Diagnosis and management of pelvic floor dyssynergia

Abstract

The term pelvic floor dyssynergia is commonly used interchangeably with the terms anismus, dyssynergic defecation or puborectalis syndrome. Patients with PFD commonly present with chronic constipation. The prevalence among the general population can range from 20-70% and among constipated patients it has been reported as high as 60%. This defecation disorder is basically caused by failure of relaxation or paradoxical contraction of the external anal sphincter and the puborectalis sling during defecation. Although there is no clear pathophysiological cause for this disorder, it has been linked to several factors such as abuse in childhood, poor toilet training, difficult childbirth, previous pelvic surgery or other psychological factors. The correct diagnosis is key to treating PFD and it starts with a thorough history and physical exam including a well performed digital rectal examination. Appropriate investigations following the initial visit can help to confirm the diagnosis and then treatment is prescribed accordingly. The patient should understand the nature of her constipation problem and participate fully in the management. The treatment is mainly conservative with diet, biofeedback and physiotherapy as the cornerstones of management. A multidisciplinary team approach will help for successful management of the patient. Surgery is normally not necessary for these patients and is only performed in extremely difficult refractory cases. By taking the time to make the correct diagnosis, patients with PFD can avoid frustration, unnecessary testing and surgery.