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Clin Colon Rectal Surg 2017; 30(01): 022-029
DOI: 10.1055/s-0036-1593430
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Functional Disorders of Constipation: Paradoxical Puborectalis Contraction and Increased Perineal Descent

Isaac Payne
1   Department of Surgery, University of South Alabama Medical Center, Mobile, Alabama
,
Leander M. Grimm Jr.
2   Division of Colon & Rectal Surgery, Department of Surgery, University of South Alabama, Mobile, Alabama
› Author Affiliations
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Publication History

Publication Date:
22 December 2016 (online)

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Abstract

Paradoxical puborectalis contraction (PPC) and increased perineal descent (IPD) are subclasses of obstructive defecation. Often these conditions coexist, which can make the evaluation, workup, and treatment difficult. After a thorough history and examination, workup begins with utilization of proven diagnostic modalities such as cinedefecography and anal manometry. Advancements in technology have increased the surgeon's diagnostic armamentarium. Biofeedback and pelvic floor therapy have proven efficacy for both conditions as first-line treatment. In circumstances where PPC is refractory to biofeedback therapy, botulinum toxin injection is recommended. Historically, pelvic floor repair has been met with suboptimal results. In IPD, surgical therapy now is directed toward the potentially attendant abnormalities such as rectoanal intussusception and rectal prolapse. When these associated abnormalities are not present, an ostomy should be considered in patients with IPD as well as medically refractory PPC.

Keywords

obstructive defecation syndrome - paradoxical puborectalis contraction - descending perineum syndrome - increased perineal descent - dyssynergic defecation - biofeedback
 

  • References

  • 1 Lembo A, Camilleri M. Chronic constipation. N Engl J Med 2003; 349 (14) 1360-1368
    CrossrefPubMedGoogle Scholar
  • 2 Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology 2006; 130 (5) 1480-1491
    Google Scholar
  • 3 Rao SS. Dyssynergic defecation. Gastroenterol Clin North Am 2001; 30 (1) 97-114
    CrossrefPubMedGoogle Scholar
  • 4 Rao SS, Welcher KD, Leistikow JS. Obstructive defecation: a failure of rectoanal coordination. Am J Gastroenterol 1998; 93 (7) 1042-1050
    CrossrefPubMedGoogle Scholar
  • 5 Altomare DF, Spazzafumo L, Rinaldi M, Dodi G, Ghiselli R, Piloni V. Set-up and statistical validation of a new scoring system for obstructed defaecation syndrome. Colorectal Dis 2008; 10 (1) 84-88
    PubMedGoogle Scholar
  • 6 Koch A, Voderholzer WA, Klauser AG, Müller-Lissner S. Symptoms in chronic constipation. Dis Colon Rectum 1997; 40 (8) 902-906
    CrossrefPubMedGoogle Scholar
  • 7 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 (8) 889-895
    CrossrefPubMedGoogle Scholar
  • 8 Wexner SD, Cheape JD, Jorge JM, Heymen S, Jagelman DG. Prospective assessment of biofeedback for the treatment of paradoxical puborectalis contraction. Dis Colon Rectum 1992; 35 (2) 145-150
    CrossrefPubMedGoogle Scholar
  • 9 Bharucha AE, Wald A, Enck P, Rao S. Functional anorectal disorders. Gastroenterology 2006; 130 (5) 1510-1518
    Google Scholar
  • 10 Mertz H, Naliboff B, Mayer E. Physiology of refractory chronic constipation. Am J Gastroenterol 1999; 94 (3) 609-615
    CrossrefPubMedGoogle Scholar
  • 11 Rao SS. Dyssynergic defecation and biofeedback therapy. Gastroenterol Clin North Am 2008; 37 (3) 569-586 , viii
    CrossrefPubMedGoogle Scholar
  • 12 Glia A, Lindberg G, Nilsson LH, Mihocsa L, Akerlund JE. Clinical value of symptom assessment in patients with constipation. Dis Colon Rectum 1999; 42 (11) 1401-1408 , discussion 1408–1410
    CrossrefPubMedGoogle Scholar
  • 13 Rao SS, Tuteja AK, Vellema T, Kempf J, Stessman M. Dyssynergic defecation: demographics, symptoms, stool patterns, and quality of life. J Clin Gastroenterol 2004; 38 (8) 680-685
    CrossrefPubMedGoogle Scholar
  • 14 Hobbis ICA, Turpin G, Read NW. Examination of the role of psychosocial factors in the pathogenesis of functional bowel disorders. Gastroenterology 1995; 108 (4) (Suppl. 02) A614 (abstract)
    PubMedGoogle Scholar
  • 15 Orkin BA, Sinykin SB, Lloyd PC. The digital rectal examination scoring system (DRESS). Dis Colon Rectum 2010; 53 (12) 1656-1660
    CrossrefPubMedGoogle Scholar
  • 16 Soh JS, Lee HJ, Jung KW , et al. The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence. Am J Gastroenterol 2015; 110 (8) 1197-1204
    CrossrefPubMedGoogle Scholar
  • 17 Steensma AB, Oom DM, Burger CW, Schouten WR. Assessment of posterior compartment prolapse: a comparison of evacuation proctography and 3D transperineal ultrasound. Colorectal Dis 2010; 12 (6) 533-539
    PubMedGoogle Scholar
  • 18 Yeh CY, Pikarsky A, Wexner SD , et al. Electromyographic findings of paradoxical puborectalis contraction correlate poorly with cinedefecography. Tech Coloproctol 2003; 7 (2) 77-81
    CrossrefPubMedGoogle Scholar
  • 19 Piloni V, Tosi P, Vernelli M. MR-defecography in obstructed defecation syndrome (ODS): technique, diagnostic criteria and grading. Tech Coloproctol 2013; 17 (5) 501-510
    CrossrefPubMedGoogle Scholar
  • 20 Diamant NE, Kamm MA, Wald A, Whitehead WE. AGA technical review on anorectal testing techniques. Gastroenterology 1999; 116 (3) 735-760
    CrossrefPubMedGoogle Scholar
  • 21 Karlbom U, Eeg-Olofsson KE, Graf W, Påhlman L. Evaluation of the paradoxical sphincter contraction by a strain/squeeze index in constipated patients. Dis Colon Rectum 2005; 48 (10) 1923-1929
    CrossrefPubMedGoogle Scholar
  • 22 Kassis NC, Wo JM, James-Stevenson TN, Maglinte DD, Heit MH, Hale DS. Balloon expulsion testing for the diagnosis of dyssynergic defecation in women with chronic constipation. Int Urogynecol J 2015; 26 (9) 1385-1390
    CrossrefPubMedGoogle Scholar
  • 23 Minguez M, Herreros B, Sanchiz V , et al. Predictive value of the balloon expulsion test for excluding the diagnosis of pelvic floor dyssynergia in constipation. Gastroenterology 2004; 126 (1) 57-62
    CrossrefPubMedGoogle Scholar
  • 24 Bove A, Pucciani F, Bellini M , et al. Consensus statement AIGO/SICCR: diagnosis and treatment of chronic constipation and obstructed defecation (part I: diagnosis). World J Gastroenterol 2012; 18 (14) 1555-1564
    CrossrefPubMedGoogle Scholar
  • 25 Kang HR, Lee JE, Lee JS , et al. Comparison of high-resolution anorectal manometry with water-perfused anorectal manometry. J Neurogastroenterol Motil 2015; 21 (1) 126-132
    CrossrefPubMedGoogle Scholar
  • 26 Chiarioni G, Whitehead WE, Pezza V, Morelli A, Bassotti G. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology 2006; 130 (3) 657-664
    Google Scholar
  • 27 Chiarioni G, Salandini L, Whitehead WE. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology 2005; 129 (1) 86-97
    CrossrefPubMedGoogle Scholar
  • 28 Heymen S, Scarlett Y, Jones K, Ringel Y, Drossman D, Whitehead WE. Randomized, controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergia-type constipation. Dis Colon Rectum 2007; 50 (4) 428-441
    CrossrefPubMedGoogle Scholar
  • 29 Rao SS, Valestin J, Brown CK, Zimmerman B, Schulze K. Long-term efficacy of biofeedback therapy for dyssynergic defecation: randomized controlled trial. Am J Gastroenterol 2010; 105 (4) 890-896
    CrossrefPubMedGoogle Scholar
  • 30 Şahin M, Doğan İ, Cengiz M, Ünal S. The impact of anorectal biofeedback therapy on the quality of life of patients with dyssynergic defecation. Turk J Gastroenterol 2015; 26 (2) 140-144
    CrossrefPubMedGoogle Scholar
  • 31 Rao SS, Benninga MA, Bharucha AE, Chiarioni G, Di Lorenzo C, Whitehead WE. ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol Motil 2015; 27 (5) 594-609
    CrossrefPubMedGoogle Scholar
  • 32 Cadeddu F, Bentivoglio AR, Brandara F, Marniga G, Brisinda G, Maria G. Outlet type constipation in Parkinson's disease: results of botulinum toxin treatment. Aliment Pharmacol Ther 2005; 22 (10) 997-1003
    CrossrefPubMedGoogle Scholar
  • 33 Shafik A, El-Sibai O. Botulin toxin in the treatment of nonrelaxing puborectalis syndrome. Dig Surg 1998; 15 (4) 347-351
    CrossrefPubMedGoogle Scholar
  • 34 Khaikin M, Wexner SD. Treatment strategies in obstructed defecation and fecal incontinence. World J Gastroenterol 2006; 12 (20) 3168-3173
    CrossrefPubMedGoogle Scholar
  • 35 Cadeddu F, Salis F, De Luca E, Ciangola I, Milito G. Efficacy of biofeedback plus transanal stimulation in the management of pelvic floor dyssynergia: a randomized trial. Tech Coloproctol 2015; 19 (6) 333-338
    CrossrefPubMedGoogle Scholar
  • 36 Kamm MA, Hawley PR, Lennard-Jones JE. Lateral division of the puborectalis muscle in the management of severe constipation. Br J Surg 1988; 75 (7) 661-663
    CrossrefPubMedGoogle Scholar
  • 37 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 (6) 475-477
    CrossrefPubMedGoogle Scholar
  • 38 Farid M, Youssef T, Mahdy T , et al. Comparative study between botulinum toxin injection and partial division of puborectalis for treating anismus. Int J Colorectal Dis 2009; 24 (3) 327-334
    CrossrefPubMedGoogle Scholar
  • 39 Parks AG, Porter NH, Hardcastle J. The syndrome of the descending perineum. Proc R Soc Med 1966; 59 (6) 477-482
    PubMedGoogle Scholar
  • 40 Kiff ES, Barnes PR, Swash M. Evidence of pudendal neuropathy in patients with perineal descent and chronic straining at stool. Gut 1984; 25 (11) 1279-1282
    CrossrefPubMedGoogle Scholar
  • 41 Woodfield CA, Krishnamoorthy S, Hampton BS, Brody JM. Imaging pelvic floor disorders: trend toward comprehensive MRI. AJR Am J Roentgenol 2010; 194 (6) 1640-1649
    CrossrefPubMedGoogle Scholar
  • 42 Soligo M, Salvatore S, Emmanuel AV , et al. Patterns of constipation in urogynecology: clinical importance and pathophysiologic insights. Am J Obstet Gynecol 2006; 195 (1) 50-55
    CrossrefPubMedGoogle Scholar
  • 43 Pucciani F. Descending perineum syndrome: new perspectives. Tech Coloproctol 2015; 19 (8) 443-448
    CrossrefPubMedGoogle Scholar
  • 44 Kahn MA, Breitkopf CR, Valley MT , et al. Pelvic Organ Support Study (POSST) and bowel symptoms: straining at stool is associated with perineal and anterior vaginal descent in a general gynecologic population. Am J Obstet Gynecol 2005; 192 (5) 1516-1522
    CrossrefPubMedGoogle Scholar
  • 45 Harewood GC, Coulie B, Camilleri M, Rath-Harvey D, Pemberton JH. Descending perineum syndrome: audit of clinical and laboratory features and outcome of pelvic floor retraining. Am J Gastroenterol 1999; 94 (1) 126-130
    CrossrefPubMedGoogle Scholar
  • 46 Mahieu P, Pringot J, Bodart P. Defecography: II. Contribution to the diagnosis of defecation disorders. Gastrointest Radiol 1984; 9 (3) 253-261
    CrossrefPubMedGoogle Scholar
  • 47 Halligan S. Commentary: imaging of anorectal function. Br J Radiol 1996; 69 (827) 985-988
    CrossrefPubMedGoogle Scholar
  • 48 Ahmad AN, Hainsworth A, Williams AB, Schizas AM. A review of functional pelvic floor imaging modalities and their effectiveness. Clin Imaging 2015; 39 (4) 559-565
    CrossrefPubMedGoogle Scholar
  • 49 Comiter CV, Vasavada SP, Barbaric ZL, Gousse AE, Raz S. Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging. Urology 1999; 54 (3) 454-457
    CrossrefPubMedGoogle Scholar
  • 50 Dietz HP. Pelvic floor ultrasound: a review. Am J Obstet Gynecol 2010; 202 (4) 321-334
    CrossrefPubMedGoogle Scholar
  • 51 Beer-Gabel M, Assoulin Y, Amitai M, Bardan E. A comparison of dynamic transperineal ultrasound (DTP-US) with dynamic evacuation proctography (DEP) in the diagnosis of cul de sac hernia (enterocele) in patients with evacuatory dysfunction. Int J Colorectal Dis 2008; 23 (5) 513-519
    CrossrefPubMedGoogle Scholar
  • 52 O'Leary D, Rostaminia G, Quiroz LH, Shobeiri SA. Sonographic predictors of obstructive defecatory dysfunction. Int Urogynecol J 2015; 26 (3) 415-420
    CrossrefPubMedGoogle Scholar
  • 53 Benezech A, Bouvier M, Grimaud JC, Baumstarck K, Vitton V. Three-dimensional high-resolution anorectal manometry and diagnosis of excessive perineal descent: a comparative pilot study with defaecography. Colorectal Dis 2014; 16 (5) O170-O175
    CrossrefPubMedGoogle Scholar
  • 54 Pucciani F, Reggioli M, Ringressi MN. Obstructed defaecation: what is the role of rehabilitation?. Colorectal Dis 2012; 14 (4) 474-479
    CrossrefPubMedGoogle Scholar
  • 55 Guillemot F, Bouche B, Gower-Rousseau C , et al. Biofeedback for the treatment of fecal incontinence. Long-term clinical results. Dis Colon Rectum 1995; 38 (4) 393-397
    CrossrefPubMedGoogle Scholar
  • 56 Bove A, Bellini M, Battaglia E , et al. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol 2012; 18 (36) 4994-5013
    CrossrefPubMedGoogle Scholar
  • 57 Bove A, Ciamarra P. The corner of the coloproctologist: what to ask to radiologist. Eur J Radiol 2007; 61 (3) 449-453
    CrossrefPubMedGoogle Scholar
  • 58 Dvorkin LS, Gladman MA, Epstein J, Scott SM, Williams NS, Lunniss PJ. Rectal intussusception in symptomatic patients is different from that in asymptomatic volunteers. Br J Surg 2005; 92 (7) 866-872
    CrossrefPubMedGoogle Scholar
  • 59 Lehur PA, Stuto A, Fantoli M , et al; ODS II Study Group. Outcomes of stapled transanal rectal resection vs. biofeedback for the treatment of outlet obstruction associated with rectal intussusception and rectocele: a multicenter, randomized, controlled trial. Dis Colon Rectum 2008; 51 (11) 1611-1618
    CrossrefPubMedGoogle Scholar
  • 60 Ding JH, Zhang B, Bi LX, Yin SH, Zhao K. Functional and morphologic outcome after stapled transanal rectal resection for obstructed defecation syndrome. Dis Colon Rectum 2011; 54 (4) 418-424
    CrossrefPubMedGoogle Scholar
  • 61 Zhang B, Ding JH, Yin SH, Zhang M, Zhao K. Stapled transanal rectal resection for obstructed defecation syndrome associated with rectocele and rectal intussusception. World J Gastroenterol 2010; 16 (20) 2542-2548
    CrossrefPubMedGoogle Scholar
  • 62 Jayne DG, Schwandner O, Stuto A. Stapled transanal rectal resection for obstructed defecation syndrome: one-year results of the European STARR Registry. Dis Colon Rectum 2009; 52 (7) 1205-1212 , discussion 1212–1214
    CrossrefPubMedGoogle Scholar
  • 63 D'Hoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg 2004; 91 (11) 1500-1505
    CrossrefPubMedGoogle Scholar
  • 64 Franceschilli L, Varvaras D, Capuano I , et al. Laparoscopic ventral rectopexy using biologic mesh for the treatment of obstructed defaecation syndrome and/or faecal incontinence in patients with internal rectal prolapse: a critical appraisal of the first 100 cases. Tech Coloproctol 2015; 19 (4) 209-219
    CrossrefPubMedGoogle Scholar
  • 65 Hotouras A, Murphy J, Boyle DJ, Allison M, Williams NS, Chan CL. Assessment of female patients with rectal intussusception and prolapse: is this a progressive spectrum of disease?. Dis Colon Rectum 2013; 56 (6) 780-785
    CrossrefPubMedGoogle Scholar
  • 66 Formijne Jonkers HA, Draaisma WA, Wexner SD , et al. Evaluation and surgical treatment of rectal prolapse: an international survey. Colorectal Dis 2013; 15 (1) 115-119
    CrossrefPubMedGoogle Scholar
  • 67 Landmann RG, Wexner SD. Paradoxical puborectalis contraction and increased perineal descent. Clin Colon Rectal Surg 2008; 21 (2) 138-145
    Article in Thieme ConnectPubMedGoogle Scholar