Paradoxical Sphincter Reaction

Paradoxical sphincter reaction is a common finding in patients with rectal emptying difficulties and is considered by some authors to

Figure 11.2. Anal plug surface electrode.

Figure 11.3. Surface EMG demonstrating paradoxical sphincter reaction. The EMG activity is increased also at straining (it would normally decrease).

Figure 11.3. Surface EMG demonstrating paradoxical sphincter reaction. The EMG activity is increased also at straining (it would normally decrease).

be an important reason for obstructed defecation.13 The dysfunction in the EAS and puborec-talis muscle results in failure to relax at attempted defecation, resulting in a maintained or increased activity that can be registered on EMG. The PSR can also be diagnosed by defecography, anorectal manometry, palpation, and dynamic pelvic magnetic resonance imaging (MRI), although EMG is usually the preferred method.14,15 The use of more than one modality to diagnose PSR is advisable because the results of these investigative methods do not always correlate with each other or with the patient's clinical symptoms.15,16

Some authors have suggested that PSR is caused by the embarrassing environment of the unphysiologic laboratory setting.17,18 Pain caused by the needle electrodes has also been suggested to elicit a PSR.17 However, in a study comparing needle electrodes with thin painless wire electrodes, PSR was recorded in all 10 patients independent of the type of electrode used.14 Regardless of this finding, the laboratory setting does seem to influence the result. It has been shown that the incidence of PSR is reduced during ambulatory manometry, when the patient is able to evacuate in privacy at home.19 Furthermore, it has been shown that the volume of the rectal balloon influences the presence of PSR.20 When the volume in the rectal balloon was increased from 0 to 150 mL, PSR at straining was resolved in nine of 18 (50%) patients. Reports from several centers have shown improved evacuation after biofeedback training in patients with PSR.11,21,22

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