| Anismus | |
|---|---|
| Other names | Dyssynergic defecation |
 | |
| Defecating proctogram. The ano-rectal angle does not open out when the individual attempts to defecate, leading to retention of the barium paste in the rectum. There is also arectocele anteriorly (visible immediately above and in front of the anal canal). | |
| Specialty | Gastroenterology |
Anismus ordyssynergic defecation is the failure of normal relaxation ofpelvic floor muscles during attempteddefecation. It can occur in both children and adults, and in both men and women (although it is more common in women). It can be caused by physical defects or it can occur for other reasons or unknown reasons. Anismus that has a behavioral cause could be viewed as having similarities withparcopresis, or psychogenic fecal retention.[citation needed]
Symptoms includetenesmus (the sensation of incomplete emptying of the rectum after defecation has occurred) andconstipation. Retention of stool may result in fecal loading (retention of a mass of stool of any consistency) orfecal impaction (retention of a mass of hard stool). This mass may stretch the walls of the rectum and colon, causingmegarectum and/ormegacolon, respectively. Liquid stool may leak around a fecal impaction, possibly causing degrees of liquid fecal incontinence. This is usually termedencopresis or soiling in children, andfecal leakage, soiling or liquidfecal incontinence in adults.
Anismus is usually treated with dietary adjustments, such asdietary fiber supplementation. It can also be treated with a type ofbiofeedback therapy, during which a sensor probe is inserted into the person'sanal canal in order to record the pressures exerted by the pelvic floor muscles. These pressures are visually fed back to the patient via a monitor who can regain the normal coordinated movement of the muscles after a few sessions.
Some researchers have suggested that anismus is an over-diagnosed condition, since the standard investigations ofdigital rectal examination andanorectal manometry were shown to cause paradoxical sphincter contraction in healthy controls, who did not have constipation or incontinence.[1] Due to the invasive and perhaps uncomfortable nature of these investigations, the pelvic floor musculature is thought to behave differently compared to normal circumstances. These researchers went on to conclude that paradoxical pelvic floor contraction is a common finding in healthy people as well as in people with chronic constipation and fecal incontinence, and it represents a non-specific finding or laboratory artifact related to untoward conditions during examination, and that true anismus is actually rare.
Symptoms include:
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To understand the cause of anismus, an understanding of normal colorectal anatomy and physiology, including the normal defecation mechanism, is helpful. The relevant anatomy includes: therectum, theanal canal and the muscles of thepelvic floor, especiallypuborectalis and theexternal anal sphincter.[citation needed]
Therectum is a section of bowel situated just above the anal canal and distal to thesigmoid colon of thelarge intestine. It is believed to act as a reservoir to store stool until it fills past a certain volume, at which time the defecation reflexes are stimulated.[4] In healthy individuals, defecation can be temporarily delayed until it is socially acceptable todefecate. In continent individuals, the rectum can expand to a degree to accommodate this function.[citation needed]
The anal canal is the short straight section of bowel between the rectum and theanus. It can be defined functionally as the distance between the anorectal ring and the end of theinternal anal sphincter. The internal anal sphincter forms the walls of the anal canal. The internal anal sphincter is not under voluntary control, and in normal persons it is contracted at all times except when there is a need to defecate. This means that the internal anal sphincter contributes more to the resting tone of the anal canal than the external anal sphincter. The internal sphincter is responsible for creating a watertight seal, and therefore provides continence of liquid stool elements.[citation needed]
Thepuborectalis muscle is one of the pelvic floor muscles. It isskeletal muscle and is therefore under voluntary control. The puborectalis originates on the posterior aspect of thepubic bone, and runs backwards, looping around the bowel.
The point at which the rectum joins the anal canal is known as the anorectal ring, which is at the level that the puborectalis muscle loops around the bowel from in front. This arrangement means that when puborectalis is contracted, it pulls the junction of the rectum and the anal canal forwards, creating an angle in the bowel called the anorectal angle. This angle prevents the movement of stool stored in the rectum moving into the anal canal. It is thought to be responsible for gross continence of solid stool. Some believe the anorectal angle is one of the most important contributors to continence.[5]
Conversely, relaxation of the puborectalis reduces the pull on the junction of the rectum and the anal canal, causing the anorectal angle to straighten out. Asquatting posture is also known to straighten the anorectal angle, meaning that less effort is required to defecate when in this position.[6]
Distension of the rectum normally causes the internal anal sphincter to relax (rectoanal inhibitory response, RAIR) and the external anal sphincter initially to contract (rectoanal excitatory reflex, RAER). The relaxation of the internal anal sphincter is an involuntary response. The external anal sphincter, by contrast, is made up of skeletal (or striated muscle) and is therefore under voluntary control. It can contract vigorously for a short time. Contraction of the external sphincter can defer defecation for a time by pushing stool from the anal canal back into the rectum. Once the voluntary signal to defecate is sent back from the brain, the abdominal muscles contract (straining) causing the intra-abdominal pressure to increase. The pelvic floor is lowered causing the anorectal angle to straighten out from ~90o to <15o and the external anal sphincter relaxes. The rectum now contracts and shortens inperistaltic waves, thus forcing fecal material out of the rectum, through the anal canal and out of the anus. The internal and external anal sphincters along with the puborectalis muscle allow the feces to be passed by pulling the anus up over the exiting feces in shortening and contracting actions.[citation needed]
In patients with anismus, the puborectalis and the external anal sphincter muscles fail to relax, with resultant failure of the anorectal angle to straighten out and facilitate evacuation of feces from the rectum. These muscles may even contract when they should relax (paradoxical contraction), and this not only fails to straighten out the anorectal angle, but causes it to become more acute and offer greater obstruction to evacuation.
As these muscles are under voluntary control, the failure of muscular relaxation or paradoxical contraction that is characteristic of anismus can be thought of as either maladaptive behavior or a loss of voluntary control of these muscles. Others claim that puborectalis can becomehypertrophied (enlarged) orfibrosis (replacement of muscle tissue with a more fibrous tissue), which reduces voluntary control over the muscle.
Anismus could be thought of as the patient "forgetting" how to push correctly, i.e. straining against a contracted pelvic floor, instead of increasing abdominal cavity pressures and lowering pelvic cavity pressures. It may be that this scenario develops due to stress. For example, one study reported that anismus was strongly associated with sexual abuse in women.[7] One paper stated that events such as pregnancy, childbirth, gynaecological descent or neurogenic disturbances of the brain-bowel axis could lead to a "functionalobstructed defecation syndrome" (including anismus).[8] Anismus may develop in persons withextrapyramidal motor disturbance due toParkinson's disease.[9] This represents a type offocal dystonia.[10] Anismus may also occur withanorectal malformation,rectocele,[11]rectal prolapse[12] andrectal ulcer.[12]
In many cases however, the underlying pathophysiology in patients presenting with obstructed defecation cannot be determined.[13]
Some authors have commented that the "puborectalis paradox" and "spastic pelvic floor" concepts have no objective data to support their validity. They state that "new evidence showing that defecation is an integrated process of colonic and rectal emptying suggests that anismus may be much more complex than a simple disorder of the pelvic floor muscles."[13]
Persistent failure to fully evacuate stool may lead to retention of a mass of stool in the rectum (fecal loading), which can become hardened, forming afecal impaction or evenfecaliths.[citation needed]
Liquid stool elements may leak around the retained fecal mass, which may lead to paradoxical diarrhoea and/or fecal leakage (usually known asencopresis in children andfecal leakage in adults).[14][15][16][17]
When anismus occurs in the context of intractableencopresis (as it often does), resolution of anismus may be insufficient to resolve encopresis.[18] For this reason, and because biofeedback training is invasive, expensive, and labor-intensive, biofeedback training is not recommended for treatment of encopresis with anismus.
The walls of the rectum may become stretched, known asmegarectum.[19]
In theRome IV classification, diagnostic criteria for "functional defecation disorders" are as follows:[20]
2 subcategories exist within the functional defecation disorders category:
For all of these Rome-IV diagnoses, diagnostic criteria must have been fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.[20] The subcategories F3a and F3b are defined by age- and gender-appropriate normal values for the technique.[20]
Previous Rome criteria recommended that anorectal testing is not usually indicated in patients with symptoms until patients have failed conservative treatment (e.g., increased dietary fiber and liquids; elimination of medications with constipating side effectswhenever possible).[citation needed]
Several definitions have been offered:
Physical examination can rule out anismus (by identifying another cause) but is not sufficient to diagnose anismus.
The measurement ofpressures within the rectum and anus with amanometer (pressure-sensing probe).
defecating proctogram, andMRI defecography
Anismus can be subcategorized into 4 types based on the results of anorectal manometry testing:[22]
Anismus is classified as a functional defecation disorder. It is also a type of rectal outlet obstruction (a functional outlet obstruction). Where anismus causes constipation, it is an example offunctional constipation. Many authors describe an "obstructed defecation syndrome", of which anismus is a cause.[24]
TheRome II classification functional defecation disorders were divided into 3 types,[25] however the symptoms the patient experiences are identical.[26]
It can be seen from the above classification that many of the terms that have been used interchangeably with anismus are inappropriately specific and neglect the concept of impaired propulsion. Similarly, some of the definitions that have been offered are also too restrictive.
The rectal cooling test is suggested to differentiate between rectal inertia and impaired relaxation/paradoxical contraction[27]
Other techniques includemanometry,balloon expulsion test,evacuation proctography (seedefecating proctogram), and MRI defecography.[28] Diagnostic criteria are: fulfillment of criteria forfunctional constipation, manometric and/or EMG and/or radiological evidence (2 out of 3), evidence of adequate expulsion force, and evidence of incomplete evacuation.[28] Recent dynamic imaging studies have shown that in persons diagnosed with anismus theanorectal angle during attempteddefecation is abnormal, and this is due to abnormal (paradoxical) movement of thepuborectalis muscle.[29][30][31]
Initial steps to alleviate anismus include dietary adjustments and simple adjustments when attempting to defecate. Supplementation with abulking agent such aspsyllium will make stool more bulky, which decreases the effort required to evacuate.[23] Similarly, exercise and adequate hydration may help to optimisestool form. The anorectal angle has been shown to flatten out when in asquatting position, and is thus recommended for patients with functional outlet obstruction like anismus.[5] If the patient is unable to assume a squatting postures due to mobility issues, a low stool can be used to raise the feet when sitting, which effectively achieves a similar position.[citation needed]
Treatments for anismus include biofeedback retraining, botox injections, and surgical resection. Anismus sometimes occurs together with other conditions that limit (seecontraindication) the choice of treatments. Thus, thorough evaluation is recommended prior to treatment.[32]
Biofeedback training for treatment of anismus is highly effective and considered the gold standard therapy by many.[18][33][34]Others however, reported that biofeedback had a limited therapeutic effect.[35]
Injections ofbotulin toxin type-A into thepuborectalis muscle are very effective in the short term, and somewhat effective in the long term.[36] Injections may be helpful when used together with biofeedback training.[37][38]
Historically, the standard treatment wassurgical resection of the puborectalis muscle, which sometimes resulted in fecal incontinence. Recently, partial resection (partial division) has been reported to be effective in some cases.[35][39]
Paradoxical anal contraction during attempted defecation in constipated patients was first described in a paper in 1985, when the term anismus was first used.[40] The researchers drew analogies to a condition calledvaginismus, which involves paroxysmal (sudden and short lasting) contraction ofpubococcygeus (another muscle of the pelvic floor). These researchers felt that this condition was a spastic dysfunction of the anus, analogous to 'vaginismus'. However, the term anismus implies a psychogenic etiology, which is not true although psychological dysfunction has been described in these patients. Hence:
Latinani - "of the anus"
Latinspasmus - "spasm"
(Derived by extrapolation with the term vaginismus, which in turn is from the Latinvagina - "sheath" +spasmus - "spasm")
Many terms have been used synonymously to refer to this condition, some inappropriately. The term "anismus" has been criticised as it implies apsychogenic cause.[41] In the most widely accepted classification systems (ICD-11 andRome-IV), the term "dyssynergic defecation" is preferred.[21][20] As stated in the Rome II criteria, the term "dyssynergic defecation" is preferred to "pelvic floor dyssynergia" because many patients with dyssynergic defecation do not report sexual or urinary symptoms,[25] meaning that only the defecation mechanism is affected.
Other synonyms include: