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DYSSYNERGIC DEFECATION - 03/09/11

Doi : 10.1016/S0889-8553(05)70169-2 
Satish S.C. Rao, MD, PhD, FRCP(LON)
Section of Neurogastroenterology, Division of Gastroenterology-Hepatology, Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa 

Resumen

Constipation is a symptom complex and not merely a disease. In the absence of secondary causes,34 it is due to either a neuromuscular dysfunction of the colon—slow transit constipation—or a neuromuscular dysfunction of the defecation unit. In many patients, there is an overlap because colon transit is delayed in two thirds of patients with difficult or disordered defecation.47 In the literature, many terms have been used to describe the constipation that is associated with anorectal dysfunction, including anismus,8, 15, 32 pelvic floor dyssynergia,60, 62obstructive defecation,28, 47paradoxic puborectalis contraction,13, 18, 19 pelvic outlet obstruction,22, 26 and spastic pelvic floor syndrome.3

Preston and Lennard-Jones32 first described the association of paradoxic anal contraction during attempted defecation in patients with constipation and coined the term anismus. These authors believed that this condition was a spastic dysfunction of the anus, analogous to vaginismus. The term anismus implies a psychogenic cause, however, which has not been described in these patients. An international group of experts have proposed the term pelvic floor dyssynergia in preference to anismus because the latter term refers only to a dysfunction of the external anal sphincter, whereas this condition may affect one or more muscles of the pelvic floor.60, 62The pelvic floor is a complex muscular apparatus that serves three important functions: defecation, micturition, and sexual function. All-encompassing terms such as pelvic floor dyssynergia, pelvic outlet obstruction, and spastic pelvic floor syndrome imply that this problem affects most of the pelvic floor and possibly all of its functions. Although some overlap has been described among patients with urinary obstruction and constipation,54 most constipated patients do not report sexual or urinary symptoms.46 These terms are not suitable.

Outlet obstruction 22, 26 implies that there is blockage to defecation. It includes functional and structural problems, such as neoplasia, rectal prolapse, anal stenosis, and others. Consequently, outlet obstruction misrepresents a functional disorder. The term obstructive defecation28, 47 is preferable, but even this falls short of the real pathophysiology because functional conditions, such as mucosal intussusception or rectal prolapse, may obstruct the voluntary act of defecation. The aforementioned terms are less than ideal for describing the real problem in these patients.

Studies have shown that most patients with difficult defecation show a failure of rectoanal coordination that consists of impaired abdominal and rectal pushing forces36, 47or paradoxic anal contraction or inadequate anal relaxation.47 A lack of coordination or dyssynergia of the abdominal and pelvic floor muscles that are involved in defecation appears to be the primary underlying mechanism. Consequently the term dyssynergic defecation 32 more appropriately describes this condition.

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 Address reprint requests to Satish S. C. Rao, MD, PhD, FRCP(LON) 4612 JCP University of Iowa 200 Hawkins Drive Iowa City, IA 52242 e-mail: satish-rao@uiowa.edu


© 2001  W. B. Saunders Company. Publicado por Elsevier Masson SAS. Todos los derechos reservados.
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Vol 30 - N° 1

P. 97-114 - mars 2001 Regresar al número
Artículo precedente Artículo precedente
  • SLOW TRANSIT CONSTIPATION
  • Adil E. Bharucha, Sidney F. Phillips
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  • FECAL INCONTINENCE
  • Mark J. Cheetham, Andrew J. Malouf, Michael A. Kamm

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