Efficacy and safety of botulinum toxin in treatment of anismus: A systematic review.
OBJECTIVE
To evaluate the efficacy and safety of botulinum toxin type A (BTX-A) in the management of patients with anismus.


METHODS
An organized search of published literature was conducted using electronic databases including: PubMed/MEDLINE, and Cochrane Central Register of Controlled Trials, also an internet-based search using "Google Scholar" service was conducted. Both comparative and observational studies were included. We excluded irrelevant articles, editorials, case reports, reviews, and meta-analyses. The studies that followed the patients less than 6 mo were excluded. Variables collected were demographic data of the patients, technique of BTX-A injection and number of sessions, short-term and long-term clinical improvement, post-injection changes in electromyography (EMG), defecography, manometry, and balloon expulsion test, and complications recorded after BTX-A injection.


RESULTS
Seven studies comprising 189 patients were included in the review. The median age of the patients was 41.2 years and female-to-male ratio was 1.3:1. The median dose of BTX-A injected per procedure was 100 IU (range, 20-100 IU). Lateral injection was done in five trails and combined lateral and posterior injections in two trials. Three studies used endorectal ultrasonography-guided technique, one study used EMG-guided technique, whereas the remaining three studies used manual palpation with the index finger. The median percentage of patients who reported initial improvement of symptoms was 77.4% (range 37.5%-86.7%), this percentage declined to a median of 46% (range 25%-100%) at 4 mo after injection of BTX-A. Rates of improvement evaluated by balloon expulsion test, EMG, and defecography ranged between (37.5%-80%), (54%-86.7%), and (25%-86.6%), respectively. Fourteen (7.4%) patients developed complications after injection of BTX-A. Complication rates across the studies ranged from 0% to 22.6%.


CONCLUSIONS
Initial satisfactory improvement of symptoms after BTX-A injection remarkably deteriorated after 3 mo of the procedure. However, repeated injection may provide better sustained results with no additional morbidities. Further analysis of more patients is necessary to conclude the safety of BTX-A for the treatment of anismus.
Sameh Hany Emile, Hossam Ayman Elfeki, Hosam Ghazy Elbanna, Mohamed Youssef, Waleed Thabet, Tito M Abd El-Hamed, Basem Said, Ahmed Lotfy, General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City 35516, Dakahlia Providence, Egypt.
Sameh Hany
SH
Emile
Sameh Hany Emile, Hossam Ayman Elfeki, Hosam Ghazy Elbanna, Mohamed Youssef, Waleed Thabet, Tito M Abd El-Hamed, Basem Said, Ahmed Lotfy, General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City 35516, Dakahlia Providence, Egypt.
Hossam Ayman
HA
Elfeki
Sameh Hany Emile, Hossam Ayman Elfeki, Hosam Ghazy Elbanna, Mohamed Youssef, Waleed Thabet, Tito M Abd El-Hamed, Basem Said, Ahmed Lotfy, General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City 35516, Dakahlia Providence, Egypt.
Hosam Ghazy
HG
Elbanna
Sameh Hany Emile, Hossam Ayman Elfeki, Hosam Ghazy Elbanna, Mohamed Youssef, Waleed Thabet, Tito M Abd El-Hamed, Basem Said, Ahmed Lotfy, General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City 35516, Dakahlia Providence, Egypt.
Mohamed
M
Youssef
Sameh Hany Emile, Hossam Ayman Elfeki, Hosam Ghazy Elbanna, Mohamed Youssef, Waleed Thabet, Tito M Abd El-Hamed, Basem Said, Ahmed Lotfy, General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City 35516, Dakahlia Providence, Egypt.
Waleed
W
Thabet
Sameh Hany Emile, Hossam Ayman Elfeki, Hosam Ghazy Elbanna, Mohamed Youssef, Waleed Thabet, Tito M Abd El-Hamed, Basem Said, Ahmed Lotfy, General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City 35516, Dakahlia Providence, Egypt.
Tito M
TM
Abd El-Hamed
Sameh Hany Emile, Hossam Ayman Elfeki, Hosam Ghazy Elbanna, Mohamed Youssef, Waleed Thabet, Tito M Abd El-Hamed, Basem Said, Ahmed Lotfy, General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City 35516, Dakahlia Providence, Egypt.
Basem
B
Said
Sameh Hany Emile, Hossam Ayman Elfeki, Hosam Ghazy Elbanna, Mohamed Youssef, Waleed Thabet, Tito M Abd El-Hamed, Basem Said, Ahmed Lotfy, General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City 35516, Dakahlia Providence, Egypt.
Ahmed
A
Lotfy
Anismus; Botox; Botulinum toxin; Botulinum toxin type A; Efficacy; Puborectalis syndrome