Correspondence

Chronic Constipation

N Engl J Med 2004; 350:1259-1260March 18, 2004

Article

To the Editor:

We are writing in response to the article by Lembo and Camilleri on chronic constipation (Oct. 2 issue).1 Injection of botulinum toxin into the puborectalis may be effective in the treatment of obstructed constipation.2-5 Furthermore, we believe that the injection of botulinum toxin is a safe treatment for patients with Parkinson's disease.6 Recent observation in several patients indicates that outlet obstruction is the main cause of anterior rectocele and provides evidence that botulinum toxin may be a remedy.5 Fourteen women with rectocele were treated with botulinum toxin, which was injected into the puborectalis; after two months, improvement in symptoms and defecographic results were noted in nine of them. At the one-year evaluation, none of the patients reported incomplete or digitally assisted rectal voiding. Rectocele was not found at physical examination. In addition, pressure during straining was reduced as compared with base-line values. Defecography showed four recurrent rectoceles, all of which were asymptomatic.

The duration of the efficacy of the injections remains to be measured, and repeated treatments are probably necessary. The optimal dose of botulinum toxin also remains to be determined; a placebo-controlled study with long-term follow-up is warranted.

Giuseppe Brisinda, M.D.
Federica Cadeddu, M.D.
Giorgio Maria, M.D.
University Hospital Agostino Gemelli, 00168 Rome, Italy
gbrisin@tin.it

6 References

1. 1

   Lembo A, Camilleri M. Chronic constipation. N Engl J Med 2003;349:1360-1368
   Full Text | Web of Science | Medline

2. 2

   Joo JS, Agachan F, Wolff B, Nogueras JJ, Wexner SD. Initial North American experience with botulinum toxin type A for treatment of anismus. Dis Colon Rectum 1996;39:1107-1111
   CrossRef | Web of Science | Medline

3. 3

   Hallan RI, Williams NS, Melling J, Waldron DJ, Womack NR, Morrison JF. Treatment of anismus in intractable constipation with botulinum A toxin. Lancet 1988;2:714-717
   CrossRef | Web of Science | Medline

4. 4

   Shafik A, El-Sibai O. Botulin toxin in the treatment of nonrelaxing puborectalis syndrome. Dig Surg 1998;15:347-351
   CrossRef | Web of Science | Medline

5. 5

   Maria G, Brisinda G, Bentivoglio AR, Albanese A, Sganga G, Castagneto M. Anterior rectocele due to obstructed defecation by botulinum toxin. Surgery 2001;129:524-529
   CrossRef | Web of Science | Medline

6. 6

   Albanese A, Brisinda G, Bentivoglio AR, Maria G. Treatment of outlet obstruction constipation in Parkinson's disease with botulinum neurotoxin A. Am J Gastroenterol 2003;98:1439-1440
   CrossRef | Web of Science | Medline

To the Editor:

In Table 3 of their review of chronic constipation, Lembo and Camilleri misclassify a number of laxatives. Polyethylene glycol–based laxatives are polymers belonging to the osmotic laxative class. Similarly, laxatives classified as poorly absorbed sugars exert their effect predominantly through an osmotic action. Like the polyethylene glycol–based laxatives, they are considered osmotic laxatives.1

James Laughton, M.B., B.S.
Schwarz Pharma, Chesham HP5 1DG, United Kingdom

1 References

1. 1

   Jafri S, Pasricha PJ. Agents used for diarrhea, constipation, and inflammatory bowel disease: agents used for biliary and pancreatic disease. In: Hardman JG, Limbird LE, eds. Goodman & Gilman's the pharmacological basis of therapeutics. 10th ed. New York: McGraw-Hill, 2001:1037-58.
   

Author/Editor Response

We agree that polyethylene glycol–based laxatives belong to the class of osmotic laxatives. We acknowledge that Table 3 of our article is unclear, in that the section listing osmotic laxatives should include the section listing poorly absorbed sugars.

Controlled studies are required to determine the role of botulinum toxin injection in the puborectalis muscle for defecatory disorders. The dose, the number of injections, the optimal site of injection, the frequency of reinjection, and the criteria for proper patient selection are not known. Until these points are clarified and the treatment is compared with biofeedback retraining of the pelvic floor, we recommend caution in the use of botulinum toxin injection for this indication.

Anthony Lembo, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215
alembo@bidmc.harvard.edu

Michael Camilleri, M.D.
Mayo Clinic, Rochester, MN 55905

Citing Articles (1)

Citing Articles

1. 1

   F. CADEDDU, A. R. BENTIVOGLIO, F. BRANDARA, G. MARNIGA, G. BRISINDA, G. MARIA. (2005) Outlet type constipation in Parkinson's disease: results of botulinum toxin treatment. Alimentary Pharmacology and Therapeutics 22:10, 997-1003
   CrossRef