Journal of Neurology, Neurosurgery, and Psychiatry 1996;60:31-35 Paradoxical puborectalis contraction is a feature of constipation in patients with multiple sclerosis Y W Chia, K P Gill, J S Jameson, A D Forti, M M Henry, M Swash, P J Shorvon Abstract Objective-To study the disturbed ano- rectal physiology associated with consti- pation in multiple sclerosis. Methods-Anorectal function in 10 patients with clinically definite multiple sclerosis and constipation has been com- pared with 10 normal persons and 11 patients with idiopathic constipation, without multiple sclerosis. Results-All 10 constipated patients with multiple sclerosis had difficulty evacuat- ing barium paste during defaecography. In four of these there was complete failure of puborectalis relaxation when straining to defaecate, and in another four there was incomplete puborectalis relaxation. There was no evidence of lower motor neuron involvement of pelvic floor mus- cles in the multiple sclerosis group. Conclusions-Paradoxical puborectalis contraction is common in patients with multiple sclerosis in whom constipation is a symptom. This may be a feature of the disturbed voluntary sphincter control mechanism, analogous to detrusor sphincter dyssnergia in the bladder. (J Neurol Neurosurg Psychiatry 1996;60:31-35) Keywords: anismus; constipation; pelvic floor disor- ders; sphincters; multiple sclerosis when it may respond to treatment with dopaminergic medication.'0 The aim of our investigation was to study the disturbed anorectal physiology associated with constipa- tion in multiple sclerosis. Patients Ten patients (mean age 44 years) with clini- cally definite multiple sclerosis and constipa- tion, nine of whom were women, were studied. These patients all had normal bowel function before developing multiple sclerosis. All also had concomitant urinary dysfunction with urge incontinence and corticospinal tract signs. Two were mildly disabled (Kurtzke dis- ability status scale (DSS) 1 0-3-5), five were moderately disabled (DSS 4 0-6&0), and three had severe disability (DSS 6&5-8 0)." Ten non-constipated subjects (mean age 35 years), nine of whom were women, served as controls. Eleven patients with constipation but without multiple sclerosis (mean age 40 years), nine of whom were women, were also studied. In all the constipated patients, with or without multiple sclerosis, constipation was severe, exceeding the criteria of Turnbull et al,"2 who defined constipation as less than three bowel movements per week and/or straining during more than 25% of defaeca- tions. All the patients with constipation had been referred to one of us (MMH) for man- agement. Departments of Surgery and Radiology, Central Middlesex Hospital, London, UK Y W Chia K P Gill J S Jameson A D Forti M M Henry P J Shorvon Department of Neurology, The Royal London Hospital, London, UK M Swash Correspondence to: Professor Michael Swash, Department of Neurology, Royal London Hospital, London El1 BB, UK. Received 22 February 1995 and in final revised form 21 August 1995 Accepted 1 September 1995 Sullivan et al' reported a 53% incidence of constipation in patients with multiple sclero- sis, and Hinds2 noted an incidence of 43%. However, the pathophysiology of constipation in this disorder is not well understood. Urinary retention in multiple sclerosis is often due to detrusor sphincter dyssnergia,3 and constipa- tion or faecal incontinence is especially fre- quent in patients with multiple sclerosis with urinary dysfunction.4 We considered that con- stipation in multiple sclerosis could be due to rectoanal dysfunction causing outlet obstruc- tion, thus resembling detrusor sphincter dyssnergia of the bladder outlet, occurring as a result of the CNS lesions in these patients.5-7 Idiopathic constipation is often associated with paradoxical contraction of the puborec- talis during defaecation, resulting in anal out- let obstruction and repeated straining during attempted defaecation. This has been called anismus.' Anismus may be associated with slow colonic transit, although most patients with anismus have normal gut transit times.9 Anismus also occurs in Parkinson's disease, Methods Anorectal physiology studies and defaeco- graphy were performed in all the patients with multiple sclerosis and in all the constipated patients without multiple sclerosis. In the nor- mal control subjects only anorectal physiology was performed. Colonic transit studies were carried out in seven patients with multiple sclerosis and in five non-multiple sclerosis constipated patients. ANORECTAL PHYSIOLOGY The following measurements were made: Anal manometry The functional anal canal length and the resting and maximal voluntary anal contraction pres- sures were measured. A closed, water filled system was used, consisting of a 4 mm diame- ter microballoon mounted on a polythene tube 2 mm in diameter, connected to a pressure transducer (Statham Instruments Inc, USA) and a pen recorder (Devices, London). A sta- 31 on January 1, 2021 by guest. Protected by copyright. http://jnnp.bmj.com/ J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.60.1.31 on 1 January 1996. Downloaded from
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Journal ofNeurology, Neurosurgery, and Psychiatry 1996;60:31-35
Paradoxical puborectalis contraction is a featureof constipation in patients with multiple sclerosis
YW Chia, K P Gill, J S Jameson, A D Forti, M M Henry, M Swash, P J Shorvon
AbstractObjective-To study the disturbed ano-rectal physiology associated with consti-pation in multiple sclerosis.Methods-Anorectal function in 10patients with clinically definite multiplesclerosis and constipation has been com-pared with 10 normal persons and 11patients with idiopathic constipation,without multiple sclerosis.Results-All 10 constipated patients withmultiple sclerosis had difficulty evacuat-ing barium paste during defaecography.In four ofthese there was complete failureof puborectalis relaxation when strainingto defaecate, and in another four therewas incomplete puborectalis relaxation.There was no evidence of lower motorneuron involvement of pelvic floor mus-cles in the multiple sclerosis group.Conclusions-Paradoxical puborectaliscontraction is common in patients withmultiple sclerosis in whom constipation isa symptom. This may be a feature of thedisturbed voluntary sphincter controlmechanism, analogous to detrusorsphincter dyssnergia in the bladder.
when it may respond to treatment withdopaminergic medication.'0 The aim of ourinvestigation was to study the disturbedanorectal physiology associated with constipa-tion in multiple sclerosis.
PatientsTen patients (mean age 44 years) with clini-cally definite multiple sclerosis and constipa-tion, nine of whom were women, werestudied. These patients all had normal bowelfunction before developing multiple sclerosis.All also had concomitant urinary dysfunctionwith urge incontinence and corticospinal tractsigns. Two were mildly disabled (Kurtzke dis-ability status scale (DSS) 1 0-3-5), five weremoderately disabled (DSS 4 0-6&0), and threehad severe disability (DSS 6&5-8 0)."Ten non-constipated subjects (mean age 35
years), nine of whom were women, served ascontrols. Eleven patients with constipation butwithout multiple sclerosis (mean age 40years), nine of whom were women, were alsostudied. In all the constipated patients, with orwithout multiple sclerosis, constipation wassevere, exceeding the criteria of Turnbull etal,"2 who defined constipation as less thanthree bowel movements per week and/orstraining during more than 25% of defaeca-tions. All the patients with constipation hadbeen referred to one of us (MMH) for man-agement.
Departments ofSurgery andRadiology, CentralMiddlesex Hospital,London, UKYW ChiaK P GillJ S JamesonA D FortiM M HenryP J ShorvonDepartment ofNeurology, The RoyalLondon Hospital,London, UKM SwashCorrespondence to:Professor Michael Swash,Department of Neurology,Royal London Hospital,London El1 BB, UK.Received 22 February 1995and in final revised form21 August 1995Accepted 1 September 1995
Sullivan et al' reported a 53% incidence ofconstipation in patients with multiple sclero-sis, and Hinds2 noted an incidence of 43%.However, the pathophysiology of constipationin this disorder is not well understood. Urinaryretention in multiple sclerosis is often due todetrusor sphincter dyssnergia,3 and constipa-tion or faecal incontinence is especially fre-quent in patients with multiple sclerosis withurinary dysfunction.4 We considered that con-stipation in multiple sclerosis could be due torectoanal dysfunction causing outlet obstruc-tion, thus resembling detrusor sphincterdyssnergia of the bladder outlet, occurring as aresult of the CNS lesions in these patients.5-7Idiopathic constipation is often associatedwith paradoxical contraction of the puborec-talis during defaecation, resulting in anal out-let obstruction and repeated straining duringattempted defaecation. This has been calledanismus.' Anismus may be associated withslow colonic transit, although most patientswith anismus have normal gut transit times.9Anismus also occurs in Parkinson's disease,
MethodsAnorectal physiology studies and defaeco-graphy were performed in all the patients withmultiple sclerosis and in all the constipatedpatients without multiple sclerosis. In the nor-mal control subjects only anorectal physiologywas performed. Colonic transit studies werecarried out in seven patients with multiplesclerosis and in five non-multiple sclerosisconstipated patients.
ANORECTAL PHYSIOLOGYThe following measurements were made:
Anal manometryThe functional anal canal length and the restingand maximal voluntary anal contraction pres-sures were measured. A closed, water filledsystem was used, consisting of a 4 mm diame-ter microballoon mounted on a polythene tube2 mm in diameter, connected to a pressuretransducer (Statham Instruments Inc, USA)and a pen recorder (Devices, London). A sta-
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tion pull through technique was used. Thenormal values for our laboratory are restingpressure 60-100 cm water and maximal vol-untary contraction pressure double the restingpressure. I3
Pudendal nerve terminal motor latency(PNTML)A specially constructed finger stall, with stimu-lating electrodes mounted at its tip andrecording electrodes mounted at the base, wasconnected to a standard EMG machine (MS6,Medelec, Woking). The pudendal nerve wasstimulated transrectally at the level of theischial spine on either side with a supramaxi-mal stimulus of about 50 V and 0 1 ms dura-tion. The mean normal value for ourlaboratory is 2 (SD 0 2) ms.14
Single fibre EMGA Medelec SFEMG needle was used to record20 different consecutive motor unit potentialsin the four quadrants of the external analsphincter muscle. The fibre density, represent-ing the packing density of muscle fibres inner-vated by a single motor unit, was calculated.The mean value for our laboratory for patientsyounger than 50 years is 1*5 (0 16).'5
Mucosal electrosensitivity (MES)This was tested using a probe with two plat-inum electrodes placed 1 cm apart at the tip ofa 10 FG polyvinyl catheter graduated in cen-timetres. A constant current generator wasused to deliver stimuli of 0 1 ms duration at 5Hz, increasing in 0 1 mA increments until athreshold of sensation was perceived. Themiddle third of the anal canal and the rectumwere assessed. The normal ranges for theseregions in our laboratory are: anal 0-10 2 mA;rectum 2-34 mA.'6
Rectal sensationA latex balloon inserted into the rectum andinflated slowly with 5 ml increments of air.'7Records were made of the volumes required togive: (a) a constant sensation of fullness (nor-mal range 0-40 ml); (b) the first sensation ofdesire to defaecate (normal range 24-98 ml);(c) the maximum tolerated volume (normalrange 125-337 ml).
DEFAECOGRAPHYWith the patient in the left lateral position on
Table 1 Comparison of anorectal physiology variables ofpatients with multiple sclerosiswith controls and non-multiple sclerosis constipated patients
*P < 0 05, Mann-Whitney U test.RP = Resting pressure; VCP = voluntary anal contraction pressure; TV = rectal threshold vol-ume; UV = urge threshold volume; MTV = maximum tolerated rectal volume; AS = anal sen-sory threshold; RS = rectal sensory threshold; PNTML = pudendal nerve terminal motorlatencies; R = right; L = left; mean FD-AS = mean fibre density in anal sphincter muscle.
an x ray imaging table 20 ml of barium pastewas introduced to coat the rectal mucosa. Thiswas followed by more barium paste until asensation of rectal fullness was reported.Barium generally filled the rectum and the dis-tal sigmoid colon. A contrast soaked tampondemonstrated the position of the vagina infemale patients. A dab of barium marked theexternal anal orifice. The patient was thenseated on a commode situated lateral to animage intensifier. Video imaging alloweddynamic evaluation of the events of defaeca-tion. Static images were obtained at rest, onmaximal voluntary contraction of the pelvicfloor, on straining, and during defaecation.Supplementary posterior images wereobtained if appropriate.8 12
COLONIC TRANSIT STUDIESThe patient ingested 20 small radio-opaquemarkers. A plain abdominal radiograph wastaken 120 hours later. Retention of morethan 20% of markers was taken to indicateslow transit. 18 '9
STATISTICAL ANALYSISThe Mann-Whitney U test was used to estab-lish the significance of any differences betweenpatients and normal subjects.
ETHICSThe research protocol was approved by theresearch ethics committee of the CentralMiddlesex Hospital, London. All investiga-tions were carried out with written informedconsent.
ResultsTables 1 and 2 summarise the results.
ANORECTAL PHYSIOLOGYAlthough in the normal range, the mean rest-ing anal canal pressure was slightly lower inthe multiple sclerosis patient group and in theconstipated patients without multiple sclerosisthan in the control group (P < 0 05); therewas no significant difference between the twogroups. The mean maximal voluntary analcontraction pressure was lower in the multiplesclerosis group than in the non-multiplesclerosis constipated group and in the controls(P < 0 05). In four patients with multiplesclerosis the maximal voluntary contractionpressure was low. The rectal threshold, urge,
Table 2 Degree ofpuborectalis relaxation on straining asseen by defaecography, and colonic transit results inpatients with multiple sclerosis
and maximal tolerable volume to balloondistension, and the anal and rectal mucosalelectrosensitivity thresholds were normal inthe multiple sclerosis and non-multiple sclero-sis constipated groups compared with the con-trol group. The mean right and left pudendalnerve terminal motor latencies (PNTMLs) inthe multiple sclerosis group were not signifi-cantly different from the controls, or from thegroup of constipated patients without multiple
sclerosis. In four of the patients with multiplesclerosis, however, the PNTML was increasedon one side. Of these four patients, three had araised fibre density in the external anal sphinc-ter muscle, and these three also had lowvoluntary anal contraction pressures. Twoother patients had raised fibre densities withnormal PNTMLs. The mean fibre density ofthe external anal sphincter muscle in the multi-ple sclerosis group was not significantlyincreased compared with the controls and tothe non-multiple sclerosis constipated group.
DEFAECOGRAPHYAll the patients with multiple sclerosis had dif-ficulty evacuating barium.'9 Four patients wereunable to relax the puborectalis muscle whenstraining to defaecate (figs 1 and 2). Two ofthese patients used rectal digitation to facili-tate defaecation, one required glycerine sup-positories, and the other regular tap waterenemas. Two patients with multiple sclerosishad incomplete puborectalis relaxation whenstraining to defaecate, and two seemed unableto generate a full straining effort, as shown bylack of pelvic floor movement, until externalabdominal pressure was applied. Only twopatients with multiple sclerosis showed normalpuborectalis relaxation and normal defaeca-tion. One patient developed an intra-analintussusception during straining thatobstructed defaecation (fig 3); she could onlyevacuate following reduction of the intussus-ception by patting rapidly on her perineum.One patient was unable to raise her intra-abdominal pressure sufficiently to initiatedefaecation normally.Of the 1 1 constipated patients without mul-
tiple sclerosis, three had failure of puborectalisrelaxation during straining to defaecate, twohad rectoceles, two had enteroceles, and onehad a posterolateral pouch. The increased fre-quency of abnormality in the multiple sclerosisgroup was significant at the P < 0 05 level(Fisher's exact test).
COLONIC TRANSIT STUDIESThese were completed in seven patients withmultiple sclerosis. Five had slow transit. Intwo of these 20% or more markers were stilldistributed through the whole colon 120 hoursafter ingestion. In three the markers were clus-tered mainly in the descending colon, sigmoidcolon, and rectum. Two of the constipatedpatients without multiple sclerosis had slowtransit constipation.
DiscussionGastrointestinal dysfunction is common inpatients with multiple sclerosis. Sullivan andEbers' reported a prevalence of 53% and Hindet al2 a prevalence of 43% in patients withmultiple sclerosis. It has been suggested thatrectoanal dysfunction, resulting in outletobstruction, may be the mechanism of consti-pation in multiple sclerosis5-7 in the same wayas poor bladder emptying may be caused bydetrusor sphincter dyssynergia.3 Mathers et alnoted a paradoxical increase in puborectalis
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Figure 3 Defaecating proctography showinigo onormal puborectalis effacemnentbudevelopment of an intra-analintussusceptioon on straining to defaecate.
contraction during a defaecation stra
EMG study of striated sphincter musetion in five patients with multiple sclerthree of these patients this abnormaconfirmed by defaecography. Similarlyet al found that six of eight patients witple sclerosis with constipation had mric abnormalities consistent with anmobstruction. The role of paradoxicalFtalis contraction in idiopathic constipabeen evaluated in EMG studies."
Eight of our10 patients with multirosis and constipation had paradoxiorectalis contraction or failure of thisto relax normally during a defaecatio:These patients used various technifacilitate defaecation, including suppcenemas, and digital evacuation. Nonepatients could completely empty theirdespite prolonged straining. Shorvorshowed that puborectalis relaxatiorproperly be demonstrated only withtum filled with barium paste, and thistechnique we used.The mean maximal voluntary con
pressure was reduced in the multiplegroup probably because there was impof the ability to contract this muscle as
of the corticospinal lesion present ipatients. This suggestion is supportecfinding of a normal PNTML and norr
density in the external anal sphincter nmost of these patients, and by Mathewho reported an increased central moduction time to the external anal s
muscle, with normal PNTML, in patiemultiple sclerosis with incontinence o:pation.2221 Despite this apparent wealthe external anal sphincter muscle, hnone of the patients we studied ha(
incontinence, perhaps because of the domi-nance of constipation as a functional disorderin these patients.29 A combination of abnormalPNTML and increased fibre density found insome parous women with faecal incontinenceand multiple sclerosis may be indicative of adouble lesion, due to demyelination of theconus, and pudendal nerve damage due tochildbirth.'
Five of the seven patients with multiplesclerosis who had colonic transit studies hadslow transit. Colonic motility is a function ofthe activity of the intrinsic enteric nervous sys-tem, but is modulated by the autonomic ner-vous system, especially by parasympatheticnervous activity. For example, high cord tran-section results in decreased, and low cordtransection in increased colonicm otility.' 2 Instudies of seven patients with multiple sclero-sis and nine patients with complete cord tran-section21 there was decreased coloniccompliance and absence of the normal post-prandial increase in motility. These observa-tions are consistent with the notion that aCNS lesion, in or rostral to the thoracic cord, is
wwith a likely cause of constipation in patients withmultiple sclerosis. Although this evidence sug-gests that incoordination of the puborectalisand external anal sphincter muscles duringdefaecation in patients with multiple sclerosis,
in in an leading to outlet obstruction and constipation,cle func- is due to a spinal lesion, understanding of itsrosis. In pathophysiology is incomplete. Mathers et al"lity was showed that this functional abnormality also
1, Weber occurred in Parkinson's disease, and that inh multi- Parkinson's disease it was responsive toanomet- dopaminergic medication, suggesting that ital outlet may result from more than one mechanism.)uborec- De Groat et aF7 showed that interruption oftion has pathways in the spinal cord can result in detru-
sor sphincter dyssynergia, and it is thereforeple scle- likely that paradoxical puborectalis contrac-
cal pub- tion in multiple sclerosis is due to interruptionmuscle of spinal pathways by demyelination.strain. Treatment of this functional disorder remains
ques to an intractable problem. Specific measures to
)sitories, weaken the puborectalis muscle in idiopathicof these anismus type constipation by myotomy,25 or
rectum, botulinum toxin injection 2 have been disap-et a12' pointing, but biofeedback training has beencould helpful in some patients.3" The role of this
the rec- treatment in patients with constipation associ-was the ated with multiple sclerosis has not yet been
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rs et al patients with multiple sclerosis and bladder dysfunction. .7Nt'urol 1995;242:105-8.itor con- 5 Weber J, Grise P, Roquebert M. Radio-opaque marker
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7 Mathers SE, Ingram DA, Swash M. Electrophysiology ofiowever, motor pathways for sphincter control in multiple sclero-
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