Patterns of anismus and the relation to biofeedback therapy.

PURPOSE: A study was undertaken to assess physiologic characteristics and clinical significance of anismus. Specifically, we sought to assess patterns of anismus and the relation of these findings to the success of therapy. METHODS: Sixty-eight patients were found to have anismus based on history and diagnostic criteria including anismus by defecography and at least one of three additional tests: anorectal manometry, electromyography, or colonic transit time study. Interpretation of defecography was based on the consensus of at least three of four observers. Anal canal hypertonia (n = 32) was defined when mean and maximum resting pressures were at least 1 standard deviation higher than those in 63 controls. There were two distinct defecographic patterns of anismus: Type A (n = 26), a flattened anorectal angle without definitive puborectalis indentation but a closed anal canal; Type B (n = 42), a clear puborectalis indentation, narrow anorectal angle, and closed anal canal. Outcomes of 57 patients who had electromyographybased biofeedback therapy were reported as either improved or unimproved at a mean follow-up of 23.7 (range, 6-62) months. These two types of anismus were compared with biofeedback outcome to assess clinical relevance. RESULTS: Patients with Type A anismus showed greater perineal descent at rest (mean, 5.1 vs. 3.5 cm; P < 0.01), greater dynamic descent between rest and evacuation (mean, 2.7 vs. 1.4 cm; P < 0.01), greater difference of anorectal angle between rest and evacuation (mean, 14.6 vs. -3.1 degrees; P < 0.001), higher mean resting pressure (mean, 77.1 vs. 62.8 mmHg; P < 0.05), lower mean squeeze pressure (58.8 vs. 80.7 mmHg; P < 0.05), and a higher incidence of anal canal hypertonia (69.2 vs. 33.3 percent; P < 0.01) than did patients with Type B anismus. Only 25 percent of patients who had Type A anismus with anal canal hypertonia were improved by biofeedback therapy. Conversely, 86 percent of patients with Type B anismus without anal canal hypertonia were successfully treated with biofeedback (P < 0.001; Fisher's exact test). CONCLUSIONS: These two distinct physiologic patterns of anismus correlate with the success of biofeedback treatment. Therefore, knowledge of these patterns may help direct therapy.

Colectomy as treatment for constipation in selected patients.

The aim of this study was to conduct a prospective assessment of the results of total abdominal colectomy and ileorectal anastomosis (TAC) in patients with colonic inertia. Overall, 416 patients were evaluated for chronic constipation. Of the patients 54 (13 per cent) had colonic inertia, defined as diffuse marker delay during transit study without paradoxical puborectalis contraction on cinedefaecography or electromyography. All 54 patients (42 women and 12 men), with a mean age of 49 (range 17-78) years, underwent TAC. Preoperative bowel frequency was a mean of one every 8 days, requiring large doses of laxatives, enemas or both. There was no major postoperative morbidity; five patients were readmitted due to bowel obstruction, three for successful conservative management while the other two required enterolysis. After a mean follow-up of 27 (range 2-51) months these 54 patients reported a mean frequency of spontaneous bowel movements of 3.7 (range 1-10) per day. 'Excellent' or 'good' outcome was reported by 51 patients (94 per cent). TAC can be performed with acceptable morbidity and 94 per cent of patients will have satisfactory improvement in bowel habit.