CASE 3068 Published on 21.11.2005
0

Nonrelaxing puborectalis syndrome

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Oliveira Pedro, Soares Pedro

Connected authors
Patient

40 years, female

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Clinical History
A 40-year-old female underwent a follow-up examination at the surgery department for a condition of obstructed defecation.
Imaging Findings
A 40-year-old female underwent a follow-up examination at the surgical department, for a condition of obstructed defecation. At our department, a defecography was performed that showed a decreased anorectal angle, at rest and during squeezing. During straining, we could see an accentuation of the impression which was made by the puborectalis muscle on the posterior wall of the rectum. We could also see a failure in the opening of the anorectal angle. There was also a rectocele and poor rectal emptying.
Discussion
Nonrelaxing puborectalis syndrome is a complex and poorly understood entity characterized by the contraction, rather than relaxation, of the puborectalis and other striated pelvic floor muscles in a paradoxical fashion during attempted evacuation. From its origin on the pubic bone, the puborectalis sling extends downwards, circles the anorectal junction posteriorly, and returns anteriorly to insert once again in the pubis. For defecation to occur, the flap-valve mechanism must be broken by inhibition of the continuous tonic activity of the pelvic floor musculature, especially the puborectalis sling, which moves downwards and backwards. The etiology is uncertain, and could be a voluntary suppression of the normal inhibitory reflex, muscular distonia, abuse of cathartics and sympathetic nerve abnormalities. The clinical manifestations include symptoms of obstructed evacuation such as tenesmus, and a sensation of incomplete evacuation. The defecographic criteria of this syndrome include the failure to open the anorectal angle (the anorectal angle represents the angle between the axis of the anal canal and a line drawn along the lower posterior border of the distal part of the rectum), persistence of the puborectalis impression and poor rectal emptying.
Differential Diagnosis List
Nonrelaxing puborectalis syndrome.
Final Diagnosis
Nonrelaxing puborectalis syndrome.
Case information
URL: https://eurorad.org/case/3068
DOI: 10.1594/EURORAD/CASE.3068
ISSN: 1563-4086
Figure 1

Figura 1

Figura 1
A defecographic image obtained at rest, showing that there is a decrease of the anorectal angle and an accentuated impression of the puborectalis muscle (arrow).
Figure 2

Figura 2

Figura 2
A defecographic image obtained on squeezing, showing a decrease of the anorectal angle and an accentuated impression of the puborectalis muscle.
Figure 3

Figura 3

Figura 3
A defecographic image on straining, showing that there is a failure to open the anorectal angle to a mean value of 136º. In this case the angle opened to a value of 106º. The image also shows the accentuated impression of the puborectalis on the rectal posterior wall (arrow)and an anterior rectocele (arrow head).
Figure 4

Figura 4

Figura 4
A defecographic image obtained post-evacuation, showing incomplete defecation.