Partial Division of Puborectalis Muscle with Lateral Internal Sphincterotomy: A Novel Surgical Technique for Management of Anal Hypertonia-Associated Anismus



Treatment of anismus usually starts with biofeedback therapy and injection of botulinum toxin in the puborectalis muscle (PRM). Patients refractory to conservative treatment may require surgery. The present cohort study aimed to assess a combined technique of partial division of PRM and tailored lateral internal sphincterotomy (LIS) in treatment of anismus.


Patients with anismus who failed conservative treatments were assessed clinically and with high-resolution anal manometry (HRAM), EMG, defecography, and underwent combined partial division of PRM on one side and tailored LIS on the contralateral side. Main outcome measures were improvement in symptoms and quality of life, changes in HRAM and defecography postoperatively, complications, and patient satisfaction.


A total of 73 patients (61 male) of a mean age of 37 years were included to the study. In total, 89% of patients showed a significant improvement in symptoms at 12 months postoperatively. The mean modified Altomare score decreased significantly (p < 0.0001) from 16.4 ± 1.7 to 6.6 ± 1 at 12 months postoperatively. There was a significant increase in the mental and physical components of quality of life at 12 months postoperatively. The numbers of patients with positive findings of anismus in postoperative defecography, EMG, and balloon expulsion test were significantly less than before surgery. The mean total satisfaction score was 86.5 ± 8.7. Five (6.5%) patients developed minor complications.


Partial division of puborectalis muscle combined with LIS is an effective technique in the management of anal hypertonia-associated anismus with satisfactory results and low incidence of complications

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Author information




MA and MF designed the study, performed the surgical procedures, and followed the patients. SE, MF, M shared in data analysis and writing of the manuscript. MA and KM contributed to collection and interpretation of data, and revising the manuscript. MA participated in critical revision of the manuscript.

Corresponding author

Correspondence to Sameh Hany Emile.

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Appendix 1

See Table 5

Table 5 STROBE statement—checklist of items that should be included in reports of cohort studies

Appendix 2

See Table 6

Table 6 Modified ODS Altomare score

Appendix 3

See Table 7

Table 7 Wexner incontinence score

Appendix 4

Surgical satisfaction questionnaire ssq-8. Instructions: following are a list of questions about your satisfaction with your surgery. all information is strictly confidential. Please check the box that best answers the question for you


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Abdelnaby, M., Fathy, M., Mikhail, H.M. et al. Partial Division of Puborectalis Muscle with Lateral Internal Sphincterotomy: A Novel Surgical Technique for Management of Anal Hypertonia-Associated Anismus. World J Surg (2021).

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