Introduction

Anismus is a disorder often used as a symptom to describe contraction rather than relaxation during defecation.¹ This contraction is caused by functional obstruction at the pelvis outlet due to paradoxical contraction of the striated sphincter muscles during defecation straining.² Several studies have shown that in order to diagnose Anismus, clinical evaluations and diagnostics tests have to be conducted. One of the common causes of animus is increased psychological distress; stress/anxiety.³

Stress/Anxiety is an interactional process that causes a psychophysiological response due to increased distress.⁴ Several factors, including, Panic Disorder, Social Anxiety Disorder etc., can stimulate increased distress.⁵ These factors include several symptoms, including muscle tension, restlessness, difficulty sleeping and anismus.⁵ In this article, we explore the connection between anismus and stress/anxiety, the treatment options available and the research that has previously been conducted.

Understanding anismus

Mechanism of anismus

Anismus can be caused by the external anal sphincter contracting paradoxically or by the failure to relax enough during the defecation process.⁶ Myotomy of the external anal sphincter or injection of botulinum toxin has been applied for the treatment of patients with dyssynergic defecation, but the results were generally poor.³ These experiences suggest that the problem is not confined solely to the paradoxical anal sphincter contraction. According to a prospective study, most patients with dyssynergic defecation demonstrate were unable to coordinate their pelvic floor, abdominal and rectoanal muscles to facilitate defecation.⁶ This failure of rectoanal coordination consists of either impaired rectal contraction (61%), paradoxical anal contraction (78%) or inadequate anal relaxation. Therefore, the main cause of this condition is dyssynergia or incoordination of the muscles involved in defecation.⁶

Diagnosis of anismus

Clinical evaluation 

During clinical evaluations, Structural lesions that cause difficulty with defecation, such as haemorrhoids, anal fissures, proctitis, rectal tumours and perirectal abscesses, should be ruled out with appropriate diagnostic tools before the patients are evaluated for Functional defecation disorders(FDD) including Anismus.⁶ Other anorectal issues that can coexist with  FDD, including excessive perineal descent syndrome, rectal prolapse, rectal mucosal intussusception, solitary rectal ulcers and paradoxical anal contraction should be taken into consideration.⁶ Thereafter, diagnostic tests should be conducted. These include anorectal manometry and defecography, among others. Anorectal manometry is a test that uses a probe with several sensors inserted into the anorectum to measure the pressure changes in the rectum and anal canal.⁶ Defecography tests the anorectal region's structural and functional abnormalities.

Stress and anxiety disorders: an overview

Types of disorders

Anxiety disorders present in several forms, these include: 

• Generalized Anxiety Disorder (GAD): GAD is associated with a persistent sense of dread or anxiety that interferes with day-to-day functioning. It is not the same as occasionally feeling anxious or worried about things because of unpleasant situations in life.⁵
• Panic Disorder: Individuals with panic disorder experience panic attacks more frequently and without warning. Panic attacks are sudden periods of intense fear, discomfort, or sense of losing control even when there is no clear danger or trigger. Not all individuals who experience a panic attack will develop panic disorder.⁵
• Social Anxiety Disorder: Social anxiety disorder is a severe, enduring fear of being observed and judged by others. For individuals with social anxiety disorder, the fear of social situations may feel so crippling that it seems beyond their ability to manage. Because of this dread, some people may find it difficult to go to work, school, or perform daily tasks.⁵

Symptoms of stress and anxiety disorders

The symptoms associated with the above-mentioned disorders can be separated into psychological symptoms and physical symptoms. Psychological symptoms include Excessive worry and rumination, Feelings of fear, apprehension, Irritability and restlessness, and difficulty concentrating.⁵ The physical symptoms include rapid heartbeat or palpitations, shortness of breath, sweating, trembling or shaking, and muscle tension. These psychological and physical symptoms can significantly interfere with a person's daily functioning and quality of life.⁵

The connection between anismus and stress/anxiety disorders

Chronic stress can contribute to the development of anismus by increasing muscle tension and spasms in the pelvic floor.¹ This occurs due to anxiety disrupting normal gastrointestinal functioning by triggering the body’s fight-or-flight response, thus leading to symptoms such as constipation associated with anismus.^7,8 High levels of psychological stress and anxiety can activate pelvic floor dysfunction, causing individuals with anismus to experience severe symptoms.⁹ Anxiety can amplify the perception of normal bodily sensations, leading those with anismus to experience a greater degree of discomfort and distress.¹⁰

Treatment approaches

Due to medical interventions such as botox injections to the puborectalis muscle having a limited effect on patients with anismus and interventions such as anorectal surgery being a negative predictor, other therapeutic alternatives are studied.^11,12 Studies have shown that physical therapy, Psycho-echo-biofeedback, a form of treatment that allows patients with anismus to relax their puborectalis muscles (PRM) on straining, is a safe and inexpensive treatment for anismus.¹²

Alternatively, individuals should manage their stress and anxiety to prevent Anismus. This can be done through psychological therapies that include stress management programmes using cognitive behavioural therapy and antidepressant medication.¹³

An integrated treatment plan is also an option, as research has shown the benefits of both treatment plans. Although medications are more effective than psychotherapy, the choice between psychotherapy and medication would be left to the patient due to potential side effects and contraindications¹⁴.

Summary

Anismus shares both physiological and psychological causes of stress and anxiety disorders. While anxiety can interfere with regular gastrointestinal function, chronic stress can lead to pelvic floor problems. Additionally, the discomfort caused by anismus symptoms may intensify anxiety. Given this complex interplay, a holistic, multidisciplinary approach to treatment is essential, addressing the condition's physical and mental health aspects. To fully comprehend the underlying relationships between anismus, stress, and anxiety disorders, more research is required.

Improvements in diagnostic methods and the refinement of integrative treatment strategies may lead to more effective management of this condition.