How is paradoxical movement of the puborectalis muscle treated?

Treatment of Paradoxical Puborectalis Muscle Movement

Biofeedback therapy is the first-line treatment for paradoxical puborectalis contraction, with 70-80% effectiveness in resolving symptoms and improving bowel function. 1, 2

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

• Digital rectal examination to assess puborectalis function during squeeze and simulated evacuation 1
• Anorectal manometry to confirm paradoxical contraction of the puborectalis during attempted defecation 1
• Balloon expulsion test to assess evacuation ability 1
• Consider defecography if discordant results between manometry and balloon expulsion test 1

Treatment Algorithm

First-Line: Biofeedback Therapy

Biofeedback is strongly recommended as the initial treatment approach for paradoxical puborectalis contraction:

1. Biofeedback training components:

   • Visual feedback using computer monitor displays
   • Audible/verbal feedback techniques
   • Training to relax pelvic floor muscles during straining
   • Coordination of relaxation and pushing to achieve defecation 2

2. Biofeedback methods:

   • Either anal manometry or electromyography (EMG) can be used as feedback modes with similar efficacy 3
   • Typically requires 6-8 one-hour sessions 4

3. Complementary techniques:

   • Correct toilet posture training (buttock support, foot support, hip abduction) 2
   • Muscle re-education to teach proper abdominal/pelvic floor muscle interaction 1
   • Pelvic floor awareness and control enhancement 1

Second-Line: For Biofeedback Failures

If biofeedback therapy fails after an adequate trial (typically 6-8 sessions):

1. Sacral nerve stimulation (SNS):

   • Effective for refractory cases with improvement in pain, straining, and need for digital manipulation
   • Involves a two-stage procedure with a test stimulation period before permanent implantation 5

2. Surgical options (for severe refractory cases):

   • Partial division of puborectalis muscle combined with lateral internal sphincterotomy
   • Reserved for patients who have failed all conservative measures
   • Has shown 89% improvement in symptoms with low complication rates (6.5%) 6

Predictors of Treatment Success

Patients more likely to respond to biofeedback therapy include those with:

• Lower or normal baseline thresholds for first rectal sensation
• Lower baseline constipation scores
• Shorter colonic transit times 2

Negative predictors of response include:

• Depression
• Elevated first rectal sensory threshold volume
• Increased frequency of abdominal pain 2

Treatment Outcomes

With appropriate biofeedback therapy:

• 80-90% of patients show resolution of paradoxical puborectalis contraction 3, 4
• Significant improvement in bowel function and abdominal symptoms 3
• Reduced or eliminated need for laxatives and enemas 4
• Increased frequency of unassisted bowel movements 4

Pitfalls and Caveats

1. Failure to diagnose paradoxical puborectalis contraction leads to inappropriate treatment with standard laxatives, which are ineffective for this condition 1

2. A normal digital rectal examination does not exclude defecatory disorders; specialized testing is often required 1

3. Patients with mixed disorders (e.g., pelvic floor dysfunction and overactive bladder) may require combination therapy 1

4. Institutional requirements and billing constraints may limit access to biofeedback therapy, creating barriers to effective treatment 2

5. Biofeedback requires patient engagement and compliance with home exercises for optimal outcomes