To determine whether a persistent contraction of the pelvic floor muscle during straining, as observed in constipated patients during defaecography, was due to a conscious action of the patients or really represented a functional disorder, segmental colonic transit studies were performed in 24 patients in whom the diagnosis spastic pelvic floor syndrome was made. Abnormal segmental transit indicating outlet obstruction occurred in 92% of the patients. Four different types of segmental transit abnormalities were observed which suggested that the spastic pelvic floor syndrome involved a functional outlet obstruction leading to retrograde filling of the colon and severe straining. A causative relation with other anorectal abnormalities is suggested.     

Funktionelle Darmentleerungsstörungen aus neurologischer Sicht

Chronic constipation can be caused by a slow transit constipation or an outlet obstruction. There can be various neuromuscular reasons for functional outlet obstruction. A paradox contraction or a lack of relaxation of the striated pelvic floor muscles occurs. Until now, the expression anismus is frequently used without differentiating according to the underlying pathophysiology. In principle, 3 disturbances can be differentiated: ferentiated: 1. The most common reason for the functional outlet obstruction is the inadequate coordination of the voluntary anal sphincters. When straining or during defecation there is a contraction of the external anal sphincter and/or of the puborectal muscle. There is no relevant organic damage of the nerves or muscles. Therapeutically, good results can be achieved with a behavioral therapy like biofeedback. 2. Spasticity of the striated pelvic floor muscles wich is caused by a lesion of the upper motoneuron, in most cases spinally localized, is another reason. Therapeutically, mainly local botulinum toxin injections are applied. 3. A more unusual reason is the dystonia of the striated sphincter of the pelvis. This is an extrapyramidal disorder which occurs either only locally or also generally. Therapeutically, local botulinum toxin injections are applied. In our opinion the term anismus should be restricted to this disorder. The reason for a function-al outlet obstruction should be found out so that a therapy can be made which is oriented on the underlying pathophysiology. A uniform nomenclature is urgently required.     

Biofeedback therapy for dyssynergic defecation

INTRODUCTION Chronic constipation is a common self-reported bowel symptom that affects 2%-30% of people in Western countries and has considerable impact on health expenses and quality of life[1]. Most patients respond either to fiber- fluid supplementatio…     

Outpatient protocol for biofeedback therapy of pelvic floor outlet obstruction

Pelvic floor outlet obstruction is a rare cause of severe constipation. Anal myectomy, subtotal colectomy, and medical therapy have limited success. The purpose of this study was to develop a short outpatient treatment using biofeedback techniques. Nine patients with severe constipation and straining resulting from pelvic floor outlet obstruction underwent complete investigation of the pelvic floor musculature and anal sphincter mechanism. Patients were unable to expel a 60-cc rectal balloon and had nonrelaxing puborectalis on defecography. The treatment protocol utilized anal surface electromyography to document improper straining and retrain pelvic floor muscles to relax during defecation. Sensory retraining with a rectal balloon, behavioral relaxation techniques, and defecation of simulated stool using a 120-cc Metamucil^® (Procter & Gamble, Cincinnati, OH) slurry in the rectum allowed re-establishment of normal defecation in all nine patients. Repeat training was required in three patients during follow-up. Treatment of pelvic floor outlet obstruction with outpatient retraining techniques is possible.Read at the meeting of The American College of Gastroenterology, San Francisco, California, October 1990.     

Constipation

Chronic constipation is a common disorder manifested by a variety of symptoms. Assessments of colonic transit and anorectal functions are used to categorize constipated patients into three groups, i.e., normal transit or irritable bowel syndrome, pelvic floor dysfunction (i.e., functional defaecatory disorders) and slow transit constipation. 'Slow transit' constipation is a clinical syndrome attributed to ineffective colonic propulsion and/or increased resistance to propagation of colonic contents. Defaecatory disorders are caused by insufficient relaxation of the pelvic floor muscles or a failure to generate adequate propulsive forces during defaecation. Colonic transit is often delayed in patients with functional defaecatory disorders. Normal and slow transit constipation are generally managed with medications; surgery is necessary for a minority of patients with slow transit constipation. Functional defaecatory disorders are primarily treated with pelvic floor retraining using biofeedback therapy.     

Treatment of the spastic pelvic floor syndrome with biofeedback

The spastic pelvic floor syndrome is a functional disorder based on contraction instead of relaxation of the pelvic floor muscle during straining, which inhibits defecation and gives rise to constipation. Until now no adequate treatment has been found for this condition. The treatment described here is aimed at teaching patients to relax their pelvic floor muscle during straining. Treatment consists of a training program with EMG feedback, followed by simulation of the defecation process, using oatmeal porridge. Patients are then given instructions to generalize the relaxation response in their daily lives. Treatment was completely successful in seven of ten patients. The three remaining patients learned to strain in the correct manner, but could not achieve generalization. Two of them underwent subtotal colectomy because of delayed colonic transit times, which subsequently resulted in normal evacuation. In the third patient, the generalization was most likely hampered by psychologic problems, for which she now receives psychotherapy.     

The surgical management of constipation.

The anal physiology laboratory plays a very important role in the selection of patients for surgical treatment for constipation. Any report which does not include reference to these methods of evaluation will not be helpful since there are several causes of constipation. The current recommended treatment for slow transit constipation is still total abdominal colectomy with ileorectal anastomosis. Treatment of pelvic floor outlet obstruction seems to be best accomplished using muscle/sensory retraining techniques since this is a functional disorder rather than an anatomical or physiological disorder. Combinations of colonic inertia, pelvic floor outlet obstruction and internal intussusception should be treated to correct the pelvic floor outlet obstruction initially, followed by correction of the colonic inertia. In this way failure will be avoided at the time of surgical treatment of the constipation.     

Outlet obstruction constipation (anismus) managed by biofeedback.

Fifteen subjects presenting with intractable constipation due to obstructive defecation, mean (SEM) duration 8.8 (1.8) years, had the inappropriate contraction and electromyographic changes in the pelvic floor muscles and external and sphincter typical of this condition. An electromyographically derived index was used to grade its severity. A self applied biofeedback device was used to allow electromyographic recording of the abnormal external anal sphincter. The subjects were encouraged to reduce the abnormal electromyographic activity on straining after instruction and training. The procedure was intended as a relearning process in which the non-relaxing activity of the pelvic floor was gradually suppressed. Biofeedback training was maintained on a domiciliary basis for a mean time of 3.1 weeks and resulted in a significant reduction in the anismus index (mean (SEM) 69.9 (7.8)% before biofeedback, mean 14 (3.9)% after biofeedback, p less than 0.01). There was an associated reduction in the time spent straining at stool and in the difficulty of defecation and an increased frequency of defecation. Defecatory video proctograms in six subjects showed improvements in the anorectal angle during straining and evacuation. The clinical benefit to the patients persisted after a mean follow up of 6.2 months.     

Dynamic Transperineal Ultrasound in the Diagnosis of Pelvic Floor Disorders

PURPOSE: Defecating proctography and more recently, magnetic resonance imaging have both been used for diagnosis in patients with pelvic floor dysfunction. This pilot study assessed the feasibility of dynamic transperineal ultrasound in a range of specific disorders affecting evacuation. METHODS: A protocol of sagittal and transverse transperineal imaging was established defining the infralevator viscera and soft tissues and the margins of the puborectalis muscle. Dynamic measurements were possible for the extent of puborectalis shortening, the anorectal angle, and the movement during straining of the anorectal junction. Calculations were made of the depth of demonstrated rectoceles, the posterior urethrovesical angle, and the movement of the urethrovesical junction. Diagnoses were confirmed by proctography (where appropriate) and clinical examination. RESULTS: Transverse images of the anal sphincter were comparable with those obtained using endoanal ultrasonography. Sagittal images permitted the measurement of puborectalis contraction and the anorectal angle comparable with those obtained during defecography. Cystoceles were able to be diagnosed during closure of the posterior urethrovesical angle and abnormal urethrovesical junction descent during straining. Rectoceles, peritoneoceles, enteroceles, and rectoanal intussusception were readily identified using dynamic transperineal ultrasonography. CONCLUSION: Dynamic transperineal ultrasound is a simple, noninvasive way to assess dynamically the interaction of the pelvic viscera and their relationship to the pelvic floor musculature in patients with evacuatory disorders and pelvic floor dysfunction.     

Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders: pilot study

PURPOSE: Defecating proctography and more recently, magnetic resonance imaging have both been used for diagnosis in patients with pelvic floor dysfunction. This pilot study assessed the feasibility of dynamic transperineal ultrasound in a range of specific disorders affecting evacuation. METHODS: A protocol of sagittal and transverse transperineal imaging was established defining the infralevator viscera and soft tissues and the margins of the puborectalis muscle. Dynamic measurements were possible for the extent of puborectalis shortening, the anorectal angle, and the movement during straining of the anorectal junction. Calculations were made of the depth of demonstrated rectoceles, the posterior urethrovesical angle, and the movement of the urethrovesical junction. Diagnoses were confirmed by proctography (where appropriate) and clinical examination. RESULTS: Transverse images of the anal sphincter were comparable with those obtained using endoanal ultrasonography. Sagittal images permitted the measurement of puborectalis contraction and the anorectal angle comparable with those obtained during defecography. Cystoceles were able to be diagnosed during closure of the posterior urethrovesical angle and abnormal urethrovesical junction descent during straining. Rectoceles, peritoneoceles, enteroceles, and rectoanal intussusception were readily identified using dynamic transperineal ultrasonography. CONCLUSION: Dynamic transperineal ultrasound is a simple, noninvasive way to assess dynamically the interaction of the pelvic viscera and their relationship to the pelvic floor musculature in patients with evacuatory disorders and pelvic floor dysfunction.     

Long-Term Study on the Effects of Visual Biofeedback and Muscle Training as a Therapeutic Modality in Pelvic Floor Dyssynergia and Slow-Transit Constipation

PURPOSE: Biofeedback training has been shown as an effective therapeutic measure in patients with pelvic floor dyssynergia, at least in the short term. Long-term effects have received less attention. Moreover, its effects in patients with slow-transit constipation have been scarcely investigated. This study was designed to assess in an objective way the medium- and long-term effects of biofeedback and muscle training in patients with pelvic floor dyssynergia and slow-transit constipation. METHODS: Twenty-four patients (14 with pelvic floor dyssynergia and 10 with slow transit) meeting the Rome II criteria for constipation, and unresponsive to conventional treatments, entered the study. Clinical evaluation and anorectal manometry were performed basally and three months after a cycle of electromyographic biofeedback and muscle training; moreover, a clinical interview was obtained one year after biofeedback. Patients with slow-transit constipation also had colonic transit time reassessed at one year. RESULTS: Clinical variables (abdominal pain, straining, number of evacuations/week, use of laxatives) all significantly improved in both groups at three-month assessment; anorectal manometric variables remained unchanged, apart from a significant decrease of sensation threshold in the pelvic floor dyssynergia group and of the maximum rectal tolerable volume in the slow-transit constipation group. At one-year control, 50 percent of patients with pelvic floor dyssynergia still maintained a beneficial effect from biofeedback, whereas only 20 percent of those complaining of slow-transit constipation did so. Moreover, the latter displayed no improvement in colonic transit time. CONCLUSIONS: In our experience, patients with pelvic floor dyssynergia are likely to have continued benefit from biofeedback training in the time course, whereas its effects on slow-transit constipation seems to be maximal in the short-term course.     

Defecation 1: Testing a hypothesis for pelvic striated muscle action to open the anorectum

Background

We conducted an observational study to assess the hypothesis that the pelvic muscles actively open the anorectal lumen during defecation.

Methods

Three groups of female patients were evaluated with video imaging studies of defecation using a grid or bony reference points. Eight patients with idiopathic fecal incontinence had video myogram defecography; eight with obstructive defecation had magnetic resonance imaging (MRI) defecating proctograms; and four normal patients had video X-ray or MRI defecating proctogram studies.

Results

In all three groups, the anorectum was stretched bidirectionally by three directional muscle force vectors acting on the walls of the rectum, effectively doubling the diameter of the rectum during defecation. The anterior rectal wall was pulled forwards, and the posterior wall backwards and downwards opening the anorectal angle, associated with angulation of the anterior tip of the levator plate (LP). These observations are consistent with a staged relaxation of some parts of the pelvic floor during defecation, and contraction of others. First, the puborectalis muscle relaxes. Puborectalis muscle relaxation frees the posterior rectal wall so that it can be stretched and opened by contraction of the LP and conjoint longitudinal muscle of the anus. Second, contraction of the pubococcygeus muscle pulls forward the anterior rectal wall, further increasing the diameter of the rectum. Third, when the bolus has entered the rectum, the external anal sphincter relaxes, and the rectum contracts to expel the fecal bolus.

Conclusions

Our results are consistent with the hypothesis that pelvic striated muscle actively opens the rectal lumen, thereby reducing internal anorectal resistance to expulsion of feces. Controlled studies of electromyographic activity would be useful to further test this hypothesis.     

Controlled randomised trial of visual biofeedback versus muscle training without a visual display for intractable constipation.

Training to contract the abdominal muscles effectively and to relax the pelvic floor during defecation straining helps some patients with severe constipation. Hitherto all such training has used a visible or audible signal of sphincter muscle activity as a biofeedback method to assist in relaxation. A randomised controlled trial comparing the outcome of muscular training without any biofeedback device with the same training supplemented by an electromyographic (EMG) record visible to the patient is reported. Significant symptomatic improvement was noted and electromyographic measurements confirmed a decrease in pelvic floor muscle activity during defecation straining after treatment in both groups. The outcome was similar in the two treatment groups. Muscular coordination training using personal instruction and encouragement without a visual display is thus a potentially successful treatment suitable for outpatient use by paramedical personnel.     

Balloon expulsion test facilitates diagnosis of pelvic floor outlet obstruction due to nonrelaxing puborectalis muscle

We compared balloon expulsion, defecography, colonic transit times, anal manometry, and electromyography in 21 patients with severe constipation. Defecography demonstrated nonrelaxation of the sphincter during straining in all patients. Only 12 patients were unable to expel a balloon. Colonic transit was normal (five) or showed rectosigmoid delay (seven). All 12 patients were offered biofeedback. The nine patients able to expel a balloon had normal colonic transit (six) or colonic inertia (two). Rectosigmoid delay was due to severe intussusception in one patient. Anal manometry and pudendal nerve latencies revealed no difference between those who could and those who could not expel a balloon. Balloon expulsion seems to be a more reliable way to diagnose pelvic floor outlet obstruction due to nonrelaxation of the puborectalis muscle. Nonrelaxation of the sphincter on defecography should be correlated with balloon expulsion and colonic transit studies.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation

BACKGROUND & AIMS: Biofeedback is reported to be as effective for slow transit constipation as for pelvic floor dyssynergia and no more effective than education. We aimed to test the hypothesis that biofeedback benefits only patients with pelvic floor dyssynergia, describe the physiologic mechanism of treatment, and identify predictors of success. METHODS: Fifty-two patients (49 women; average age, 35 years), all with delayed whole gut transit, included 34 with pelvic floor dyssynergia, 12 with slow transit only, and 6 who met only 1 of 2 criteria for pelvic floor dyssynergia. All received 5 weekly biofeedback sessions directed at increasing rectal pressure and relaxing pelvic floor muscles during straining plus practice defecating a balloon. Patients were retested by questionnaire; symptom diary; balloon defecation; transit study at 1, 6, 12, and 24 months; and anorectal manometry at 1 and 6 months. RESULTS: At 6 months, greater improvements were seen in pelvic floor dyssynergia compared with slow transit only; 71% versus 8% reported satisfaction ( P = .001), and 76% versus 8% reported >/=3 bowel movements per week ( P < .001). Improvements were maintained at 24 months of follow-up. Biofeedback eliminated dyssynergia in 91% and enabled 85% to defecate the balloon. Satisfaction was correlated with improved ability to defecate the balloon (rho = .73; P < .001), reductions in dyssynergia (rho = .69; P < .001), and increased rectal pressure during straining (rho = .36; P < .01). Success was predicted by pelvic floor dyssynergia, milder constipation, and less frequent abdominal pain at baseline. CONCLUSIONS: Biofeedback is an effective treatment for pelvic floor dyssynergia but not slow transit constipation.     

Audit of Constipation in a Tertiary Referral Gastroenterology Practice

Objective : Our objective was to assess how often "outlet obstruction" was the cause of constipation in a tertiary referral population. Methods : We retrospectively audited the case records of 70 consecutive patients referred to a single gastroenterologist in a tertiary referral motility clinic. Patients were classified by physiological tests of colonic transit, as well as tests of anorectal and pelvic floor function. A subset of 28 patients also underwent a battery of tests to assess the autonomic nervous system supply. Results : Thirty-six patients had symptoms suggestive of a rectal outlet obstruction syndrome. Thirty seven percent of patients had pelvic floor dysfunction, 27% had slow transit constipation, and 8% had anismus. Fully 55% of those with pelvic floor dysfunction had slow transit in addition. The remaining patients (23%) had at least two of Manning's criteria suggestive of the irritable bowel syndrome. Only four patients had documented abnormalities of autonomic function. Conclusions : Pelvic floor dysfunction is the most common cause of severe constipation in a tertiary referral motility clinic; slow transit constipation and irritable bowel syndrome occur equally. An algorithmic approach to evaluating patients using clinical features, anorectal functions tests, and assessment of colonic transit facilitates selection of management strategies. Autonomic dysfunction occurs rarely.     

A cause of terminal constipation: hypertonia of the striated pelvic muscle. Value of complementary studies

The aim of this study was to define an other cause of idiopathic constipation with a mathematic automatic classification Fifty patients were studied by colonic transit time, anorectal manometry and defecography. Three classical causes were found: 12 patients had hypertonic upper anal pressure; 8 patients had abnormal rectonanal inhibitory reflex and 12 patients had anatomic conditions reducing stool frequencies Automatic mathematic classification coming from optimised bowls technic has led to the characterization of a new cause. Eight young women (mean age 33 years) with hypertonic striated pelvic muscles on straining were identified. Three items were significantly different: defect of sphincteric relaxation without high sphincteric pressure; closure or non opening anorectal angle, hypertonic levator ani on straining. There was a significant high frequency (p less than 0.05) of urinary disorders in this new group. All abnormalities occurred during defecation. This group can be studied with other methods: balloon expulsion, anal electromyography. Clinical identity with urinary pathology may be explained by common neurologic disorders of pelvic striated muscle innervation.     

Pelvic floor dyssynergia and bimodal rehabilitation: results of combined pelviperineal kinesitherapy and biofeedback training

Dyschezia may be caused by pelvic floor dyssynergia, which takes place when a paradoxical contraction or a failure to relax the pelvic floor muscles occurs during attempts to defecate. The aim of our study was to set up a new bimodal rehabilitation programme for pelvic floor dyssynergia, which combined pelviperineal kinesitherapy and biofeedback, and to evaluate the results of this treatment. Thirty-five patients (age range: 28–64 years; mean age: 42.5 years) from the outpatient unit of the Clinica Chirurgica of the University of Florence, Italy, and an age-matched group of 10 healthy control subjects (age range: 31–59 years; mean age 45.7 years) with normal bowel habits and without any defecatory disorders, were studied. The 35 patients were symptomatic for dyschezia without slow colonic transit and had been diagnosed as being affected by pelvic floor dyssynergia. No evidence of any organic aetiology was present but all demonstrated both manometric and radiological evidence of inappropriate function of the pelvic floor. All of the patients underwent bimodal rehabilitation, using the combined training programme Clinical evaluation, computerized anorectal manometry and defecography were carried out 1 week before and 1 week after a completed course in bimodal rehabilitation. The control group underwent manometric and defecographic examination. Their results were compared with those of the 35 patients before and after training. After the programme, all 35 patients had a very significant increase in stool frequency (P<0.001), while laxative and enema-induced bowel movements had become significantly less frequent (P<0.001). After bimodal rehabilitation, computerized anorectal manometry showed some peculiar results. Resting anal canal pressure had increased but not significantly. Pre-programme values that indicated a shorter duration (“exhaustio”) of maximal voluntary contraction than found in the controls had returned to normal values. The rectoanal inhibitory reflex (RAIR), with incomplete relaxation, which had been shorter than that of controls, became normal by the end of the rehabilitation. All RAIR parameters were significantly different especially when pre- and post-treatment values were compared (P<0.001). No differences were found as regards rectal sensation parameters and rectal compliance between those before or after bimodal rehabilitation. Defecographic pre-treatment X-ray films showed indentation of the puborectalis and poor anorectal angle (ARA) opening, at evacuation, with trapping barium of at 50%. After pelviperineal kinesitherapy and biofeedback training, the indentation had disappeared and the ARA had become significantly larger (P<0.001) during evacuation. No differences were found after rehabilitation, when both were compared with those of controls. The pelvic floor descent was also significantly deeper (P<0.001) than before the start of the programme. The bimodal rehabilitation technique can be considered a useful therapeutic option for functional dyschezia as shown by our clinical evaluations, manometric data and defecographic reports. Accepted: 10 February 1998     

Anismus: Fact or fiction?

PURPOSE: Although anismus has been considered to be the principal cause of anorectal outlet obstruction, it is doubtful whether contraction of the puborectalis muscle during straining is paradoxical. The present study was conducted to answer this question. METHODS: During the first part of the study, we retrospectively reviewed 121 patients with constipation and/or obstructed defecation (male:female, 10/111; median age, 51 years). All of these patients underwent electromyography (EMG) of the pelvic floor and the balloon expulsion test (BET) in the left lateral position. Evacuation proctography was performed in all of these patients in the sitting position. Both the posterior anorectal angle and the central anorectal angle were measured. EMG and BET were also performed in ten controls (male:female, 4/6; median age, 47). In 147 patients with fecal incontinence (male:female, 24/123; median age, 58) only EMG activity was recorded. Criteria for anismus during straining were increase or insufficient (<20 percent) decrease of EMG activity, failure to expel an air-filled balloon on BET, and decrease or insufficient (<5 percent) increase of anorectal angle on evacuation proctography. Between June 1994 and March 1995, we conducted a second prospective study in a consecutive series of 49 patients with constipation and/or obstructed defecation and 28 patients with fecal incontinence. Both groups were compared with 19 control subjects. In this study, all three tests were performed. EMG and BET were performed both in the left lateral position and in the sitting position. RESULTS: The retrospective study was undertaken by comparing the constipated patients with the incontinent patients and the controls, and the anismus detected by EMG was found in, respectively, 60, 46, and 60 percent. Failure to expel the air-filled balloon was observed in 80 constipated patients (66 percent) and in 9 control subjects (90 percent). Based on posterior anorectal angle and central anorectal angle measurements, anismus was diagnosed in, respectively, 21 and 35 percent of constipated patients. In the prospective study, none of the tests showed significant differences regarding the prevalence of anismus between the two subgroups of patients and the control subjects. The prevalence of anismus only differed between constipated and incontinent patients when the diagnosis was based on BET in the sitting position (67 vs.32 percent;P <0.005). Our study shows that contraction of the puborectalis muscle during straining is not exclusively found in patients with constipation and/or obstructed defecation. The three tests most commonly used for the diagnosis of anismus showed an extremely poor agreement. CONCLUSION: Based on these findings, we doubt the clinical significance of anismus.     

Are pelvic floor movements abnormal in disordered defecation?

Pelvic floor movements were assessed by videoproctography in 126 subjects: neuropathic fecal incontinence patients (n=44), chronic constipation patients (n =52), and controls (n=30). A significantly lower pelvic floor position at rest and a more obtuse anorectal angle were found in incontinent patients than in controls (P <0.01). constipated patients showed no significant difference from controls at rest. There was less pelvic floor movement during contraction in incontinent patients than in controls, indicating a flaccid, noncontractile pelvic floor in neuropathic incontinence. Movement during contraction in constipated subjects was also less than in controls. Changes in the pelvic floor position during straining were the same as in controls. These data indicate that the pelvic floor is flaccid and noncontractile in neuropathic fecal incontinence, which supports the concept of a progressive neuropathy involving the sacral outflow. Similar changes are not seen at rest in patients with constipation even though they have a long history of straining.