Comparative Study between Surgical and Non-surgical Treatment of Anismus in Patients with Symptoms of Obstructed Defecation: A Prospective Randomized Study
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This study came to compare the results of biofeedback retraining biofeedback (BFB), botulinum toxin botulinum type A (BTX-A) injection and partial division of puborectalis (PDPR) in the treatment of anismus patients.
Patients and Methods
Consecutive patients treated for anismus fulfilled Rome II criteria for functional constipation at our institution were evaluated for inclusion. Participants were randomly allocated to receive BFB, BTX-A injection, and PDPR. All patients underwent anorectal manometry, balloon expulsion test, defecography, and electromyography activity of the anal sphincter. Follow up was conducted weekly in the first month then monthly for about 1 year. Study variables included clinical improvement, patient satisfaction, and objective improvement.
Sixty patients with anismus were randomized and completed the study. The groups differed significantly regarding clinical improvement at 1 month (50% for BFB, 75%BTX-A injection, and 95% for PDPR, P = 0.006) and differences persisted at 1 year (30% for BFB, 35%BTX-A injection, and 70% for PDPR, P = 0.02). Constipation score of the patients significantly improved postPDPR and BTX-A injection. Manometric relaxation was achieved significantly in the three groups.
Biofeedback retraining has a limited therapeutic effect, BTX-A injection seems to be successful for temporary treatment but PDPR is found to be an effective with lower morbidity in contrast to its higher success rate in treating anismus.
- Preston DM, Lennard-Jones JE. Anismus in chronic constipation. Dig Dis Sci 1985;30:413-418. CrossRef
- Wexner SD, Bartolo DC. eds. Constipation: Etiology, Evaluation and Management. Oxford: Butterworth-Heinemann, 1995, 1-272.
- Weber J, Ducrotte PH, Touchais JY, Roussigno C, Denis RN. Biofeedback training for constipation in adults and children. Dis Colon Rectum 1987;30:844–846. CrossRef
- Fleshman W, Dreznik Z, Cohen E, Fry RD, Kodner IJ. (a): Balloon expulsion test facilitates diagnosis of pelvic floor outlet obstruction due to nonrelaxing puborectalis muscle. Dis Colon Rectum 1992;35:1019-1025. CrossRef
- Wexner SD, Cheape JD, Jorge JM, Heymen S, Jagelman PG. Prospective assessment of biofeedback for the treatment of paradoxical puborectalis syndrome. Dis Colon Rectum 1992;35:145-150. CrossRef
- Johansson C, Nilsson BY, Mellgren A, Dolk A, Holmstrom B. Paradoxical sphincter reaction and associated colorectal disorders. Int J Colorectal Dis 1992;7:89-94. CrossRef
- Kuijpers HC, Bleijenberg G. The spastic pelvic floor syndrome: a cause of constipation. Dis Colon Rectum 1986;28:669-672. CrossRef
- Schouten WR, Briel JW, Auwerda JJA, van Dam JH, Gosselink MJ, Ginai AZ, Hop WCJ. Anismus: fact or fiction? Dis Colon Rectum 1997;40:1033-1041. CrossRef
- Wasserman JF. Puborectalis syndrome: rectal stenosis due to anorectal spasm. Dis Colon Rectum 1964;7:87-98. CrossRef
- Wallace WC, Madden WM. Experience with partial resection of the puborectalis muscle. Dis Colon Rectum 1969;12:196-200. CrossRef
- Keighley MRB, Shouler P. Anorectal outlet syndrome: is there a surgical option? JR Soc Med 1984;77:559-563.
- Kamm MA, Hawely PR, Lennard-Jones JE. Lateral division of puoborectalis muscle in the management of severe constipation. Br J Surg 1988;75:661-663. CrossRef
- Barnes PR, Hawley PR, Preston DM, Lennard-Jones JE. Experience of posterior division of the puborectalis muscle in the management of chronic constipation. Br J Surg 1985;72:475-477 CrossRef
- Maria G, Brisinda G, Bentivoglio AR, Cassetta E, Albanese A. Botulinuxn toxin in the treatment of outlet obstruction constipation caused by puborectalis syndrome. Dis Colon Rectum 2000;43:376-380. CrossRef
- Rao SS. Constipation: evaluation and treatment. Gastroenterol Clin North Am 2003;32:659-683. CrossRef
- Andromanakos N, Skandalakis P, Troupis T, Filippou D. Constipation of anorectal outlet obstruction: pathophysiology, evaluation and management. J Gastroenterol Hepatol 2006;21(4):638–646. CrossRef
- Park UC, Choi SK, Piccirillo MF, Verzaro R, Wexner SD. Patterns of anismus and the relation to biofeedback therapy. Dis Colon Rectum 1996;39:768–773. CrossRef
- Gilliland R, Heymen S, Altomar DF, Park UC, Vickers D, Wexner SD. Outcome and predictors of success of biofeedback for constipation. Br J Surg 1997;84:1123-1126. CrossRef
- Farid M, El Monem HA, Omar W, El Nakeeb A, Fikry A, Youssef T, Yousef M, Ghazy H, Fouda E, El Metwally T, Khafagy W, Ahmed S, El Awady S, Morshed M, El Lithy R. Comparative study between biofeedback retraining and botulinum neurotoxin in the treatment of anismus patients. Int J Colorectal Dis 2009;24(1):115-120. CrossRef
- Hallan RI, William NS, Melling J, Waldron DJ, Womack NR, Morrison JF. Treatment of anismus in intractable constipation with botulinum A toxin. Lancet 1988;2:714-717. CrossRef
- Jankovic J, Brin MF. Therapeutic uses of botulinum toxins. N Engl Med 1 1991;324:1186-1194.
- Farid M, Youssef T, Mahdy T, Omar W, Moneim HA, El Nakeeb A, Youssef M. Comparative study between botulinum toxin injection and partial division of puborectalis for treating anismus. Int J Colorectal Dis 2009;24(3):327-334 CrossRef
- Kawimbe BM, Papachrysostomou M, Binnie NR, Clare N, Smith AN. Outlet obstruction constipation (anismus) managed by biofeedback. Gut 1991;32:1175-1179. CrossRef
- Ron Y, Avni Y, Lukovetski A, Wardi J, Geva D, Birkenfeld S, Halpern Z. Botulinum toxin type-A in therapy of patients with anismus. Dis Colon Rectum 2001;44:1821-1826. CrossRef
- Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut 1999;45(Suppl 2):II43-II4.
- Halligan S, Bartram C, Park HJ, Kamm M. Proctographic features of anismus. Radiology 1995;197:679-682.
- McGee SG, Bartram CI. Intra-anal intussusception: diagnosis by posteroanterior stress proctography. Abdom Image 1993;18:136-140
- Pemberton JH, Rath DM, Ilstrup M. Evaluation and surgical treatment of severe chronic constipation. Ann Surg 1991;214:403-413. CrossRef
- Agachan F, Chen T, Pfeifer J, Reissman P, Wexner SD. A constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum 1996;39(6):681-685. CrossRef
- Glia A, Gylin M, Gullberg K, Lindberg G. Biofeedback retraining in patients with functional constipation and paradoxical puborectalis contraction: comparison of anal manometry and sphincter electromyography for feedback. Dis Colon Rectum 1997;40:889-895. CrossRef
- Meagher AP, Sun WM, Kennedy ML, Smart RC, Lubowski DZ. Biofeedback for anismus: has placebo effect been overlooked? Colorectal Dis 1999;1(2);80-87. CrossRef
- Rhee PL, Choi MS, Kim YH, Son HJ, Kim JJ, Koh KC, SW, Rhee JC, Choi KW. An increased rectal maximum tolerable volume and long anal canal are associated with poor short-term response to biofeedback therapy for patients with anismus with decreased bowel frequency and normal colonic transit time. Dis Colon Rectum 2000;43:1405-1411.
- McKee RF, McEnroe L, Anderson JH, Finlay IG. Identification of patients likely to benefit from biofeedback for outlet obstruction constipation. Br J Surg 1999;86:355–359. CrossRef
- Shafik A, El-Sibai O. Botulinum toxin in the treatment of nonrelaxing puborectalis syndrome. Dig Surg 1998;15:347-351. CrossRef
- Joo JS, Agachan F, Wolff B, Nogueras JJ, Wexner SD. Initial North American experience with botulinum toxin type A for treatment of anismus. Dis Colon Rectum 1996;39:1107-1111. CrossRef
- Loening-Baucke V. Modulation of abnormal dynamics by biofeedback treatment in chronically constipated children with encopresis. J Pediatr 1990;116:214-222. CrossRef
- Duthie GS, Bartolo DCC. Anismus: the cause of constipation? Results of investigation and treatment. World J Surg 1992;16:831-835. CrossRef
- Comparative Study between Surgical and Non-surgical Treatment of Anismus in Patients with Symptoms of Obstructed Defecation: A Prospective Randomized Study
Journal of Gastrointestinal Surgery
Volume 14, Issue 8 , pp 1235-1243
- Cover Date
- Print ISSN
- Online ISSN
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- Obstructed defecation
- Chronic constipation
- Pelvic floor
- Industry Sectors