Both Anal Retentiveness (ar) And Retro Pudendal
Docket: 1-5525
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Customer: CMAJ Dec 15/98
15525 Dec. 15/98 CMAJ /Page 1469
CIRCUMSTANTIAL EVIDENCE
by Gregory J.R. Charrois, BSc; Mark Ewanchuk
Evidence for a new classification of anal-retentiveness:
torpid posteriosus and retro-pudendal hesitancy
vided informed consent. Each student underwent an
SPGN biopsy and completed the standard AR diagnosis
Abstract
form (DSM-IV). All biopsies of the SPGN were con-
ducted at the University of Alberta Hospitals. AR was
The introduction of ICD-10 has led to considerable
diagnosed solely on the basis of DSM-IV criteria,
debate over the proper diagnosis and treatment of
whereas RPH was diagnosed completely on the basis of
retro-pudendal hesitancy (RPH). Many feel that the
the biopsy results.
diagnosis should apply to all those with anal-reten-
tiveness (AR). However, the authors discovered new
The study was approved by the Ethics Counsel of
clinical and laboratory evidence showing that AR is
the University of Alberta Hospitals.
but one type of RPH. As such, they propose a reclas-
sification of AR as type I RPH, a condition involving
Results
the superior pudendal-geniculate nucleus (SPGN). In
contrast, type II RPH — another lesion of the SPGN
The overall prevalence of AR in the sample was
— produces the characteristic torpid posteriosus (TP).
80%. In contrast, 90% of the SPGN biopsy specimens
showed some degree of pathology (Table 1). The 2 data
sets were compared to determine whether there was co-
morbidity. Without exception, every student with AR
also had an SPGN lesion. The 10% difference in the
Both anal-retentiveness (AR) and retro-pudendal prevalence of RPH versus AR indicated that these were
hesitancy (RPH) among medical students have
indeed 2 distinct conditions. Upon further histological
grown to epidemic proportions. As a result, many
evaluation, all of the students with AR were found to
have mistakenly assumed that these were the same dis-
have a proliferative increase in the basophilic keenus
order. However, the description of the superior puden-
cells of the SPGN. The remaining 10% who had an
dal-geniculate nucleus1 (SPGN) has led to the under-
SPGN lesion had a diffuse infiltration of acidophilic in-
standing of the pathophysiology of RPH2 and its
dolent cells. [Photographs of the histological sections
recognition as a distinct condition. Surprisingly, despite
were not available at the time of publication.]
overwhelming evidence, there is still some debate over
Given this remarkable and absolute correlation be-
this topic in the AR literature.3 Nevertheless, RPH was
tween the 2 types of lesions, we decided to perform an ad
included as a distinct condition in the ICD-10. How-
hoc evaluation of the students to determine whether the
ever, these 2 conditions show such similar clinical
symptoms that they have become rather difficult to dif-
Table 1: Prevalence of types I and II retro-pudendal
hesitancy (RPH) among medical students at the
ferentiate. Only biopsy of the SPGN can conclusively
University of Alberta (n = 200)
differentiate a diagnosis of RPH from simple AR.
Prevalence
Therefore, we conducted a blinded study involving
rate, %
Correlation*
medical students at the University of Alberta (a) to con-
Type I RPH
80
r = 1
firm that AR and RPH were indeed distinct conditions
Increased keenus
and (b) to evaluate the prevalence of AR and RPH
cell count
80
among medical students.
Type II RPH
10
r = 1
Methods
Increased indolent
cell count
10
*Relation between prevalence of type I RPH (anal-retentiveness) and in-
All 200 first- and second-year medical students at the
creased keenus cell count, and between type II RPH (torpid posteriosus)
University of Alberta agreed to enter the study and pro-
and increased indolent cell count.
CMAJ • DEC. 15, 1998; 159 (12)
1469
© 1998 Canadian Medical Association
Docket: 1-5525
Initial: JN
Customer: CMAJ Dec 15/98
15525 Dec. 15/98 CMAJ /Page 1470
NEW CLASSIFICATION OF ANAL-RETENTIVENESS
infiltration of indolent cells represented any significant
RPH, AR and TP. We propose that AR and TP are, in
condition. All participants were asked to complete the
fact, subtypes of RPH: types I and II respectively. One
DSM-IV questionnaire for torpid posteriosus (TP)
cannot deny that AR and TP may be demonstrated to
(Table 2). Surprisingly, there was a perfect correlation be-
represent distinct lesions of the SPGN. These 2 disor-
tween the 2 conditions (r = 1, Table 1).
ders should thus be named for their anatomical location.
The overall prevalence of type I RPH (AR) was
New classification
80%. This rate is similar to others reported among
medical students at other universities across Canada.
On the basis of these preliminary clinical results and
However, preliminary data from Ontario indicates that
previous reports of the anatomy and pathology of these
this number may be significantly higher in that
disorders, we suggest a new classification scheme for
province.4 Perhaps more intriguing was the 10% preva-
lence of type II RPH (TP) in our study, because people
Table 2: Common characteristics observed in medical students
with this condition often exhibit a complete lack of
with types I and II RPH
imagination and motivation. Most of the students in
Type I RPH (anal-retentiveness)
Type II RPH (torpid posteriosus)
this group ardently claimed that the appearance of this
Avoidance of social interaction
Surplus amounts of spare time
condition could be tightly correlated with their en-
Low liver microsomal enzyme
Multiple high scores on video
trance to medical school. However, these statements
levels
games
Chronic fatigue
Well rested
were not followed up because of time restrictions. This
Early arrival for most
Missing on most weekend nights
is perhaps an area that warrants further study.
appointments
Frequent arguments with
At present, we are unable to identify the cause of these
Library adhesions
superiors
2 disorders. However, with specific histological and clini-
Pencil calluses on thumb and
Distended abdomen and
forefinger
buttocks
cal criteria for each condition, we are now planning a
Frequent reading-induced eye
Well-defined thenar eminence
multicentre study to assess the prevalence of types I and
strain
II RPH and to search for causative factors. With the
Docket: 1-5525
Initial: JN
Customer: CMAJ Dec 15/98
15525 Dec. 15/98 CMAJ /Page 1471
NEW CLASSIFICATION OF ANAL-RETENTIVENESS
proper diagnosis and understanding of the pathology in-
volved, new treatments may be on the horizon. Initial re-
ports indicate that antagonists for both keenus cells5 and
indolent cells6 may indeed be available. Taken together,
these breakthroughs hold promise for those now suffering
from these devastating retro-pudendal conditions.
References
1.
Charrois GJR. Location and description of the superior pudendal-geniculate
nucleus. Pudenda Acta 1997;210:675-90.
2.
Ewanchuk M, Charrois GJR, Back L, Smith D, Char D. Pathophysiology of
lesions to the superior pudendal-geniculate nucleus. Pudenda Acta 1997;214:
890-901.
3.
Back L, Ewanchuk M, Smith D, Char D. Retro-pudendal hesitancy vs. anal
retentiveness: Is there a distinction? [review]. Pudendal Rev 1998;120:34-69.
4.
Charrois GJR, Ewanchuk M, Back L, Smith D, Lipcotti F. Retro-pudendal
hesitancy in professional university programs: prevalence and consequence.
Pudendal Rev 1998;145:26-45.
5.
Ewanchuk M. Anti-proliferative agents are useful in slowing the growth of
keenus cells in vivo. Pundena Clin 1998;14:120-9.
6.
Charrois GJR. Motivational cytokines selectively target indolent cells. Pun-
dena Clin 1998;16:116-35.
Mr. Charrois and Mr. Ewanchuk are medical
students at the University of Alberta, Edmonton,
who admit to suffering from type II
retro-pudendal hesitancy.
