Paradoxical Puborectalis Syndrome

Paradoxical Puborectalis Syndrome (PPS)

pelvic-floor-squat-toiletThe term “puborectalis syndrome” was first introduced by Wasserman IF in 1964 as a syndrome composed of clinical signs and symptoms related to hypertrophy of the puborectalis.  One of it’s chief characteristics is constipation.  

The puborectalis muscle is a muscular sling that wraps around the lower rectum as it passes through the pelvic floor. It helps to maintain fecal continence.  At “rest,” the puborectalis is contracted, pulling the rectum forward, creating a sharp angle in the rectum which helps to prevent passive leakage of stool. When we sit to pass stool,  the puborectalis reflexively relaxes and straightens out, allowing stool to pass more easily through the rectum into the anal canal.

Paradoxical puborectalis syndrome occurs when the muscle does not relax when one bears down to pass stool. It actually contracts harder, creating an even sharper angle in the rectum, resulting in difficulty emptying the rectum.  It has a sensation similar to “pushing against a closed door.” Many patients of this syndrome have constant constipation, often needing an enema to have a bowel movement. Another distinguishing factor is the lack of associated rectal pain or discomfort.  The possible causes of PPS include; improper functioning of the nerves and/or muscles of the pelvic floor, and/or psychological factors.  

Women continue to make up the majority of patients with constipation and disorders of defecation. Women who had been treated with hysterectomy were likely to report decreased number of bowel movements, hard stools, and increased use of laxatives.  Taylor T, Smith A N, Fulton P M. Effect of hysterectomy on bowel function. BMJ. 1989;299:300–301.[PMC free article]  [PubMed]

Another condition similar to PPS is Pelvic Outlet Obstruction (POO) and it is also a cause of constipation and muscular dysfunction of the pelvic floor. Between 31 and 40 percent of POO patients have PPS.  (Glia A, Lindberg G, Nilsson LH, Mihocsa L, Akerlund JE. Scand J Gastroenterol. 1998 Dec;33(12):1273-9.)

Paradoxical Puborectalis Syndrome – Diagnosed

**The following information is taken from a paper entitled “Is Paradoxical Contraction of Puborectalis Muscle of Functional Importance?” It is from the periodical Colon and Rectum Diseases in 1987.  You can skip it – and move on to the treatment methods if you want. But I found the following information informative. 🙂 My purpose is to explain how the puborectalis muscle does not relax, and induces constipation and ultimately pelvic floor pain. 

PPS is usually diagnosed by the patient having a 1) history of constipation, 2) difficulty passing stool, and 3) and/or a manometry, EMG, and defecography that demonstrate the puborectalis muscle not relaxing during the act of having a bowel movement.  Ballon expulsion can be used as well.  

Concentric Needle Electromyography (EMG): With the patient in the left lateral position, a concentric needle EMG electrode was inserted into the puborectalis muscle in the midline behind the anal verge. The responses of the puborectalis muscle to voluntary contraction and to the request to simulate defecation straining were recorded and displayed, using conventional EMG apparatus….A genuine defecation straining effort was seen when there was descent of the perineum, sometimes with the passage of flatus. The increase in EMG activity in the puborectalis muscle during contraction (squeeze activity) was also assessed (Figs. 1 and 2). A similar increase in activity occurs normally during coughing. Control patients show decreased muscle activity on simulated defecation straining and increased activity during voluntary contraction or coughing. – (Neill ME, Parks AG, Swash M. Physiological studies of the anal sphincter musculature in faecal incontinence and rectal pro- lapse. Br J Surg 1981;68:531-6.)

Concentric Needle EMG Results: There was increased EMG activity in the puborectalis during defecation straining in 38 (76 percent) patients with constipation, ten (48 percent) patients with perineal pain, and four (50 percent) patients with solitary rectal ulcer syndrome.

Balloon Expulsion: The balloon used for this study was latex, 5 cm in length, mounted on a firm plastic catheter (external diameter 6 ram). The catheter terminated in a three-way tap for the introduction of water. With the patient in the left lateral position, the deflated, lubricated balloon was introduced into the rectum and inflated with 50 ml of water. The patient was then asked to expel the balloon. Normal subjects can accomplish this, but patients with Anismus (refers to the failure of the normal relaxation of pelvic floor muscles during attempted defecation) fail to do so, or achieve expulsion only after a period of straining. (Turnbull GK, Lennard-Jones JE, Bartram CI. Failure of rectal expulsion as a cause of constipation: why fibre and laxatives sometimes fail. Lancet 1986;1:767-9.) 

Anorectal manometry was performed in 40 women, who consulted for functional disorders of the lower gastrointestinal tract and had been sexually abused. Anismus, defined as a rise in anal pressure during straining, was observed in 39 of 40 abused women, but in only six of 20 healthy control women (P < 0.0001). (Anismus as a marker of sexual abuse. Consequences of abuse on anorectal motility. Leroi AM1, Berkelmans IDenis PHémond MDevroede G.)


Stylized diagram showing action of the puborectalis sling, and the formation of the anorectal angle. A-puborectalis, B-rectum, C-level of anorectal ring and anorectal angle, D-anal canal, E-anal verge, F-representation of internal and external anal sphincters, G-coccyx & sacrum, H-pubic symphysis, I-Ischium, J-pubic bone.

Anismus is felt to be a learned inappropriate response. 

Balloon Expulsion Test Results: Thirty-two of the 50 patients with constipation underwent balloon expulsion studies. Twenty-two of these showed paradoxical contraction of the puborectalis muscle during straining, eight showed normal relaxation of the puborectalis, and in two patients there was no change in muscle activity during straining. Four of the 22 patients with constipation with paradoxical activity of the puborectalis muscle on straining were able to expel the balloon, and all of these had abnormal perineal descent during straining. The remaining 18 patients with increased activity of the puborectalis muscle during straining could not pass the balloon; only three of these showed abnormal perineal descent. Balloon expulsion was normal in seven of the eight patients with constipation in whom the puborectalis muscle relaxed normally during simulated defecation straining . In the one remaining patient resting puborectalis activity was only partially inhibited during simulated. Two patients in whom there was no change in puborectalis activity were able to expel the balloon.

Paradoxical puborectalis contraction was observed in 76 percent of patients with constipation, 50 percent of patients with solitary rectal ulcer syndrome, and 48 percent with perineal pain.  Paradoxical increase in puborectalis activity has been observed in normal subjects during straining, but the incidence of this finding in a population of normal subjects has not been formally assessed.

Paradoxical Puborectalis Syndrome – BioFeedback as Treatment

According to Brian R. Kann, MD,  “The mainstay of treatment is biofeedback therapy. As patients perform this specialized form of pelvic floor physical therapy, they are often able to view EMG or manometry tracings produced by a sensor in the rectum so that they can actually visualize the results of their efforts to relax the pelvic floor. Portable units have even been developed for home use. The success rate of biofeedback for this condition ranges from 40-90%, and most failures are due to the patient not keeping up with their exercises or performing them incorrectly.

A review of biofeedback for constipation found seven studies between 1988 and 1992 that demonstrated success rates of 18.2% to 100%. (Enck P. Biofeedback training in disordered defecation. A critical review. Dig Dis Sci. 1993;38:1953–1960.  [PubMed])

Puborectalis  – Home Treatment – Squatting

The puborectalis muscle is considered to be under voluntary control, and the relaxation of this muscle can be manipulated by movement and posture. This action is maintained by the contraction of the puborectalis muscle.  It remains contracted when we are standing or sitting and can be relaxed to remove tension at the Anorectal junction in the squat posture. During defecation (if you are squatting) there is flexion of the thighs and this straightens out this angle and facilitates evacuation with greater ease. 

The anal canal and the rectum form an angle of about 80 degrees. The Squat posture allows the sling like puborectalis muscle to relax and release its grip on the rectal wall – this creates a clear passage between squatty-pottythe colon and the anus.   Additionally, leaning forward while in the squat posture helps relax the muscle and helps remove the locking posture, which is normally closed by the muscle in its contracted state to maintain continence in the sitting and standing postures.  Squatting is said to protect the nerves that control the prostate, bladder and uterus from becoming stretched and damaged.

Most importantly for PPS, squatting relaxes the puborectalis muscle which normally chokes the rectum in order to maintain continence.  I read once that a Israeli doctor did a experiment to see how many seconds it typically took for people to defecate.  It was on average 50 seconds for squatting and 130 seconds for toilet sitting.  The squatters also felt that they had completely eliminated more than the sitters. 

The following shows the steps to elimination when you squat to poop!

  1. Assume the squat position
  2. The rectum and anal canal come into a straight line
  3. The abdominal pressure is raised
  4. The pelvic floor is lowered
  5. The sphincter relaxes
  6. Stool passes through the anal canal

You can use a Squatty Potty to help in this, or consider making your own.  It helps flex the thigh at the hip, promoting better evacuation.

If you happen to not have a stool around, consider this method. Place your left foot on the toilet seat.  This will flex the left thigh a the hip. In this position the angle between the right and left thighs should be about 100-140 degrees to achieve relatively the same squatting position.  (I have tried this and it works for me)

Try consciously memorizing the sensations of elimination from the steps above each day for 3 weeks.  But try to relax your pelvic floor and remember what that relaxed muscle state feels like.

I found that if you practiced squatting with a half foam roller or towel placed behind the back of your heels – it helps you to feel the muscles relax and contract.  The squat assisted method is from Katy Bowman, she is a biomechanist that is well worth following if you have any pelvic floor issues. half-dome-squat

Practice making your “memory” of the sensations occur physically once you are confident you know the sensation of the relaxed puborectalis and anal sphincter muscles well. (The anal sphincter is an involuntary muscle and relaxation allows the stool to enter the anal canal for exit.) 

The external anal sphincter is a muscle which is under voluntary control and can be manipulated up to a limit by thought processes. Contracting this muscle by voluntary thought processes allows us to “HOLD” the stool in place and ignore the urge to go until it is convenient to do so.

Concentrate as you expand and contract the pelvic muscle groups deliberately and continue practicing until you are able to sense the same memorized sensations learned through becoming more aware of these two muscle sets during bowel movements, when the muscles automatically relax as part of reflexive action.

Deliberately relax the puborectalis and the anal sphincter muscles together at the same time, once or twice throughout each day.

If you are a butt clencher – I encourage you to stop that now.  Movement Revolution has a great blog post on this. 

Other Ways to Help Fight Constipation 

Besides the relaxing of the pelvic floor there are many other ways in which you can deal with constipation to help you loosen up.  I have a page on that here

I came across this article from Alignment Monkey and she had some excellent advice. Here are some of the following that she recommends – with my comments in brackets to the right.

  • Dr. Kharazzian shares 3 ways to train the brain for better digestion. (Interesting)
  • Drink two glasses of water with lemon first thing in the morning before eating and after brushing your teeth. Lemon increases bile and bile is a natural laxative. (I know that it works for many, but I find that Apple Cider Vinegar or Lemon make me acidic. So if that happens to you – stop)
  • Castor oil packs – (I have used these as well but not sure yet if they work.)
  • Stop sucking your belly in. When you suck your belly in, you are really sucking up and slowing down elimination!  (This is so true, and great advice – don’t clench your butt either)
  • Get a Visceral Manipulation™ session to increase motility and mobility of your colon and liver. (I like what Dr Gold talks about here regarding constipation and your ileocecal valve.) Check Alignment Monkey out for help – she is in the Portland Area.
  • Self-Care belly massage! It only takes 5-10 minutes a day. (Check this out on my constipation page)
  • Move more. Sit less. Take a video tour of her dynamic workstation HERE and check out the Don’t Just Sit There Program! (This would be good to take – on my TO DO list)
    And then go for a walk every day.  I can’t stress enough how important this is! (ME TOO)
  • Do spinal twists, or all of these Restorative Exercises™ on the Smart Digestion DVD. Gentle Exercise Prescription for: * Chronic Constipation * Acid Reflux * IBS * Heartburn * Bloating * These exercises are easy to work into your day and the work wonders for constipation! (I am going to get this DVD myself)
  • Breathe for colon mobility!  (Yes – I am practicing breathing allot more – and it does help.)