Presentation
Difficult defecation
Patient Data
This is the evacuatory phase of a fluoroscopic defecating proctogram. The pelvic floor lies low at rest, with minimal change at the onset of straining. Multiple attempts have been made at evacuation but there is no appropriate opening of the anorectal angle and none of the barium paste is expelled. A small anterior rectocele is noted.
Case Discussion
The appearances are suggestive of anismus, also known as anorectal dys-synergy. The same findings can also be caused by situational anxiety; therefore, they must be correlated with the symptoms and examination findings, and other tests such as the balloon expulsion test.
In anismus, there is no appropriate relaxation of the levator sling during evacuation, resulting in maintenance of an acute anorectal angle and no opening of the anal canal, and no expulsion of barium paste on proctography.
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