ANISMUS AND BIOFEEDBACK - WHO BENEFITS

Background: Biofeedback is the main treatment for dyschezia in patient s with anismus, but retraining may fail because of the frequent associ ation of pelvirectal disorders with anismus. We set out to identify in dices of biofeedback failure in the treatment of anismus. Patients and methods: From May 1990 to May 1993, 27 patients (20 women and seven m en; median age 46 years) with anismus in which dyschezia was not impro ved by laxative agents were enrolled in a biofeedback retraining progr amme. All patients underwent proctologic examination, anal manometry a nd defecography. Anismus was defined as an increase in anal pressure d uring attempted defecation in conjunction with an impairment of rectal emptying as assessed using an objective test (barium paste expulsion) . Associated disorders were encountered frequently. These included abn ormal perineal descent (22 cases), large rectocoele (12 cases), high-g rade rectal prolapse (six cases), abnormally high anal canal pressures at rest (seven cases) and abnormal rectal response to inflation (20 c ases). Anismus was the sole abnormality in 12 patients when perineal d escent, low-grade prolapse and abnormal rectal sensations were not tak en into account. Results: Biofeedback retraining did not suppress dysc hezia in 13 out of 27 patients. Neither associated disorders (rectocoe le, rectal prolapse, abnormal perineal descent, anal pressure and abno rmalities of rectal sensation) nor a relevant past history (hysterecto my, laxative abuse, use of antidepressive agents) were encountered mor e frequently in these 13 patients than in the other 14. The duration o f symptoms before treatment was significantly longer in the group unre sponsive to biofeedback retraining (81+/-61 compared with 33+/-34 mont hs for the responsive group, P<0.01), but the total duration of sympto ms and the number of retraining sessions attended did not differ signi ficantly between the two groups. Conclusions: (1) Extensive examinatio n (defecography and manometry) before biofeedback retraining of anismu s is not mandatory because the failure of retraining (48%) is not rela ted to the presence of associated pelvirectal disorders. (2) A long pa st history of dyschezia seems to provide an index of the failure of bi ofeedback retraining.