eP628 - Chemodenervation of the Puborectalis for Levator Syndrome: A Mixed Methods Analysis

Purpose/Background: Background: Levator Ani Syndrome (LS) and dyssynergic defecation (DD) are complex functional pelvic floor conditions which are often difficult to treat. Different modalities have been employed to combat these conditions including botulinum toxin (BT) for chemodenervation of the puborectalis, but data for this is limited and unconvincing. We aimed to characterize the objective and subjective effectiveness of chemodenervation of the puborectalis in patients treated with botulinum toxin for levator syndrome/DD.Methods/Interventions:

Methods: A mixed methods study consisting of a retrospective review and telephone interview of patients who underwent chemodenervation of the puborectalis at a single health system (2017-2023) was performed. Patient demographics, pre-treatment manometry results, symptoms, duration of symptoms and participation in pelvic floor physical therapy (PFPT) were recorded. Number of injections, duration of effect and pain scores were also recorded. Descriptive statistics were performed.Results/Outcomes:

Results: There were 22 patients included, with a median follow up of 158 days(IQR 88-535). The median age was 55 years(IQR 38-69.8) and 63.6%(14) were female. Fifty percent of the patients had a diagnosis of LS, 45.5%(10) had DD, and 1 had severe anal pain as an indication for injection. Fifteen patients underwent 1 injection, while 31.8%(7) required repeat injections (range 2-6). The median duration between injections was 161 days(IQR113-200.5). Most, 77.3%(17), engaged in PFPT prior to/concurrently with BT injections; 41.2%(7) found utility in PFPT; 47.1%(8) did not find it useful, and 11.7% were unsure. There were no 30-day complications. A total of 13(59%) patients participated in interviews and 10(76.9%) reported improvement in at least one symptom. The most common complaint prior to BT injection was constipation (11;84.6%), followed by anorectal pain (9;69.2%) incomplete evacuation(8;61.5%) and tenesmus(7;53.8%); 76.9%(10) of patients experienced ≥2 symptoms prior to injection. Nine(63.6%) patients had subjective relief of constipation symptoms, and of those that experienced pain, 66.7%(9) had relief. Of those that had incomplete evacuation and tenesmus prior to injection, 25.0%(2) and 14.3%(1) reported relief, respectively. The median time to symptom relief after initial injection was 3 days(IQR2-7), and the median duration of symptom relief was 90 days (IQR36-120). Most, 53.8%(7) patients stated they would undergo BT injections again if they had to start over. Those that did not experience relief and said they would not try again did not regret having the injections but “did not think it was beneficial” and were “disappointed.” Those that said they would repeat the process were “happy with the way it turned out.” They would “highly recommend” and think, “[it] should be offered to more people.”Conclusion/

Discussion:

Conclusion: Overall, a large proportion of patients with LS/DD experienced relief from pain and constipation following BT injections with no adverse events. Despite having a “temporary” medication effect, most required only one injection and had durable relief. This data suggests, contrary to current literature, that BT injection to the puborectalis may provide satisfactory results with minimal risk to patients who otherwise would continue to suffer from debilitating anorectal pathology.