Differentiation Between Paradoxical Puborectalis Contraction and Puborectalis Hypertrophy

Paradoxical puborectalis contraction is a very common disorder and is thought to be the sole cause of puborectalis syndrome, especially since biofeedback is successful in some patients with PPC.17 Few series include patients with PH, and many surgeons believe that division of the pub-

Figure 26.4. The shelf sign. The top row shows the typical shelf sign preoperative^ at rest (left), squeeze (center), and defection (right); the barium retained in the rectum cannot be evacuated. Postoperatively (bottom row), the anorectal angle is still 90 degrees at rest (left), while at straining (middle) and defecation (right) the anorectal angle is greater than 90 degrees and the barium can be evacuated.

orectalis should be abandoned due to the potential for incontinence. However, in these authors' experience, PH is also a very important cause of puborectalis syndrome. Ger et al14 studied 116 patients with chronic constipation and found that the evacuation pressure by anorectal manometry (ARM) was divided into a normal relaxed pattern, an equivocal or nonrelaxed pattern, and a paradoxical contracted pattern. Some patients with the equivocal or nonrelaxing pattern may have had PH. If PPC is the only cause of puborectalis syndrome, then theoretically biofeedback should cure all patients. However, at most only 70% of patients with PPC respond to biofeedback. In fact, more recent data suggest success rates of approximately 55%.5 Therefore, PH is an important cause of puborec-talis syndrome, although seldom recognized. The differences between PPC and PH are summarized in Table 26.2.

Table 26.2. The differences between PPC and PH




Puborectalis organic abnormal

Puborectalis functional abnormal

Length of the anal canal

More than 4cm

Less than 4 cm

Evacuation pressure

Not change or slightly decrease

Increase paradoxical


See Table 26.1

See Table 26.1

Shelf sign



Change of the anorectal angle in video defecography

Less than 3 degrees

More than 3 degrees

Paradoxical contraction




No response

Respond mostly

Pathology of puborectalis



PPC, paradoxical puborectalis contraction

PH, puborectalis hypertrophy

EMG, electromyography

SFEMG, single fiber electromyography

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  • joan colton
    Is paradoxical puborectalis dysfunction a symptom of CRST syndrome?
    1 month ago

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