Document Detail

Excellent response rate of anismus to Botulinum toxin if rectal prolapse misdiagnosed as anismus ("pseudoanismus") is excluded.
MedLine Citation:
PMID:  21689279     Owner:  NLM     Status:  Publisher    
Background:  Anismus causes obstructed defaecation (OD) due to inappropriate contraction of the puborectalis/external sphincter. Proctographic failure to empty after 30 seconds is used as a simple surrogate for simultaneous EMG/proctography. Botulinum toxin is theoretically attractive but efficacy is variable. We aimed to evaluate botulinum toxin in treating OD due to anismus. Method:  Patients with proctographic anismus were given botulinum toxin into the puborectalis/external sphincter under local anaesthetic. Responders (resolution then recurrence of OD over a 1-2 month period) underwent repeat injection. Non-responders underwent rectal examination under anaesthetic (EUA). EUA-diagnosed rectal prolapse was graded using the Oxford Prolapse Grade 1-5. Results:  56 patients were treated with botulinum toxin. 22 (39%) responded initially and, 21/22 (95%) underwent repeat treatment. At median follow up of 19.2(7.0-30.4) months, 20/21 (95%) had a sustained response and required no further treatment. Isolated OD symptoms (OR 7.8, p=0.008) but not proctographic or physiological factors predicted response on logistic regression analysis. In 33 (97%) of 34 non-responders significant abnormalities were demonstrated at EUA include 31 (94%) grade 3-5 rectal prolapse, 1 internal anal sphincter myopathy and 1 fissure. Exclusion of these alternative diagnoses revised the initial response rate to 96%. Discussion:  Simple proctographic criteria overdiagnose anismus and underdiagnose rectal prolapse. This explains the published variable response to botulinum toxin. Failure to respond should prompt EUA seeking undiagnosed rectal prolapse. A response to an initial dose of botulinum toxin might be considered a more reliable diagnosis of anismus than proctography.
Roel Hompes; Chris Harmston; Niels Wijffels; Oliver M Jones; Chris Cunningham; Ian Lindsey
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2011-1-19
Journal Detail:
Title:  Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland     Volume:  -     ISSN:  1463-1318     ISO Abbreviation:  -     Publication Date:  2011 Jan 
Date Detail:
Created Date:  2011-6-21     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  100883611     Medline TA:  Colorectal Dis     Country:  -    
Other Details:
Languages:  ENG     Pagination:  -     Citation Subset:  -    
Copyright Information:
Copyright © 2011 The Association of Coloproctology of Great Britain and Ireland.
Pelvic Floor Centre, Dept of Colorectal Surgery, Oxford.
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