Treatment of Paradoxical Puborectalis Contraction (PPC) Using Botulinum Toxin-A

Purpose: Paradoxical puborectalis contraction (PPC) or Anismus is known to have a pathogenesis of abnormal contraction of puborectalis at defecation and its managements are not satisfactory, Recently, therapy of PPC and its associated syrnptars using Botulinum toxin-A (BTX-A) has been introduced. we evaluate the effect of BTX-A injection to the puborectalis for the patients with PPC. Methods: Fourteen patients were diagnosed as paradoxical puborectalis contraction on defecography and/or anorectal manometry and electromyography (EMG) during September 1998 to January 2001 in Daegu Catholic Medical Centre, Catholic University of Daegu, All patients were underwent 30 (15+15) units of BTX-A injection on each side of puborectalis guided by EMG. Among them, five patients needed further injection of 20 (10+10) units because the expected results were not satisfied. Follow-up were conducted on one month and one year after BTX -A injection and the patients were assessed for the constipation score and anorectal manometry, Results: After injection of BTX-A, constipation score was significantly decreased from 15.53.5 (meanSD) to 5.7 4.3. Maximal resting and squeezing pressure also decreased from 48.422 mmHg, 96.939.8 to 41.217, 68.338.2, respectively. Twelve patients who were followed up more than one year after injection, the constipation score (n~12) increased up to 7.72.9 (mean SD). Among them, three patients have had stool softeners or laxatives to evacuate and the remained nine patients did not have any kinds of drug or food for defecation. There was no complication for the injection BTX-A. Conclusions: BTX-A injection seems to be effective for the treatment of PPC and the long term therapeutic effect can be defined through double blind placebo-controlled trials.