of neuronal degeneration with prolonged usage. It is imperative that patients adhere to and not exceed the recommended dosages. Data regarding laxative use for this condition have failed to show a significantly better response than placebo. Prokinetic agents are intuitively the ideal choice to stimulate colonic motility. Currently there is only one available prokinetic agent, tegaserod, approved for the treatment of constipation that improves colonic transit. Its data are almost entirely based on treatment of IBS, and there is a lack of information for its use in slow-transit constipation. Other prokinetic agents in various stages of testing include bethanechol, neostigmine, cholecystokinin antagonists, misoprostol, colchicine, neurotrophin-3, and other 5HT4 agonists such as prucalopride and mosapride (49).
As with slow-transit constipation, initial management using bowel regimens, laxatives, enemas, suppositories, and fiber supplementation is appropriate for patients with dyssynergic defecation, yet many will have already tried conservative management before undergoing testing to confirm the diagnosis. These treatments are relatively well tolerated with few serious side effects. They have not been shown to have greater efficacy when compared with placebo, and their role in the treatment of dyssynergic defecation remains uncertain. Specific treatment for this condition tends to focus on biofeedback because of studies indicating that this is an acquired behavioral disorder of defecation. Modalities such as diaphragmatic muscle training, simulated defecation, and manometric or electromyography-guided anal sphincter and pelvic muscle relaxation have been employed independently or combined with other techniques. These techniques have yielded symptomatic improvement in approximately 60% to 80% of patients. Many patients with dyssynergic defecation also have abnormal rectal sensation, so rectal sensory conditioning may provide additional benefit (33,49,169,170). Others have tried botulinum toxin injections to paralyze the puborectalis and anal sphincter muscle. Small case series have shown modest early improvement, but the results do not appear to be long lasting (171,172). A recent randomized trial of 48 participants comparing botulinum toxin to biofeedback retraining found better initial improvement with the botulinum toxin (70% vs. 50%) but no difference at 1 year (33% vs. 25%) (173).
Pessary for Treatment of Pelvic Organ Prolapse