Paradoxical sphincter contraction is rarely indicative of anismus

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.

Figure 1

: 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

: 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

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