Pelvic Floor Nonrelaxation: Approach to Evaluation and Treatment

Abstract

Dyssynergic defecation can be a complex, burdensome condition. A multidisciplinary approach to these patients is often indicated based on concomitant pathology or symptomatology across the pelvic organs. Escalating treatment options should be based on shared decision making and include medical and lifestyle optimization, pelvic floor physical therapy with biofeedback, Botox injection, sacral neuromodulation, rectal irrigation, and surgical diversion.

Keywords: Botulinum toxin; anismus; dyssynergic defecation; pelvic floor; sacral neuromodulation.

Fig. 1

Algorithm for evaluation and treatment of dyssynergic defecation.

Fig. 2

Electromyography (EMG) showing normal increase in signal with squeeze and decrease with push ( A ). EMG consistent with dyssynergia, increase in activity with push ( B ). Pink line is squeeze, yellow is rest, and green is push.

Fig. 3

Defecography. ( A ) Normal rest, ( B ) normal push, ( C ) rest with dyssynergic defecation, ( D ) push with dyssynergic defecation; patient was unable to evacuate any contrast.

Fig. 4

Setup and technique for injection of Botox into puborectalis. A standard anorectal set is used to allow for full examination and anoscopy under sedation ( A ). Setup is prepared including local anesthetic of choice (short needle) and Botox injection (spinal needle) ( B ). Patient is positioned in lithotomy and local anesthetic is administered in perianal block to allow for a more comfortable anorectal exam under sedation ( C ). Using anoscopy to expose the anal canal, the tip of the coccyx is palpated ( D ). A spinal needle tip is used to feel the coccyx, and then moved laterally into the puborectalis, injecting Botox into both ( E ) right ( E ) and left sides of the muscle.