Anismus, Physiology, Radiology: Is It Time for Some Pragmatism? A Comparative Study of Radiological and Anorectal Physiology Findings in Patients With Anismus

Umberto Pisano,Lesley Irvine,Justina Szczachor,Ahsin Jawad,Andrew MacLeod,Michael Lim 대한대장항문학회 2016 Annals of Coloproctolgy Vol.32 No.5

Purpose: Anismus is a functional disorder featuring obstructive symptoms and paradoxical contractions of the pelvic floor. This study aims to establish diagnosis agreement between physiology and radiology, associate anismus with morphological outlet obstruction, and explore the role of sphincteric pressure and rectal volumes in the radiological diagnosis of anismus. Methods: Consecutive patients were evaluated by using magnetic resonance imaging proctography/fluoroscopic defecography and anorectal physiology. Morphological radiological features were associated with physiology tests. A categorical analysis was performed using the chi-square test, and agreement was assessed via the kappa coefficient. A Mann-Whitney test was used to assess rectal volumes and sphincterial pressure distributions between groups of patients. A P-value of <0.05 was significant. Results: Forty-three patients (42 female patients) underwent anorectal physiology and radiology imaging. The median age was 54 years (interquartile range, 41.5–60 years). Anismus was seen radiologically and physiologically in 18 (41.8%) and 12 patients (27.9%), respectively. The agreement between modalities was 0.298 (P = 0.04). Using physiology as a reference, radiology had positive and negative predictive values of 44% and 84%, respectively. Rectoceles, cystoceles, enteroceles and pathological pelvic floor descent were not physiologically predictive of animus (P > 0.05). The sphincterial straining pressure was 71 mmHg in the anismus group versus 12 mmHg. Radiology was likely to identify anismus when the straining pressure exceeded 50% of the resting pressure (P = 0.08). Conclusion: Radiological techniques detect pelvic morphological abnormalities, but lead to overdiagnoses of anismus. No proctographic pathological feature predicts anismus reliably. A stronger pelvic floor paradoxical contraction is associated with a greater likelihood of detection by proctography.

항문 연축증(Anismus) 환자에서 Biofeedback 훈련의 치료효과

유광현,나용호,진경민 대한대장항문학회 1996 Annals of Coloproctolgy Vol.12 No.2

항문경 환자에서 직장 최대인내용적의 차이에 따른 바이오피드백 치료의 효과

최문석 ( Moon Seok Choi ),이풍렬 ( P oong Lyul Rhee ),손희정 ( Hee Jung Son ),김재준 ( Jae Jun Kim ),고광철 ( Kwang Cheol Koh ),백승운 ( Seung Woon Paik ),이종철 ( Jong Chul Rhee ),최규완 ( Kyoo Wan Choi ),전호경 ( Ho Kyung Chu 대한소화기학회 1999 대한소화기학회지 Vol.33 No.5

Background/Aims: Biofeedback is the only successful treatment method for anismus, but little is known about factors to predict its effect. Rectal maximum tolerable volume (MTV) is increased in some patients with anismus, which reflects sustained rectal retention and subsequent reduction of rectal elasticity. We performed this study to investigate the difference in success rate of biofeedback according to rectal MTV status among the patients with anismus. Methods: Thirty patients with anismus were enrolled and classified into two groups according to rectal MTV status which was mea sured by rectal barostat. The group 1 revealed increased rectal MTV (>322 ml, n=16) and group 2 showed normal rectal MTV (≤322, n=14). Electromyogram-based biofeedback was performed for 2 weeks, and stool frequency before and after therapy was compared. Results: Stool frequency (defeca tion episodes/week) was significantly increased after therapy from 1.81 ±0.94 to 4.38 ±2.72 in group 1 (p<0.05) and from 1.74 ±0.74 to 5.18 ±1.95 in group 2 (p<0.05). Stool frequency was increased by 3 times/week after therapy (regarded as success) in 21 among 30 patients. Success rate of group 1 (50%) was significantly lower than that of group 2 (93%) (p<0.01). Conclusions: The therapeutic efficacy of biofeedback was significantly lower in anismus patients with increased rectal MTV than in those with normal rectal MTV. Rectal MTV seems to be an important factor to predict the effec of biofeedback in patients with anismus. (Kor J Gastroenterol 1999;33:635 - 641)

항문경 환자의 바이오피드백 치료 효과에 영향을 미치는 인자: 단변량 및 다변량 분석

김영호(Young Ho Kim),최규완(Kyoo Wan Choi),이종철(Jong Chull Rhee),백승운(Seung Woon Paik),김재준(Jae Jun Kim),고광철(Kwang Cheol Koh),이풍렬(Poong Lyul Rhee),최문석(Moon Seok Choi),손희정(Hee Jung Son) 대한소화기학회 1999 대한소화기학회지 Vol.34 No.2

Background/Aims: Biofeedback is known as the most effective treatment for patients with anismus, but it is ineffective in some patients. Furthermore, little has been known about factors to predict response to biofeedback. The aim of this study was to evaluate the factors associated with poor response to biofeedback. Methods: Biofeedback was performed for 45 consecutive patients with anismus. Demographics, symptoms, and parameters of anorectal physiologic tests were compared between responders (in whom bowel frequency increased up to three times or more a week after biofeedback) and non-responders (in whom bowel frequency remained less than three times a week). Results: Thirty-one patients (68.9%) responded to biofeedback and fourteen (31.1%) did not. Anal canal length was longer in non-responders than in responders (4.53±0.50 cm vs. 4.08±0.56 cm, p=0.02) and rectal maximum tolerable volume (MTV) was larger in non-responders than in responders (361±87 ml vs. 302±69 ml, p=0.02). On multivariate analysis, anal canal length and rectal MTV were the factors that show significant difference between responders and non-responders (p=0.027 and p=0.034, respectively). Conclusions: Our results showed that a long anal canal and increased rectal MTV are associated with poor response to biofeedback for patients with anismus. (Kor J Gastroenterol 1999;34:197 - 204)

만성 변비 환자에서의 대장 아전절제술의 임상적 결과

남기현,손승국 대한대장항문학회 2000 Annals of Coloproctolgy Vol.16 No.6

직장류 환자에 대한 바이오피드백 치료

김봉수,황용희,최건필 대한대장항문학회 2001 Annals of Coloproctolgy Vol.17 No.2

Two distinct defecographic patterns of paradoxical puborectalis contraction

Choi,Sang Kyung,Wexner,Steven D. 慶尙大學校 1996 論文集 Vol.35 No.2

본 연구는 만성악성변비의 주요한 원인으로 인식되는 역설적치골직장근수축증(paradoxical pub-orectalis contracation, 이하 PPC라 한다)의 배변조영술상(defecography)의 표현양상을 분석하여 기존의 소위 PPC라고 진단된 질환이 배변조양술상에서 두가지의 표현양상을 보인다는 것을 말하고자 한다. 만성악성변비를 주증상으로 cinedefecogram상 PPC라고 진단한 34명의 배변조영술기록 테이프를 후향적으로 분석한 결과 17명의 경우는 항문외괄약근(external anal sphincter, EAS)의 역설적 수축이 존재하는데 비해 치골직장근(puborecptalis PR)의 이완은 정상인과 같았다(group A). 다른 17명의 경우는 EAS와 PR의 역설적인 수축현상을 보여 주었다. (group B). 휴식기 평균압(resting pressure), high pressure zone, rectoanal inhibitory reflex는 양그룹간에 통계적으로 유의한 차이가 없었고 pudendal nerve terminal motor latency와 근전도상의 역설적 수축의 발현율도 두 그룹간에 유의한 차이가 없었다. Slow colonic transit를 동반한 경우는 B군에서 유의하게 많았으며 (P<0.01) perineal descent는 A군에서 많이 동반되었다(P<0.05). 배변시와 휴식기시의 perineal descent의 차이 (dynamic perineal descnet)는 B군에서 뚜렷이 감소되어 있었다(P<0.01). 결론적으로 PPC는 배변조영술상 두가지의 뚜렷한 양상으로 나타나며 이 두양상의 차이는 항문생리검사(anorectal physiology)상에서도 동반된 소견이 상이하였다. 이러한 두 양상의 존재는 PPC의 치료방침중 가장 주요하게 대두된 biofeedback의 치료결과를 좌우하는 큰 요인으로 부각될 것이 예견된다. The aim of this study was to analyze the cinedefecographic patterns of paradoxical pub-orectalis contracation(PPC) in consecutive patients with chronic constipation underwent cinedefecography. Thirty four patients were included, 17 of whom had non-relaxing and / or paradoxical contraction of the external anal sphincter(EAS) with normal puborecptalis (PR) relaxation(group A). Another 17 patients had non-relaxing and/or paradoxical contraction of both the EAS and PR(group B), Mean srsting pressure(RP), the menan lengths of the high pressure(HPZ), and the status of the rectoanal inhibitory re-flex(RAIR) were not statistically different between the two groups. Pudendal nerve ter-minal motor latency(PNTML) and EMG evident of PPC were not statically different between the two group. Slow colonic transit was more frequently associated with group B than group A(p<0.01). Rectoceles were associated with pradoxical contraction in 77% of all cases but there were no statistical different of association rate between the group-s(p>0.05). Increased perineal descent(PD) was more frequently found in group A than in group B(p,0.05). The mean PD difference between push and rest was significantly dec-reased(p<0.01) in group B but the mean ARA difference between push and rest was not different in two groups. In conclusion, there are two distinct paradoxical contraction patterns which may occur either independently or together. Physiologically, their differences are highlighted by different associated finding. Recognition of the heterogenesity of the conditions may impact upon therapy.

경련성 골반상 증후군의 임상적 연구

박효진(Hyo Jin Park),조재식(Jae Sik Cho),배희동(Hee Dong Bae),정준표(Jun Pyo Chung),이상인(Sang In Lee),박인서(In Suh Park),지훈(Hoon Ji),손승국(Seung Kook Sohn) 대한소화기학회 1994 대한소화기학회지 Vol.26 No.3

The spastic pelvic floor syndrome is a functional disorder due to abnormal contraction in- stead of relaxation of the pelvic floor muscle during straining. This inhibits defecation and gives rise to constipation. We carried out the clinical and psychologic analysis, defecogram, electrophysiologic tests, and treatment in 17 patients with spastic pelvic floor syndrome. The mean age of patients was 48.2+10.1 years. The male to female ratio was 1:7.5. Prirnary com plaints were incomplete evacuation 82.3%, constipation 52.9%, tenesmus 41.2%, straining 41.2 %, and dysuria 29.4%. The patterns of personality using the MMPI showed somatization type in 7 cases and psychophysiologic reaction type in 4 cases. Defecogram revealed paradoxical contraction of puborectalis in 100.0% of cases,incomplete evacuation 76.5%, rectocele 58.8%, incontinence 17.6%, intussusception 5.9%, and excessive pelvic floor descent 5.9%. The ano- rectal angle in patients did not increase during straining and rernained about 90. The mean maximum resting and squeezing anal canal pressures were 94.4 + 48.4mmHg, and 136.4 + 28.8 mmHg. Seven patients(70.0%) were unable to expel a balloon. The pudendal neuropathy re- vealed in 4 patients(40.0%). Seven patients underwent a EMCr-based biofeedback therapy. Four among them(57.1%) had increased bowel frequency and improved the symptom of in- complete evacuation. In conclusion, careful history taking, physical examination and colorectal motility tests perrnit diagnosis of spastic pelvic floor syndrome. This disease is related with incoordination of pelvic floor muscle, so treatment should be aimed at restoration of normal muscle function through biofeedback.(Korean J Gastroenterol 1994; 26: 482 490)

풍선배출검사, 배변조영술 소견 및 역행성 항문괄약근 수축소견 사이의 일치성

김홍주 ( Kim Hong Ju ),이석호 ( Lee Seog Ho ),김현준 ( Kim Hyeon Jun ),정일권 ( Jeong Il Gwon ),김홍수 ( Kim Hong Su ),박상흠 ( Park Sang Heum ),김선주 ( Kim Seon Ju ) 대한소화기학회 2003 대한소화기학회 추계학술대회 Vol.2003 No.-

<목적> 배변조영술상 항문경 소견과 항문직장내압 검사상 배변시 항문괄약근의 역행성 수축 및 풍선배출검사상 이상소견은 출구폐쇄형 만성변비의 진단 수단으로 활용되고 있으나, 비특이적이며, 검사간의 일치성이 적다는 보고가 있었다. 연자 등은 출구폐쇄형 배변장애의 진단에 비교적 특이적인 풍선배출검사를 기준으로 각 검사소견들간의 일치성을 조사하였고, 풍선배출이상에 기여할 수 있는 항문직장부의 구조적, 기능성 이상소견을 알아보고자 하였다. <방법> 2003년 3월

경련성 골반저 증후군에서 풍선 배출검사와 회음부 계측검사의 의의

백승운(Seung Woon Paik),이종철(Jong Chul Rhee),김재준(Jae Jun Kim),고광철(Kwang Cheol Koh),이풍렬(Poong Lyul Rhee),손정일(Chong Il Sohn),이화영(Wha Young Lee),전성국(Sung Kook Jun) 대한소화기학회 1998 대한소화기학회지 Vol.31 No.3

Background/Aims: We investigate the usefulness of balloon expulsion test and perineometry in the diagnosis of defecation disorder, especially spastic pelvic floor syndrome. Methods: Patients with defecation disorder were tested to identify the cause with balloon expulsion test in left lateral decubitus position and sitting position, perineornetry, colon transit time test, defecography, anorectal manometry and sigmoidoscopy. Ten asymptomatic persons were also examined as normal control. Results: Among 91 patients with defecation disorder the spastic pelvic floor syndrome was the most common cause. The weight that was needed to expel the balloon in the left lateral decubitus position in spastic pelvic floor syndrome patients was significantly higher than in the normal controls and other disease groups (p<0.05). The time that was needed to expel the balloon in the sitting position in spastic pelvic floor syndrorne patients was also significantly longer than in the normal controls and other disease groups (p<0.05). Perineal movement in patients with spastic was significantly shorter than in the normal controls and other disease groups (p<0.05). The weight and time needed to expel the balloon in pelvic floor syndrome were inversely related to the ejection fraction on defecogram (r=-0.303, p=0.027 and r=-0.305, p=0.026 respectively). Conclusions: Balloon expulsion test and perineometry are good diagnostic tests for spastic pelvic floor syndrome. (Korean J Gastroenterol 1998;31:309-318)