Botulinum toxin type-A injection to treat patients with intractable anismus unresponsive to simple biofeedback training

Table 1 Dose assignment of botulinum toxin type A

Muscle	Position			Total
	3 o’clock	6 o’clock	9 o’clock
Puborectalis	15u	20u	15u	50u
EAS	15u	20u	15u	50u
Total	30u	40u	30u	100u

EAS: External anal sphincter.

Table 2 Anorectal manometry parameter, balloon expulsion test results, and constipation scoring system before and after botulinum toxin type A injection and consecutive pelvic biofeedback training

	Pre-BTX-A injection	Post-BTX-A injection and consecutive biofeedback training	t	P
Pressure of rectum during defecation (mmHg)	64 ± 27	67 ± 28	1.335	0.192
Rest pressure of anal canal (mmHg)	93 ± 16.5	63 ± 8.6.3	11.726	0.000
Pressure of anal canal during defecation (mmHg)	105 ± 28.3	42 ± 8.9	12.328	0.000
Functional length of anal sphincter (cm)	4.5 ± 0.84	3.2 ± 0.54	8.9	0.000
Balloon expulsion test success rate	0%	74.2% (23/31)	9.185	0.002
Chronic constipation score	14.3 ± 2.49	6.4 ± 3.20	14.108	0.000

The BTX-A injection obviously improved the dilemma of animus treatment. We found that BTX-A injection produced an instant result to decrease resistance during defecation. The constipation scoring system (CSS) questionnaire was used after the injection. We found that BTX-A injection followed by pelvic biofeedback training significantly improved difficult defecation. According to the results of the CSS evaluation, patients were significantly improved in all symptom aspects mentioned in the CSS. BTX-A: Botulinum toxin type A.

Table 3 Detailed constipation scoring system differences between pre- and post-botulinum toxin type A injection

	Pre-BTX-A injection	Post-BTX-A injection and consecutive biofeedback training	t	P
Frequency of bowel movements	0.39 ± 0.62	0.10 ± 0.30	3.057	0.005
Difficulty: painful evacuation	3.29 ± 0.53	1.45 ± 0.72	13.146	0.000
Completeness: feeling incomplete	3.45 ± 0.57	1.52 ± 0.72	14.816	0.000
abdominal pain	0.77 ± 1.1	0.54 ± 0.85	2.040	0.050
Time: minutes in lavatory per attempt	2.38 ± 0.88	0.97 ± 0.66	10.330	0.000
Assistance: type of assistance	1.81 ± 1.73	0.39 ± 0.77	4.295	0.000
Failure: unsuccessful attempts for evacuation per 24 h	1.00 ± 0.37	0.29 ± 0.46	7.473	0.000

BTX-A: Botulinm toxin type A.

Table 4 Results of constipation scoring system evaluation, fecal incontinence occurrence, and satisfaction rate after treatment and before paper

Follow-up	CSS	Fecal incontinence occurred	Satisfaction rate
After BTX-A injection and consecutive biofeedback training	6.4 ± 3.20	22.6% (7/31)	77.4% (24/31)
Before the paper	6.5 ± 3.20	3.2% (1/31)	74.2% (23/31)
T or χ2	-0.902	5.167	0.088
P	0.374	0.023	0.767

BTX-A: Botulinum toxin type A; CSS: Constipation scoring system.