Ebook Anorectal surgery - Made easy: Part 2

chapter

Biofeedback

11

Dyssynergic defecation is one of the most common forms of
functional constipation both in children and adults.
It is defined as incomplete evacuation of fecal material from the
rectum due to paradoxical contraction or failure to relax pelvic floor
muscles when straining to defecate.
Up to one half of patients with constipation suffer from the entity
known as dyssynergic defecation.
This is an acquired behavioral problem and is caused by the
inability to coordinate the abdominal and pelvic floor muscles to
evacuate stools.
In the current scenario, it is possible to diagnose this problem
through:
• History
• Prospective stool diaries
• Anorectal physiologic tests.
Biofeedback also known as neuromuscular training is:
• The use of electronic or electromechanical equipment to
measure
• Provide information about specific physiologic functions
• That can then be controlled in therapeutic directions.
Neuromuscular training or biofeedback therapy is an instrumentbased learning process that is based on ‘‘operant conditioning’’
techniques.
The goal of neuromuscular training using biofeedback techniques
is to restore a normal pattern of defecation.

A Standard Biofeedback Training Protocol
The mainstay of behavior therapy is to first explain the anorectal
dysfunction and discuss its relevance with the patient before
approaching the treatment.


Biofeedback 233

The next step includes training the patients on a more effective
use of the abdominal muscles to improve pushing effort.
Patients are next shown anal manometry or EMG recordings
displaying their anal function and are taught through trial and error
to relax the pelvic floor and anal muscles during straining.
This objective is first pursued with the help of visual feedback
on pelvic floor muscle contraction, accompanied by continuous
encouragement from the therapist.
When the patient has learned to relax the pelvic floor muscles
during straining, the visual and auditory help are gradually
withdrawn.
Biofeedback is often recommended for children who have
constipation and encopresis.
Associated with specific:
• Physical
• Anatomic
• Postsurgical complications.
Also recommended for children who exhibit:
• Pelvic floor dyssynergia
• Paradoxical contraction.
Biofeedback treatment of constipation and encopresis typically
involves some combination of the following:

• Training in discriminating the sensation of rectal distention
• Strengthening or controlled relaxation of the external anal
sphincter through electromyography (EMG) training
• Training in the synchronization of internal and external anal
sphincter responses
• Training in the coordination of abdominal and pelvic floor
musculature for elimination (For those who have pelvic floor
dyssynergia or paradoxical contraction).
Pelvic floor dyssynergia is the abnormal closure of the anal canal
during straining for defecation.
During attempts to defecate, children who have dyssynergia
squeeze the buttocks and hips but are unable to relax the external
anal sphincter.
The child squeezes the anal canal during defecation:


234 Anorectal Surgery

• To control the amount of stool being passed
• To protect against pain.
These abnormal defecation dynamics are thought to develop in
response to past painful bowel movements.
When any behavior is reinforced, may it be complex maneuver
like eating or a simple task like muscle contraction, its likelihood of
being repeated and perfected increases several fold.
In patients with dyssynergic defecation, the goal of neuromuscular
training is two fold:
• To correct the dyssynergia in coordination of the abdominal,
rectal, and anal sphincter muscles to achieve a normal and
complete evacuation

• To enhance rectal sensory perception in patients with
impaired rectal sensation.

In children, it is essential and prerequisite to decide which
type of biofeedback be provided to a particular patient as the type
of biofeedback used is a function of the physiologic mechanisms
hypothesized to underlie the child’s soiling.
For example, training aimed at improving rectal sensation is
indicated, if a child’s soiling is thought to be associated with poor
sensation of the urge to stool.
Sphincter strengthening through EMG biofeedback would be a
better option, if soiling is associated with poor control caused by a
weak external anal sphincter.
Most available research apparently focuses on biofeedback
treatment of constipation and encopresis associated with pelvic
floor dyssynergia.
Most children who have encopresis contract the external anal
sphincter during defecation, thereby impairing their ability to empty
the rectum completely and which in turn compounds ongoing
impaction.
To assess pelvic floor dyssynergia two electrodes are used:
1. Surface EMG electrodes to monitor abdominal muscles
2. An anal sensor (manometric sensor within anal canal or
surface EMG electrodes just outside the anal opening).


Biofeedback 235

To evaluate the ability of the child to maintain external anal
sphincter relaxation while contracting abdominal muscle.

Biofeedback training is used to teach appropriate response.
Training varies in type and duration for each response.
Improve or correct dyssynergia: If there is dyssynergia between the
two muscle regions this training is used.
Along with manometric—guided pelvic floor relaxation,
this training consists of improving the abdominal push effort
(diaphragmatic muscle training) lastly followed by simulated
defecation training.
Rectoanal coordination: The purpose of this training is to produce
a coordinated defecatory movement consisting of an adequate
abdominal push effort which in turn is reflected by a rise in
intrarectal pressure on the manometric tracing that is synchronized
with relaxation of the pelvic floor and anal canal as depicted by a
decrease in anal sphincter pressure.
Ideally the subject should be seated on a commode with the
manometry probe in situ, to facilitate this training.
Posture and sitting correction needs a special mention before
any maneuver:
• As against the regular posture of keeping the legs together
correct the same by keeping the legs apart.
• Also correct the sitting angle at which the patient will attempt
the defecation maneuver (i.e. leaning forward).
After this correction the patient is asked:
• To take a good diaphragmatic breath
• To push and bear down as if to defecate.
Encourage the patient to watch the monitor while performing
this maneuver.
Throughout the maneuver keep a close watch and correct the
patients posture and breathing techniques.
An instant feedback of their performance is provided to the

patient from the visual display of the pressure changes in the rectum
and anal canal on the monitor, this helps them to understand and
learn quickly.


236 Anorectal Surgery

At least 10 to 15 maneuvers are performed. To provide the subject
with a sensation of rectal fullness or desire to defecate, the balloon
in the rectum is distended with 60 ml of air.
While observing the pressure changes in the rectum and anal
canal on the display monitor the patient is encouraged to push and
attempt defecation, as soon as the he/she experiences this desire to
defecate.
The breathing and postural techniques are corrected, once again.
The maneuvers are repeated approximately 5 to 10 times.
Following instructions are passed to the patient during the
attempted defecation, to titrate:
• The degree of abdominal push
• The anal relaxatory effort
• Specifically not to push excessively.
Reason being this is often counterproductive and leads to voluntary
withholding.
The balloon is deflated, after each attempt, and reinflated before
the next attempt.
The balloon is fully deflated and the probe is removed, after
completion of this maneuver.
In case an EMG device is used either of the following observation
during the maneuver is essentially noted by the patient:
• To reduce the amplitude of electrical wave forms on the

monitor
• To decrease the intensity of sound signals.
Simulated defecation training: The patient is trained and taught to
expel artificial stool in the laboratory by using the correct technique.
Either a 50 ml water-filled balloon or an artificial stool is placed in
the rectum to perform this maneuver.
The patient is asked to sit on a commode and to attempt
defecation, after the balloon is placed in the rectum in the left lateral
position.
During the attempt to pass the balloon assistance is provided to
the patient and he/she is taught:
• To relax the pelvic floor muscles
• To correct the posture and breathing techniques.


Biofeedback 237

Apply gentle traction to the balloon, if the patient is not able to
expel the balloon, just to add to the patient’s efforts.
Gradually and with repetition of the maneuver, the subject
learns how to coordinate the defecation maneuver and to expel the
balloon.
Sensory training: The main goal of this training is:
• To improve the thresholds for rectal sensory perception
• To promote better awareness for the process of passing stool.
Intermittent inflation of the balloon in the rectum, is the primary
maneuver.

The primary objective is to teach the patient to perceive a
particular volume of balloon distention but with the same intensity

as they had previously experienced with a larger volume of balloon
distention.
First and foremost the balloon is inflated progressively till the
patient experiences an urge to defecate. Note this threshold volume.
The balloon is reinflated to the same volume, after deflation and
to educate the subject and to trigger appropriate rectal sensations,
the maneuver is repeated two or three times.
The balloon volume is decreased in a stepwise manner by about
10% with each subsequent inflation, thereafter.
During each distention, the patient is encouraged:
• To observe the monitor
• To note the pressure changes in the rectum
• Simultaneously pay close attention to the sensation they are
experiencing in the rectum.
• To use the visual cues for volumes that are either not readily
perceived or only faintly perceived.
In case if the patient fails to perceive:
• A particular volume
• Reports a significant change in the intensity of perception
After a 5-second warning the balloon is inflated again either:
• By using the same volume
• By using the volume that was previously perceived (higher).
By the end of each session, newer thresholds for rectal perception
are established:


238 Anorectal Surgery

• By repeated inflations and deflations
• Through a process of trial and error.

Depending on their individual needs each training session
should be customized for each patient in following aspects:
• Duration and frequency of training
• The number of neuromuscular training sessions
• The length of each training session.
Each training session typically takes 1 hour. The visits to the
motility lab are planned once in two weeks. Four to six training
sessions are required on an average. Though it is not possible predict
how many sessions a particular subject needs.
Periodic reinforcements at 6 weeks, 3 months, 6 months, and 12
months after completion of neuromuscular training, may provide
additional benefit.
These periodic reinforcements can improve the long-term
outcome of these patients.
Devices and techniques for biofeedback: Several devices and methods
are available, and newer techniques continue to evolve, the reason
being neuromuscular training is an instrument-based learning
technique.
Some of the devices being commonly used include:
• Manometric-based biofeedback treatment with a solid-state
manometry system
• EMG biofeedback
• Balloon defecation training
• Home training devices.
Ideally suited and recommended for biofeedback therapy is, the
solid-state manometry probe with microtransducers and a balloon.
A visual display of pressure activity throughout the anorectum is
provided by the transducers that are located in the rectum and anal
canal.
This visual display in turn provides visual feedback to the subject.

To provide both visual and auditory feedback, surface EMG
electrodes can be incorporated on the probe.
The same probe can be used to provide sensory training. All in all
the system can serve as a comprehensive device for neuromuscular
training.


Biofeedback 239

In place of manometric device, an EMG biofeedback system can
be used. This EMG biofeedback system consists of:
• A surface EMG electrode that is mounted on a probe or
• Affixed to the surface of the external anal sphincter muscle.
The EMG biofeedback system provides instant visual feedback,
the EMG signals that are picked up from the surface of the anal
sphincter muscle are in turn displayed on the monitor.
Instant feedback regarding the changes in electrical activity of
the anal sphincter, can be generated from the pitch of the auditory
signals.
Such feedback responses help the patient titrate the defecation
effort and in turn can augment the learning process.
Home training devices largely use an EMG home trainer or silicon
probe device attached to a hand-held monitor with an illuminated
liquid crystal display.
The pressure or electrical activity of the patient’s sphincter
responses can be displayed on a simple gauge, a strip chart recorder,
or a color liquid crystal display and these are used to provide visual
feedback for the subject.

Efficacy of Biofeedback Therapy

The symptomatic improvement rate ranges between 44 and 100%
in different uncontrolled clinical trials.
The results show that biofeedback therapy is superior to
controlled treatment approaches, such as:
• Diet
• Exercise
• Laxatives
• Use of polyethylene glycol
• Diazepam
• Placebo
• Balloon defecation therapy or
• Sham feedback therapy.
Though offered in few centers only and without adverse effects,
biofeedback therapy is a multidisciplinary approach and is laborintensive.


240 Anorectal Surgery

A home-based, self-training program is essential, to treat the vast
number of constipated patients in the community.

Other Measures for Treating Dyssynergic Defecation
Injection of botulinum toxin into the anal sphincter has been tried
with mixed results.
Different surgical procedures like division of puborectalis muscle
with varying degree of success have been described for managing
dyssynergic defecation.
Biofeedback training seems to be a good treatment for lower
gastrointestinal disturbances, especially for pelvic floor dyssynergia.
The effects of such training may not be limited to the anorectum

and might also be useful in other conditions in which pelvic floor
dyssynergia plays a role.
With biofeedback therapy the symptom improvement is caused
by a change in underlying pathophysiology, it is not only efficacious
but also superior to other modalities.
Use of home biofeedback programs along with development of
user-friendly approaches to biofeedback therapy will significantly
enhance the adoption of this treatment by gastroenterologists and
colorectal surgeons.
In children who have pelvic floor dyssynergia and are not
showing a positive response to standard medical management,
recommended biofeedback protocol is a brief training program of
around two to four sessions.
Biofeedback training to be more effective needs to be a complete
comprehensive package of:
• Biobehavioral treatment of encopresis
• Cleanout
• Medications
• Sitting schedule
• Dietary restrictions recommendations.
On the basis of cause, severity of incontinence, or initial
manometry, a successful outcome could not be predicted.
In response to bearing down, most patients could be taught to
relax their sphincter.


Functional Anorectal
­Disorders

chapter

12

A functional anorectal disorder is defined as “a variable combination
of chronic or recurrent anorectal symptoms not explained by
structural or biochemical abnormalities”, or in simple terms,
“Anorectal symptoms, the etiology of which is currently unknown or
is related to the abnormal functioning of normally innervated and
structurally intact muscles, or is attributed to psychological causes”.
Chronic anal or perianal pain without evident cause produces
maximum mixed reactions among family, friends and physicians as
compared to other disorders.
Usually the result of common and easily recognized disorders
such as:
• Anal fissure
• Anal fistula
• Intersphincteric abscess
• Thrombosed hemorrhoids or
• Anorectal cancer.
Pain in the anal canal or perineum is easily manageable, but
when no cause can be found management is difficult.
Often referred from one specialist to another, the patients are
then offered a variety of different and yet ineffective treatments.

The functional anorectal disorders are defined primarily on
the basis of the symptoms.
Men and women of all ages are affected by anorectal disorders.
Their management is not limited to the evaluation and treatment
of hemorrhoids.
The spectrum of anorectal disorders ranges from benign and

irritating (pruritus ani) to potentially life-threatening (anorectal
cancer) disorders.
Patients usually present with ‘‘constipation’’, but the clinical
picture of these disorders includes:


242 Anorectal Surgery

• Rectal pain and bleeding
• Digitalization
• Incomplete evacuation
• A feeling of obstruction.
Because many findings can be seen in normal patients as well,
and the symptoms are nonspecific it makes the patient evaluation
and diagnosis difficult.
A combination of the following work-up helps arrive at the
diagnosis:
• Clinical picture
• Defecography
• Pathology
• Anal tonometry (occasionally)
• Pudendal terminal motor nerve latency
Some of the most common anorectal disorders include:
• Levator ani syndrome
• Proctalgia fugax
• Pruritus ani
• Solitary rectal ulcer syndrome
• Fecal incontinence
• Pelvic floor dyssynergia
• Anal fissures.

With clinical experience it has been concluded that the
classification of perianal pain set is inadequate.
Not only are there many overlapping features, but also the
syndromes as described do not allow recognition of discrete causes
in individual patients and so do not lead to effective means of
investigation or management.
Generally treated medically with dietary changes, these disorders
are responsive to biofeedback.
Surgical intervention has not been universally successful and is
reserved for patients with intractable symptoms.
Cardinal features of chronic functional anorectal disorders
include the following:
• Diagnosed mainly by symptoms, objective findings aid in the
diagnosis of these disorders


Functional Anorectal Disorders 243

• Though discomfort or pain is the predominant symptom;
patients may also have dysfunctional voiding or defecation
• Associated findings frequently include impaired quality of life,
anxiety, and depression
• Though it is presumed that visceral hypersensitivity and
pelvic floor dysfunction may play a role, pathophysiology is
not properly studied and poorly understood
• Because therapeutic approaches have not been rigorous,
therapy is guided by clinical features.

Levator Ani Syndrome
Irrespective of the fact that several syndromes have been described,

the most common question in the mind of a colorectal surgeon is:
What is the cause of this idiopathic perianal pain and how can it be
relieved?
The first reference to anal pain appeared in 1859 when a
syndrome called “Coccygodynia” was described.
Ever since a number of different terms have been used, adding to
confusion as to the definition of this syndrome.
Coccygodynia is said to consist of a:
• Vague tenderness or ache in the region of the sacrum and
coccyx
• In the adjacent muscles and soft tissues.
• Often associated with similar rectal and perianal discomfort.
• The pain radiates to the back of the thighs or buttocks,
occasionally.
Most patients are women the prevalence ration has been found
up to 85%.
The syndrome usually presents in the third to sixth decade of
their life and symptoms often persist for many years.
In course of time it was noted that sitting seemed to induce or
exacerbate the pain, and lead to the suggestion that it was referred
from chronic spasm of the levator ani muscles either because of
infection or trauma to these muscles.


244 Anorectal Surgery

It was later suggested to the use of the term ‘levator syndrome’,
and treatment in form of digital massage of the pelvic floor
musculature was offered.
The levator ani syndrome is also called:

• Levator spasm
• Puborectalis syndrome
• Chronic proctalgia
• Pyriformis syndrome
• Pelvic tension myalgia.
The pain in this syndrome is usually described as:
• Vague
• Dull ache or
• Pressure sensation high in the rectum
• Getting worse with sitting or lying down
• Lasting for hours to days.
The prevalence of symptoms compatible with levator ani
syndrome is not very high in the general population and it is more
common in women.
Around one-fourth patients suffering from this symptom consult
a physician, yet it is presumed that the associated disability is
significant.
More than half of affected patients are aged 30 to 60 years and
prevalence tends to decline after age 45.

Pathophysiology
Though the exact etiology is unknown different studies have
suggested. Different hypothesis for the pathology of levator ani
syndrome, some of which are as mentioned:
• That levator ani syndrome results from spastic or overly
contracted pelvic floor muscles
• That levator ani syndrome is associated with psychological
stress, tension, and anxiety
• It is unclear if the association between chronic pelvic pain and
psychosocial distress on multiple domains (e.g. depression

and anxiety, somatization, and obsessive-compulsive
behavior) reflects an underlying cause or an effect of pain


Functional Anorectal Disorders 245

• That levator ani syndrome may be due to visceral hyperalgesia
or increased pelvic floor muscle tension, supported by the fact
that there is tenderness to palpation of pelvic floor muscles in
chronic pelvic pain and levator ani syndrome
• That levator ani syndrome patients may have increased anal
pressures or electromyogram activity. Higher anal pressures
may reflect increased external or internal anal sphincter
tone
• Inability to relax pelvic floor muscles suggests pelvic floor
dysfunction.

Diagnostic Criteria
If the patient complains of atleast 12 weeks consecutively in previous
12 months for the following:
1. Chronic or recurrent rectal pain or aching and discomfort
2. Episodes last 20 minutes or longer
3. Other causes of rectal pain such as ischemia, inflammatory bowel
disease cryptitis, intramuscular abscess, fissure hemorrhoids,
prostatitis, and solitary rectal ulcer have been excluded, then the
patient can be labeled as suffering from levator ani syndrome.

Clinical Evaluation
The diagnosis of levator ani syndrome is based on symptoms alone.
One important sign which can raise the diagnosis is:

• Posterior traction on the puborectalis revealing tight levator
ani muscles and tenderness or pain
• Tenderness usually may be predominantly left-sided
• Massage of this muscle will generally elicit the characteristic
discomfort.
Depending on the above-mentioned sign and symptom complex
the syndrome has been classified into two levels:
• A “highly likely” diagnosis of levator ani syndrome if symptom
criteria are satisfied and these physical signs are present, or
• A “possible” diagnosis if the symptom criteria are met but the
physical signs are absent.


246 Anorectal Surgery

To exclude alternative diseases, clinical evaluation will usually
include sigmoidoscopy and appropriate imaging studies such as
defecography, ultrasound, or pelvic CT.

Treatment
Appropriate testing (e.g. sigmoidoscopy, defecography, ultrasound,
or pelvic MRI) should be performed as necessary:
• To exclude other causes of pain (e.g. Crohn’s disease, anal fissures)
• To identify associated conditions (e.g. defecatory disorders).
Though there is no fullproof therapy, a variety of treatments
have been described that aim at reducing tension in the levator ani
muscles:
• Digital massage of the levator ani muscles
• Sitz baths
• Muscle relaxants such as:

–Methocarbamol
– Diazepam
–Cyclobenzaprine.
• Electrogalvanic stimulation
• Biofeedback training
Ultrasound-guided injection of local anesthetics or alcohol
for pelvic nerves (e.g. pudendal nerve) has most of the times not
resulted in any improvement.
In situations where it becomes essential to offer treatment
it would be wise to select a modality like biofeedback which has
no significant adverse effects and prevent further harm to the
patient.
Many patients fail to respond to treatment. Yet surgery should be
avoided.

Proctalgia Fugax
Proctalgia fugax is an enigmatic disorder. Proctalgia fugax is a
condition characterized by recurring attacks of pain deeply inside
the rectum.


Functional Anorectal Disorders 247

Described in 1935, proctalgia fugax as against levator ani syndrome, is a relatively well-defined syndrome of obscure causation.
Ever since it was named in 1935, in an article entitled “Proctalgia
fugax: a little known form of pain in the rectum”—It has been a
source of controversy.
The majority of observations that were made then in 1935, in the
article mentioned hold true today.
Proctalgia fugax is described as sudden, severe, irregular attacks

of rectal pain lasting several seconds or minutes followed by
complete resolution without any untoward effects.
Proctalgia fugax has also been defined as recurring attacks of
distressing rectal pain with no local positive findings in the rectum.
Attacks are infrequent, occurring less than five times a year in
more than half of the patients.

Pathophysiology
The etiology remains unknown, however most theories are focused
on spasm of the levator ani muscle and sigmoid colon, where as
some studies suggest that smooth muscle spasm may be the cause
of proctalgia fugax.
It has certain features which suggest that it is due to a sustained
muscle spasm.
Because of the short duration and sporadic, infrequent nature of
this disorder, the identification of physiological mechanisms of this
disorder is difficult.
Many patients on psychological testing have been found to be
perfectionistic, anxious, and/or hypochondriacal.
It is commoner in men than women, though prevalence rates
may vary in men and women.
Beginning in early adult life and the symptoms cease
spontaneously in late middle life.
The ages of the patients varies between 18 and 65 years.
Estimated prevalence ranges from 8 to 18%. However only 17 to
20% of those affected report the symptoms to their physicians.
Yet a curiously large number of reports have concerned doctors.


248 Anorectal Surgery

Diagnostic Criteria
1. Recurrent episodes of pain localized to the anus or lower rectum
2. Episodes last from seconds to minutes
3. There is no anorectal pain between episodes.
Proctalgia may be classified into severe and mild attacks.
Occuring usually between 4 and 5 am; on rare occasions more
than one attack occurs in the same night.
Attacks may occur on several consecutive nights, during periods
of anxiety or fatigue.
Commonly there is an average interval of about one month
between attacks.
The severe attacks have an aura which:
• It is localized to the lower abdomen
• It is of a vague nature difficult to describe.
About half to one a minute before the attack, the patients
becomes aware that the pain will occur, and may wake up from
sleep before any pain.
The pain itself is:
• Deep seated or high in the rectum
• Severe and agonizing
• Lasts 10 to 15 minutes
• It is accompanied by marked syncope.
No evidence of spasm in the rectum has been noted in most
patients, as far as the finger could reach.
The mild attack is:
• Felt lower down in the rectum
• Lasts much longer (20 to 90 minutes)
• Mostly not accompanied by syncope
• Clinical examination during the attack on several occasions

showed spasm of the sphincters.

Characteristics of Pain
The pain follows a definite pattern, and no local cause can be found
to account for it.
In its most common form the disease starts with nocturnal
attacks of pain. Other ways of onset are less common and the
patients ultimately develop the nocturnal attacks.


Functional Anorectal Disorders 249

Particularly common at night it can occur at any time.
It begins suddenly and progresses to a cramp-like pain which
may be very severe, but which usually resolves after less than 30
minutes.
The pain is felt at a constant site above the level of the external
anal sphincter in the anal canal or rectum.
A feature which suggests that it may be due to a cramp-like spasm
of the muscles of the pelvic floor is that the pain may sometimes
be relieved by flexing the extended legs as far as possible onto the
abdominal wall, as when sitting on the floor.
There is a high incidence of symptoms of irritable bowel
syndrome in patients with proctalgia fugax. However, the pain itself
is not accompanied by an acute bowel disturbance.
Specific description of pain like “gnawing, aching, cramp-like, or
stabbing” has been reported by some patients.
But there are many more vivid accounts:
• Like a sharp object held up at the rectosigmoid
• As if the rectum were being squeezed in a vice

• Like a wire tied tightly round the bowel
• Like a small ball expanding slowly.
Some patients suffering from the descending perineum
syndrome also complain of perianal pain.
In these patients a dull aching pain in the posterior perineum
is associated with:
• Abnormal descent of the perineum during straining at
defecation
• Sometimes with prolapse of the anterior rectal mucosa.
The pain is:
• Prominent after defecation, or
• After prolonged standing
• It is usually relieved by lying down
• The pain sometimes improves when the abnormal defecation
habit is modified, though in these cases pelvic floor repair may
be necessary.


250 Anorectal Surgery

Clinical Evaluation
Diagnosis is based on symptoms alone. There are no physical
examination findings or laboratory tests that support the diagnosis.
Examination reveals that the perineum descends below the
plane of the ischial tuberosities at rest, or during straining in patients
suffering from the descending perineum syndrome.
Other endoscopic and imaging modalities are used to exclude
other underlying disorders.

Treatment

The real difficulty in treating proctalgia lies in preventing attacks.
This is practically impossible and all efforts directed towards this
end have failed so far.
Treatment for most patients consists only of reassurance and
explanation, because episodes of pain are very brief.
Before referral most of the patients have been treated without
success.
Various treatments including tricyclic antidepressants, benzo­
diazepines, phenothiazines, paracetamol, codeine, dihydro-codeine,
and stronger narcotic analgesics are offered to patients.
Others have recommended clonidine or amylnitrate.
However, a small group of patients who have proctalgia fugax
on a frequent basis: Have shown improvement and reduction in the
duration of episodes of proctalgia with inhalation of salbutamol (a
beta adrenergic agonist).
Local measures such as local anesthetic creams, and surgical
approaches such as maximal anal stretch procedures, removal of
anal mucosal tags, hemorrhoidectomy or pelvic floor repair, were
also unsuccessful.


In most cases, in patients considered to be suffering from
pain of psychogenic origin, if subjected to psychiatric evaluation,
no abnormality other than that attributed to the effect of chronic
unrelieved pain is usually found.
It is difficult to devise appropriate treatment because the exact
pathophysiology is unknown.


Functional Anorectal Disorders 251

Percutaneous vibration has been used without effect in some
patients.
Pudendal nerve block relieved the pain on the treated side for a
few hours only and that too in small number of patients.
Similarly, carbamazepine is also ineffective or only partially
effective.
Treatment thus remains unsatisfactory. Massage of the pelvic
floor musculature was uniformly ineffective.

The patient should avoid the kind of food or drug that, in his
experience, precipitates the pain.
The belief that Proctalgia fugax is a visceral neurosis is supported
by the fact that a number of variety of the measures have been selfdevised by the patient and have given good relief in good number
of patients.
Though in any complaint which is naturally self-resolving and
of short duration, it is admitted that this is a common enough
happening.

Most patients learn from their own experience some
maneuver which seems to help them relieve the symptoms.
Different maneuvers tried are as follows:
• The application of warmth, whether:
– By clothing or
– By a hot-water bottle
• Others get respite from change in position
– To the genupectoral, or
– To the squatting, or
– To sitting on the edge of a chair, or
– Even to a sitting-up position in bed.

• In some patients the pain may almost disappear on passage of
flatus.
• Similarly the discharge of any particulate fecal material, even
in small amounts; may relieve pain in some patients.
• It is likely that each effort only signals the relaxation of muscle
spasm and the end of an attack.


252 Anorectal Surgery

Fig. 12.1:  Genupectoral position

In some instances, the effort of ineffectual straining may only
intensify and prolong the spasm because the patient can expel
nothing at all from the rectum.

Once the attack is impending, postural treatment is
considered the most effective. The genupectoral position can be
adopted (Fig. 12.1).
Or the patient is advised to lie down on the right side with the
buttocks slightly elevated on a pillow, and this should be supplemented
by firm pressure on the anus using the left hand for that purpose.
This may help abort or greatly alleviate a severe attack.
It can be relieved most effectively by the immediate taking of
food or drink. The mechanism presumed behind this is that the
initiation of the gastrocolic reflex inhibits the painful muscle spasm.
Most of the other lines of treatment like the ones mentioned
below are largely impracticable:
• The passing of a rectal catheter, or even
• The giving of a small enema, warm or cold, water or oil, or

even air alone.
It seems likely that any success in such maneuvers results from
engaging the attention and by arousing interest, curiosity, or
expectation.


Functional Anorectal Disorders 253

Use of Clonidine for Proctalgia Fugax
Clonidine works by stimulation of alpha receptors which in turn:
• Produce relaxation of the rectal smooth muscle (effect on
para­sympathetic neurones)
• Relaxation of internal anal sphincter (effect on sympathetic
neurones).
The antispastic effect of clonidine might possibly inhibit the
spasm of levator ani and external anal sphincter.
Apart from this, the central sedative and analgesic actions of
clonidine also appear to be very useful in producing relief.
Clonidine though needs more evaluation, appears to be effective
in treatment of proctalgia fugax.

Perineal Descent Syndrome
Perineal descent was first described by Parks et al in 1966.
It was assumed to be the final outcome of a cycle that included
regularly straining with bowel movements which in turn caused the
anterior rectal wall to balloon into the anal canal.
The hypothetical sequence of events have been documented as
follows:
• Patients usually have a complain of a feeling of inadequate
evacuation of stool

• Which results in more straining
• Finally ending up with weakness of the pelvic floor
musculature.

Constant straining and the resulting perineal descent have
been reported to stretch the pudendal nerve and ultimately leading
to incontinence.
Similarly, it has been demonstrated that abnormal perineal
descent results in changes to the external sphincter, that are
consistent with neuropathy.

Pathogenesis
Perineal descent syndrome has usually been attributed to:
• Pelvic floor weakness resulting from


254 Anorectal Surgery

–Neuropathy
– Trauma during:
- Pregnancy or
-Childbirth
– Abnormal defecation behaviors.
However, the claims that there is relation between increased
perineal descent and pudendal neuropathy have been proved
otherwise.
With increasing number of vaginal deliveries, a prolonged
terminal motor latency is seen yet no association between perineal
descent and pudendal neuropathy has been demonstrated in these
patients.

Individuals with descending perineal syndrome present with:
– Constipation in the early phase
– Incontinence as damage continues to the pelvic floor.

Diagnosis
Diagnosis of descending perineal syndrome is based on:
• Clinical symptoms
• Physical examination
• Defecography.

Physical Examination
In the left lateral position, on physical examination; the perineum is
seen ballooning outward during straining.

Defecography
Despite the variance in the measurements of perineal descent,
defecography can be used to:
• Document descent (>4 cm)
• Assess for any other pathology.

Treatment
Treatment consists of:
• Biofeedback
• High-fiber diets for constipated patients.


Functional Anorectal Disorders 255

Pruritus Ani
Pruritus ani is defined as intense chronic itching affecting perianal skin.

Characterized by intense itching around the anus pruritus ani, is
a troublesome symptom that is associated with most forms of anal
disease, but in some patients with this symptom no etiological anal
disease may be found.
As good number of patients suffer prolonged intractable
symptoms and treatment is often unsuccessful. It is a frustrating
condition for both patients and clinicians.
Actually the symptoms of itching or irritation of the perianal skin
are usually a disorder of mixed etiology:
• Partly dermatological
• Partly psychological
• Occasionally proctological.
Yet, the sufferer is frequently referred to a proctologist when
simple or homely treatments fail for two prime reasons:
• Because of the precision of its fundamental location
• Because the majority of coexisting conditions are anorectal,
predominately hemorrhoids and fissures.
Even though the dermatological conditions are usually not
restricted to the perianal area, the morphology of perianal skin
lesions may be atypical for the disease elsewhere.
Paradoxically in most patients the problem is due either:
• To inadequate cleansing of the anus or
• To over-vigorous attempts to polish it clean.
The symptoms usually range from mild to intense, but when
these are severe and persistent, depression may result.
However, a detailed history and examination are necessary, as
75% of cases have coexisting pathology.

Etiology
Prevalence

• Affects 1 to 5% of the population.
• Atleast four times more common in men.
• It is most frequent between the fourth and sixth decades of life.


256 Anorectal Surgery

As against the fact that nearly 100 different causes for pruritus
ani have been reported, most patients with pruritus ani do not have
a discernible cause for their condition, pruritus ani is classified as
idiopathic when no cause can be found.
Though but not conclusively proved to be of relevance the
following factors play an important role in the etiopathology of
pruritus ani:
• Fecal contamination of the perineum
• In the absence of gross soiling
– Irritant chemicals in the feces
–Allergies
- Locally applied agents or
- Components of diet
• A psychosomatic etiology has been suggested.
Undoubtedly the condition provokes great anxiety in its most
severe forms.

Proctological Conditions
A minority of patients have an easily recognizable proctological
condition such as:
• Anal fissures
• Anal fistulas
• Papillomas

• Skin tags
• Prolapsing hemorrhoids, or
• Rectal prolapse.
Hygiene:  Perineal fecal contamination: Fecal contamination causing
pruritus ani is because of prolonged contact with a moist substance
or a hygiene issue.
Small particles of feces accumulate on the perianal skin, in
presence of any condition that hampers efficient wiping of the anus
and these accumulated particles act as an irritant.
Fecal contamination or soiling may be overt or occult. The
patients with occult soiling are unaware of the same yet the soiling
is good enough to initiate itch and scratching.