Pelvic floor spasm syndrome

　　During straining to defecate, the intra-abdominal pressure increases, causing the perineum to descend, leading to the gradual weakening of pelvic floor muscle tension. The etiology of this syndrome is not yet fully clear and may be related to congenital abnormalities, inflammation, and the abuse of laxatives. This functional disorder is likely a dysfunction of normal muscles rather than a persistent spasm of abnormal muscles, as rectal manometry and electromyography have proven that the function of the external anal sphincter is normal during anal rest and closure. Some patients have delayed colonic transit time, and there is no benefit from a subtotal colectomy, so the delayed colonic transit time in patients with pelvic floor spasm syndrome should be considered as a result of fecal retention caused by outlet obstruction, rather than a decrease in colonic motility. In 1993, Stelzner found that the persistent constipation in patients with pelvic floor spasm syndrome was related to an increased activity of the sphincter muscles. Pelvic floor spasm syndrome may also be related to neurologic dysfunction because the stimulation at the sensory receptor level can treat pelvic floor spasm syndrome. The mechanism of action may be to depolarize the nerve fibers conducting tactile sensation, especially Aβ fibers, resulting in presynaptic inhibition, inhibiting the transmission to the spinal motor neurons, thus causing the muscles that produce spasms to relax. Like all functional diseases, pelvic floor spasm syndrome may be related to psychological factors.

　　Concomitant conditions such as intestinal hernia and visceral prolapse may occur; the perineal nerves may also be damaged simultaneously; other secondary changes may also occur (such as intestinal hernia and visceral prolapse), and digital rectal examination may show rectal prolapse, mucosal relaxation, or internal and external hemorrhoids, etc. A hernia occurs when an organ or tissue leaves its normal anatomical position and enters another part through a congenital or acquired weak point, defect, or gap. Intestinal hernia is a common and frequent disease that endangers human health, and almost cannot be cured spontaneously except for a few infants.

　　Female patients are more common, with a male-to-female ratio of about 1:2; both genders may experience difficulties in defecation, discomfort, and pain; defecation occurs 2 to 3 times a day, and may be accompanied by bloating, hematochezia, and chronic constipation; the perineal nerves may also be damaged simultaneously; other secondary changes may also occur (such as intestinal hernia, visceral prolapse, etc.), and digital rectal examination may show rectal prolapse, mucosal relaxation, or internal and external hemorrhoids, etc.

　　1. Increase the intake of coarse fiber foods in the diet: because dietary fiber absorbs water in the intestines, it increases the volume and weight of the feces, stimulates peristalsis, smoothes the feces, and promotes defecation. For example: chives, celery, Chinese cabbage, bananas, oranges, mushrooms, black fungus, buckwheat, oatmeal, etc., are all high-fiber foods.

　　2. Increase water intake: drink 6 to 8 cups of water a day. Dietary fiber absorbs water in the intestines and swells, softening the feces and stimulating peristalsis.

　　3. Eat more honey and sesame seeds: Not only are they nutritionally rich, but they are also good for moistening the intestines and promoting defecation. Take a cup of honey water in the morning and evening or mix 10 to 15 milliliters of sesame oil with 5 to 10 milliliters of honey and take it on an empty stomach, which is extremely effective for preventing and treating constipation. Sesame seeds should be washed, roasted, ground, and then eaten, which has the effect of moistening the intestines and promoting defecation.

　　4. Exercise appropriately and actively prevent constipation.

　　X-ray contrast examination: characterized by the 'swan sign', which is the upright positioning of the lateral sitting film (pubic symphysis facing up), the entire image is very similar to a swan swimming in water; the anterior rectum is the swan's head, the anal canal is the swan's beak, the thinned rectum distal to the spasm is the swan's neck, and the proximal rectum and distal sigmoid colon are the body and tail of the swan. The 'swan sign' appears in 100% of cases.

　　In addition to conventional treatment, attention should be paid to diet for pelvic floor spasm syndrome patients: prefer nutrient-rich, easy-to-digest, light foods; eat more fruits and vegetables, and drink plenty of water. Avoid spicy foods and greasy, heavy foods.

　　Physical therapy and biofeedback therapy may have short-term efficacy, and if there are other complications, surgical treatment should be considered. The treatment for pelvic floor spasm syndrome can include electromyography (EMG) biofeedback therapy, balloon feedback therapy, and neural regulation therapy, among others. Below are the methods for treating pelvic floor spasm syndrome:

　　1. Electromyography (EMG) biofeedback therapy:Consisting of three stages. The first stage uses Myotron 220 anal electrode to measure muscle tension, converting it to a numerical display of the average value every 3 seconds. After inserting the electrode, the patient exerts force to defecate for 9 to 12 seconds. If the value increases, it indicates muscle contraction, and the diagnosis can be made clear; if the value decreases during contraction, it must be relaxed. Through EMG feedback, one can gradually understand the feeling of correct contraction and learn to use the correct contraction mechanism. The second stage stimulates defecation with oatmeal. If the contraction method is correct, the oatmeal can be excreted. This stage continues to use EMG feedback for reinforcement. The third stage requires the patient to go to the toilet after each meal, exerting the maximum force to defecate 5 times, and focusing on correctly contracting and relaxing to help the formation of feces and increase the patient's urge to defecate.

　　2. Balloon Feedback Therapy:The patient relaxes the external sphincter himself, inserts the catheter into the rectum about 8cm, and then injects about 20ml of gas into the bladder. After at least 10 seconds, slowly withdraw the balloon, while exerting defecation. The patient must learn to contract and relax correctly to easily complete these actions. Pulling out the balloon while exerting helps the patient form a correct feedback. The second and third stages are the same as EMG biofeedback therapy.

　　3. Nerve Regulation Therapy (neuromodulation):Under general anesthesia, determine the position of the S2, S3, S4 nerve roots, and give subchronic stimulation to both S3 nerve roots. The guide needle must be inserted into the subcutaneous tissue because, in the anesthetic condition, the patient may have early potential migration. The voltage used for treatment is 1-10V, frequency 20Hz, and the subchronic stimulation on the general side usually lasts for 4-14 days, while the long-term stimulation using bilateral implanted electrodes can last for 7-26 days. Everaert et al. studied 10 cases of pelvic floor spasm syndrome. Nine of them had a very good effect on nerve regulation. Foreman's research shows that the perineum, the most painful area of the spinal cord, if the stimulation is consistent with the skin distribution area of the sensory nerve fibers of the posterior root of the spinal nerve, then the pain relief effect of nerve regulation on pelvic floor spasm syndrome is very good, and constipation symptoms will also improve.

　　4. Local Injection:Botulinum toxin A blocks the release of cholinergic neurotransmitters at the neuromuscular junction, paralyzing the muscles at the injection site for a long time, thereby improving symptoms.