Podcast
Questions and Answers
What is the primary reason behind constipation?
What is the primary reason behind constipation?
What happens to the anorectal angle during normal defecation?
What happens to the anorectal angle during normal defecation?
What is the characteristic finding during physical examination of a patient with paradoxical puborectalis contraction?
What is the characteristic finding during physical examination of a patient with paradoxical puborectalis contraction?
What is the purpose of defecography in diagnosing paradoxical puborectalis syndrome?
What is the purpose of defecography in diagnosing paradoxical puborectalis syndrome?
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Why is it essential to exclude paradoxical puborectalis syndrome in a patient with an anterior rectocele?
Why is it essential to exclude paradoxical puborectalis syndrome in a patient with an anterior rectocele?
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What is the primary method of diagnosing paradoxical puborectalis syndrome?
What is the primary method of diagnosing paradoxical puborectalis syndrome?
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What percentage of cases can paradoxical puborectalis contraction instigate functional constipation?
What percentage of cases can paradoxical puborectalis contraction instigate functional constipation?
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What is an important consideration when evaluating patients with paradoxical puborectalis contraction?
What is an important consideration when evaluating patients with paradoxical puborectalis contraction?
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What is a manifestation of increased perineal descent?
What is a manifestation of increased perineal descent?
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What is a common symptom experienced by patients with increased perineal descent?
What is a common symptom experienced by patients with increased perineal descent?
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What is the primary role of biofeedback in the treatment of paradoxical puborectalis contraction?
What is the primary role of biofeedback in the treatment of paradoxical puborectalis contraction?
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What is the usual treatment approach for increased perineal descent?
What is the usual treatment approach for increased perineal descent?
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What is the role of cinedefecography and electromyography in the evaluation of paradoxical puborectalis contraction?
What is the role of cinedefecography and electromyography in the evaluation of paradoxical puborectalis contraction?
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What is the last resort treatment option for patients who insist on surgical intervention?
What is the last resort treatment option for patients who insist on surgical intervention?
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Study Notes
Functional Constipation
- Constipation can be attributed to multiple causes, including congenital, acquired behavioral, infectious, or anatomic and physiological abnormalities.
Nonrelaxing Puborectalis
- Failure of puborectalis relaxation or paradoxical contraction leads to pelvic outlet obstruction and failed elimination.
- The anorectal angle is normally straightened during defecation due to relaxation of the puborectalis and external anal sphincter.
- The syndrome of nonrelaxing puborectalis is diagnosed through physical examination and anorectal physiologic testing.
Diagnosis of Paradoxical Puborectalis Syndrome
- Physical examination involves noting increased anal canal tone and mobility of the posterior loop of the puborectalis during squeezing.
- Defecography, manometry, electromyography (EMG), or dynamic pelvic magnetic resonance imaging (DPMRI) confirm the diagnosis.
- The diagnosis should be excluded in patients with anterior rectocele, as paradoxical puborectalis syndrome can instigate this condition in up to 45% of cases.
Associated Factors
- Paradoxical puborectalis contraction can be a manifestation of coping from sexual assault or abuse.
- It can also be a learned response to passage of large painful bowel movements during childhood.
Increased Perineal Descent
- Perineal descent may be a manifestation of weakness of the pelvic floor support structures.
- Patients present with increased perianal and perineal descent upon straining, leading to constipation and symptoms.
- Over time, the anterior rectal wall may prolapse through the anal canal, causing bleeding and irritation.
Treatment and Management
- Treatment is generally conservative, with biofeedback playing a principal role.
- Patient compliance is essential for favorable results.
- Failure of biofeedback may be augmented with botulinum toxin injection for paradoxical puborectalis contraction.
- Increased perineal descent is treated with biofeedback and perineal support maneuvers.
- Surgery has little or no role in these conditions, but may be offered as a last resort in the form of a stoma.
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Description
This quiz explores the various causes of functional constipation, including congenital, acquired, infectious, and physiological abnormalities, as well as the role of the puborectalis muscle in anal outlet obstruction.
