Abstract
INTRODUCTION: Anismus is a common cause of constipation and outlet obstruction. Standard therapy with laxatives or biofeedback has conflicting results. Surgical treatment gives poor results and has practically been abandoned. PURPOSE: This study was designed to evaluate the efficacy of botulinum toxin type-A (Botox®) injection to the puborectalis muscle in patients with anismus. METHODS: Twenty-five patients (15 females; mean age, 23.2) with history of constipation and symptoms of outlet obstruction underwent anorectal perfusion manometry and video-proctography. All patients were found to have a nonrelaxing puborectalis muscle on both modalities. All have been unable to expel a rectal balloon. Each patient who participated in the study was randomly assigned to undergo local injection of Botox—10 units to each side of the puborectalis or 20 units to the posterior aspect of this muscle. Eight patients underwent further injections1–5 every 3 months in accordance with previous results. Follow-up was conducted 1, 4, 12, and 24 weeks after injection. Straining, anorectal pain, and overall satisfaction were assessed on a visual analog scale. Weekly evacuation, fecal incontinence, and complications were recorded. At the weekly meeting, each patient underwent anorectal manometry with a balloon expulsion test. RESULTS: Manometric relaxation was achieved after the first injection in 18 patients (75 percent). Once relaxation was achieved, it lasted throughout the follow-up. Nine patients (37.5 percent) expelled the rectal balloon after the first injection. Seven of 16 patients who failed the first injection had an additional one. In 2 patients it was successful (28.6 percent). Symptom improvement of 29.2 percent in straining index was recorded during follow-up. In 3 patients (12.5 percent) pain developed after injection. No other complications were observed. Overall satisfaction with Botox injection results was observed in 58.3 percent. CONCLUSIONS: Botox injection to the puborectalis muscle has been found to have a limited therapeutic effect on patients suffering from anismus. Our results justify the need for further double-blind placebo-controlled trials to determine the exact role of botulinum toxin type-A in anismus.
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References
Hinton JM, Lennard-Jones JE. Constipation: definition and classification. Postgrad Med J 1968;44:720–3.
Kuijpers HC, Bleijenberg G. The spastic pelvic floor syndrome: a cause of constipation. Dis Colon Rectum 1985;28:669–72.
Rutter KR. Electromyographic changes in certain pelvic floor abnormalities. Proc R Soc Med 1974;67:53–6.
Shouler P, Keighley MR. Changes in colorectal function in severe idiopathic chronic constipation. Gastroenterology 1986;90:414–20.
Jones PN, Lubowski DZ, Swash M, Henry MM. Is paradoxical contraction of puborectalis muscle of functional importance? Dis Colon Rectum 1987;30:667–70.
Wexner SD, Marchetti F, Salanga VD, Corredor C, Jagelman DG. Neurophysiologic assessment of the anal sphincters. Dis Colon Rectum 1991;34:606–12.
Mathers SE, Kempster PA, Law PJ,et al. Anal sphincter dysfunction in Parkinson's disease. Arch Neurol 1989;46:1061–4.
Mathers SE, Kempster PA, Swash M, Lees AJ. Constipation and paradoxical puborectalis contraction in anismus and Parkinson's disease: a dystonic phenomenon? J Neurol Neurosurg Psychiatry 1988;51:1503–7.
Loening-Baucke V. Persistence of chronic constipation in children after biofeedback treatment. Dig Dis Sci 1991;136:153–60.
Bleijenberg G, Kuijpers HC. Treatment of the spastic pelvic floor syndrome with biofeedback. Dis Colon Rectum 1987;30:108–11.
Barnes PR, Hawley PR, Preston DM, Lennerd-Jones JE. Experience of posterior division of the puborectalis muscle in the management of chronic constipation. Br J Surg 1985;72:475–7.
Yoshioka K, Keighley MR. Anorectal myectomy for outlet obstruction. Br J Surg 1987;74:373–6.
Dolly JO, Black J, Williams RS, Melling J. Acceptors for botulinum neurotoxin reside on motor nerve terminals and mediate its internalization. Nature 1984;307:457–60.
Mauriello JA Jr, Coniaris H, Haupt EJ. The use of botulinum toxin in the treatment of one hundred patients with facial dyskinesias. Ophthalmology 1987;94:976–9.
Greene P, Kang U, Fahn S, Brin M, Moskowitz C, Flaster E. Double-blind, placebo controlled trial of botulinum toxin injections for the treatment of spasmodic torticollis. Neurology 1990;40:1213–8.
Tim R, Massey JM. Botulinum toxin therapy for neurologic disorders. Postgrad Med 1992;91:327–34.
Pasricha PJ, Ravich WJ, Hendrix TR, Sostre S, Jones B, Kalloo AN. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 1995;32:774–8.
Gui D, Cassetta E, Anastasio G, Bentivoglio AR, Maria G, Albanese A. Botulinum toxin for chronic anal fissure. Lancet 1994;344:1127–8.
Hallan RI, Williams NS, Melling J, Waldron DJ, Womack NR, Morrison JF. Treatment of anismus in intractable constipation with botulinum toxin. Lancet 1988;2:714–7.
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;39:1107–11.
McGee SG, Bartram CI. Intra-anal intussusception: diagnosis by posteroanterior stress proctography. Abdom Imaging 1993;18:136–40.
Park UC, Choi SK, Piccirillo MF, Verzaro R, Wexner SD. Patterns of anismus and the relation to biofeedback therapy. Dis Colon Rectum 1996;39:768–73.
Gilliland R, Heymen S, Altomare DF, Park UC, Vickers D, Wexner SD. Outcome and predictors of success of biofeedback for constipation. Br J Surg 1997;39:1123–6.
Schouten WR, Briel JW, Auwerda JJ,et al. Anismus: fact or fiction. Dis Colon Rectum 1997;40:1033–41.
Shafik A, El-Sibai O. Botulin toxin in the treatment of nonrelaxing puborectalis syndrome. Dig Surg 1998;15:347–51.
Maria G, Brisinda G, Bentivoglio AR, Cassetta E, Albanese A. Botulinum toxin in the treatment of outlet obstruction constipation caused by puborectalis syndrome. Dis Colon Rectum 2000;43:376–80.
Fisher SE, Breckon K, Andrews KA, Keighley MR. Psychiatric screening for patients with fecal incontinence or chronic constipation referred for surgical treatment. Br J Surg 1988;76:352–5.
Borodic GE, Joseph M, Fay L, Cozzolino D, Ferrante RJ. Botulinum A toxin for the treatment of spasmodic torticollis: dysphagia and regional toxin spread. Head Neck 1990;12:392–9.
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Ron, Y., Avni, Y., Lukovetski, A. et al. Botulinum toxin type-a in therapy of patients with anismus. Dis Colon Rectum 44, 1821–1826 (2001). https://doi.org/10.1007/BF02234461
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DOI: https://doi.org/10.1007/BF02234461