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. 1997 Aug;41(2):258–262. doi: 10.1136/gut.41.2.258

Paradoxical sphincter contraction is rarely indicative of anismus

W Voderholzer 1, D Neuhaus 1, A Klauser 1, K Tzavella 1, S Muller-Lissner 1, N Schindlbeck 1
PMCID: PMC1891465  PMID: 9301508

Abstract

Background—Anismus is thought to be a cause of chronic constipation by producing outlet obstruction. The underlying mechanism is paradoxical contraction of the anal sphincter or puborectalis muscle. However, paradoxical sphincter contraction (PSC) also occurs in healthy controls, so anismus may be diagnosed too often because it may be based on a non-specific finding related to untoward conditions during the anorectal examination. 
Aims—To investigate the pathophysiological importance of PSC found at anorectal manometry in constipated patients and in patients with stool incontinence. 
Methods—Digital rectal examination and anorectal manometry were performed in 102 chronically constipated patients, 102 patients with stool incontinence, and in 18 controls without anorectal disease. In 120 of the 222 subjects defaecography was also performed. Paradoxical sphincter contraction was defined as a sustained increase in sphincter pressure during straining. Anismus was assumed when PSC was present on anorectal manometry and digital rectal examination and the anorectal angle did not widen on defaecography. 
Results—Manometric PSC occurred about twice as often in constipated patients as in incontinent patients (41.2% versus 25.5%, p<0.017) and its prevalence was similar in incontinent patients and controls (25.5% versus 22.2%). Oroanal or rectosigmoid transit times in constipated patients with and without PSC did not differ significantly (total 64.6 (8.9) hours versus 54.2 (8.1) hours; rectosigmoid 14.9 (2.4) hours versus 13.8 (2.5) hours). 
Conclusions—Paradoxical sphincter contraction is a common finding in healthy controls as well as in patients with chronic constipation and stool incontinence. Hence, PSC is primarily a laboratory artefact and true anismus is rare. 



Keywords: anismus; paradoxical sphincter contraction; constipation; stool incontinence; anorectal manometry

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Figure 1 .

Figure 1

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: Frequency of manometric paradoxical sphincter contraction (PSC) in the three groups studied. The ordinate shows the percentage of patients in each group with and without PSC. If the data from the controls and incontinent patients were pooled the p value decreased (p=0.01). 


Figure 2 .

Figure 2

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: Mean (SEM) total and segmental transit times in constipated patients with (n = 29) and without (n = 33) PSC. † and ‡ represent two patients in whom manometric, defaecographic and proctographic examinations revealed PSC, thus establishing the diagnosis of "anismus". Note that † had slow total transit as well as slow segmental (right and left hemicolon) transit. 


Figure 3 .

Figure 3

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: Frequency of examinations that proved positive for PSC in patients with defaecography, manometry, and digital rectal examination. 


Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Arhan P., Devroede G., Jehannin B., Lanza M., Faverdin C., Dornic C., Persoz B., Tétreault L., Perey B., Pellerin D. Segmental colonic transit time. Dis Colon Rectum. 1981 Nov-Dec;24(8):625–629. doi: 10.1007/BF02605761. [DOI] [PubMed] [Google Scholar]
  2. Barnes P. R., Hawley P. R., Preston D. M., Lennard-Jones J. E. Experience of posterior division of the puborectalis muscle in the management of chronic constipation. Br J Surg. 1985 Jun;72(6):475–477. doi: 10.1002/bjs.1800720623. [DOI] [PubMed] [Google Scholar]
  3. Barnes P. R., Lennard-Jones J. E. Function of the striated anal sphincter during straining in control subjects and constipated patients with a radiologically normal rectum or idiopathic megacolon. Int J Colorectal Dis. 1988 Nov;3(4):207–209. doi: 10.1007/BF01660715. [DOI] [PubMed] [Google Scholar]
  4. Bielefeldt K., Enck P., Zamboglou N., Moedder U., Erckenbrecht J. F. Anorectal manometry and defecography in the diagnosis of fecal incontinence. J Clin Gastroenterol. 1991 Dec;13(6):661–665. doi: 10.1097/00004836-199112000-00010. [DOI] [PubMed] [Google Scholar]
  5. Cummings J. H., Jenkins D. J., Wiggins H. S. Measurement of the mean transit time of dietary residue through the human gut. Gut. 1976 Mar;17(3):210–218. doi: 10.1136/gut.17.3.210. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Duthie G. S., Bartolo D. C. Anismus: the cause of constipation? Results of investigation and treatment. World J Surg. 1992 Sep-Oct;16(5):831–835. doi: 10.1007/BF02066978. [DOI] [PubMed] [Google Scholar]
  7. Enck P. Biofeedback training in disordered defecation. A critical review. Dig Dis Sci. 1993 Nov;38(11):1953–1960. doi: 10.1007/BF01297069. [DOI] [PubMed] [Google Scholar]
  8. Halligan S., Bartram C. I., Park H. J., Kamm M. A. Proctographic features of anismus. Radiology. 1995 Dec;197(3):679–682. doi: 10.1148/radiology.197.3.7480738. [DOI] [PubMed] [Google Scholar]
  9. Infantino A., Masin A., Pianon P., Dodi G., Del Favero G., Pomerri F., Lise M. Role of proctography in severe constipation. Dis Colon Rectum. 1990 Aug;33(8):707–712. doi: 10.1007/BF02150750. [DOI] [PubMed] [Google Scholar]
  10. Johanson J. F., Sonnenberg A., Koch T. R., McCarty D. J. Association of constipation with neurologic diseases. Dig Dis Sci. 1992 Feb;37(2):179–186. doi: 10.1007/BF01308169. [DOI] [PubMed] [Google Scholar]
  11. Jones P. N., Lubowski D. Z., Swash M., Henry M. M. Is paradoxical contraction of puborectalis muscle of functional importance? Dis Colon Rectum. 1987 Sep;30(9):667–670. doi: 10.1007/BF02561685. [DOI] [PubMed] [Google Scholar]
  12. Klauser A. G., Ting K. H., Mangel E., Eibl-Eibesfeldt B., Müller-Lissner S. A. Interobserver agreement in defecography. Dis Colon Rectum. 1994 Dec;37(12):1310–1316. doi: 10.1007/BF02257803. [DOI] [PubMed] [Google Scholar]
  13. Klauser A. G., Voderholzer W. A., Heinrich C. A., Schindlbeck N. E., Müller-Lissner S. A. Behavioral modification of colonic function. Can constipation be learned? Dig Dis Sci. 1990 Oct;35(10):1271–1275. doi: 10.1007/BF01536418. [DOI] [PubMed] [Google Scholar]
  14. Kuijpers H. C., Bleijenberg G., de Morree H. The spastic pelvic floor syndrome. Large bowel outlet obstruction caused by pelvic floor dysfunction: a radiological study. Int J Colorectal Dis. 1986 Jan;1(1):44–48. doi: 10.1007/BF01648836. [DOI] [PubMed] [Google Scholar]
  15. Preston D. M., Lennard-Jones J. E. Anismus in chronic constipation. Dig Dis Sci. 1985 May;30(5):413–418. doi: 10.1007/BF01318172. [DOI] [PubMed] [Google Scholar]
  16. Turnbull G. K., Bartram C. I., Lennard-Jones J. E. Radiologic studies of rectal evacuation in adults with idiopathic constipation. Dis Colon Rectum. 1988 Mar;31(3):190–197. doi: 10.1007/BF02552545. [DOI] [PubMed] [Google Scholar]

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