1, the establishment of the concept of pelvic floor relaxation syndrome is the result of the continuous understanding of its etiology The pelvic floor relaxation syndrome is a group of syndromes caused by reflex or random abnormalities of the pelvic floor muscles [1], which is characterized clinically by the failure of coordinated relaxation or abnormal contraction of the pelvic floor muscles during defecation and the increase of pelvic floor outlet resistance, causing defecation difficulties and other symptoms. The evolution of its name derives from the continuous research on its etiology. The disease is now considered to be a group of syndromes that, in addition to constipation symptoms, may be combined with irritable bowel syndrome [2], dyspareunia [3], anorectal pain [4], Parkinson’s disease [5], and other diseases, and its possible etiology involves the overall pelvic floor muscle groups (transverse and smooth muscles), peripheral neuromodulation (sacral parasympathetic nerves, pubic nerves) [6], central neuromodulation (central, spinal and multiple neuronal injury and trauma) [7], developmental abnormalities [8], psychological and behavioral abnormalities [9], and abnormal brain-gut axis regulation [10] are multifactorially related. As early as 1964, Wasseman first discovered that the puborectalis muscle could not be relaxed during defecation and named the disease as “puborectalis syndrome”. In 1985, Kuijpers found by pelvic floor electromyography that the problem was not only of the puborectalis muscle but also of the transverse pelvic floor muscle as a whole, and therefore named the disease “spastic pelvic floor syndrome”. In 1995, Professor Li Shizhong [11] discovered that the overall muscle coordination of the pelvic floor was impaired, and on this basis, he proposed the name “pelvic floor dystonia syndrome”, which has been used in China since then. The names anismus (anal spasm), pelvic floor dysfunction (pelvic floor dysfunction) and dyssnergic defecation (pelvic floor dyslaxation, used in the Rome III [12] criteria for functional gastrointestinal disorders) are frequently found in foreign literature. Patients’ symptoms can be manifested as pelvic floor dysfunction, divided into bowel symptoms such as soft stools with persistent straining to defecate, incomplete bowel movements, prolonged bowel movements, and anal swelling; and urinary symptoms such as difficulty or waiting to urinate and pelvic floor pain. According to statistics, constipation due to pelvic floor relaxation accounts for more than 50% of chronic intractable constipation, accounting for 63.4% according to the statistics of Nanjing Hospital of Traditional Chinese Medicine. Therefore, the recognition and treatment of such diseases also becomes a breakthrough in the treatment of constipation. 2, complex etiology requires comprehensive and refined diagnostic ideas (1) Analysis of possible etiology from medical history Start from the patient’s chief complaint or the most desired main symptom and ask about its main symptom characteristics. In 421 cases of chronic constipation with complete statistics from Nanjing Hospital of Traditional Chinese Medicine, the symptoms of pelvic floor dyslaxation syndrome were ranked as follows: daily bowel movement but time and effort to pass (93.4%), soft but incomplete bowel movement (88.3%), anal obstruction (71%), abdominal distension (70.5%) and anal swelling (64%); concomitant symptoms included reliance on laxatives or corkage (56%), presence of abdominal pain related to defecation (30%), difficulty in urination and inability to complete urination related to urination (28%), the presence of long-term use of antipsychotic drugs, the presence of concomitant neuromuscular diseases such as stroke, Parkinson’s disease, spinal cord injury, neurological tumors, disc herniation, etc., the presence of a history of traumatic surgery, and the patient’s education, socio-occupational and intellectual level, initiating, precipitating and aggravating factors, etc. The main symptoms were similar to those of foreign studies [1]. (2) Analysis of possible diagnosis from physical examination Starting from the four local diagnoses of the anus, the patient’s gluteal groove (reflecting pelvic floor muscle tone), perianal skin color, scarring, deformity or erosion were first observed, and then the perianal skin was lightly touched for contraction, the tension, contraction force, duration of contraction and post-contraction muscle tone of the anal canal, whether the rectum was dilated, and whether there was fecal retention and texture in the rectum, and then the index finger was turned toward the The dorsal puborectal muscle ring was then turned to compare the angular changes of the anorectal angle at rest and in the simulated defecation state (the angle became larger in the normal defecation state and smaller or unchanged in the abnormal state), and finally the index finger was turned to the ventral side to observe whether there was a combination of rectal protrusion and mucosal overturning. The whole body examination should focus on the patient’s nutritional status, mental status, abnormal tremor, four abdominal examinations, tongue and pulse, etc. (3) Comprehensive judgment from multiple pelvic floor physiological examinations More than 50% of the diagnostic information can be obtained based on detailed history questioning and physical examination, and based on the above etiological considerations, we can subdivide and confirm the diagnosis in different ways. According to the anorectal manometry we can know the patient’s anal canal tension, whether the rectal defecation power is adequate, whether the defecation resistance comes from the paradoxical contraction of the transverse muscle or the inability of smooth muscle to relax or the inability to control the muscle, whether the rectal sensation is hypersensitive or hyposensitive, and whether the inhibitory reflex exists. Nanjing Hospital of Traditional Chinese Medicine counted 421 cases of chronic constipation according to Rome III criteria, of which type 1: sufficient abdominal pressure or rectal pushing force during defecation and paradoxical rise of anal canal pressure (49%), type 2: sufficient abdominal pressure or rectal pushing force, pelvic floor muscle cannot relax or the relaxation amplitude is less than 20% (20%), type 3: no sufficient abdominal pressure or rectal pushing force, paradoxical rise of anal canal pressure ( Type 4: without sufficient abdominal pressure or rectal pushing force, the pelvic floor muscle cannot relax or the relaxation is less than 20% (11%); according to the pelvic floor surface electromyography we can know the functional status of type I and type II transverse muscle; according to the pelvic floor evoked potential we can determine whether it is a pubic neuropathy or central conduction abnormality, whether it is a sensory pathway or motor pathway abnormality; according to the defecography or Other tests include colonoscopy, blood biochemistry, thyroid function, brain CT or MR, and colonic transmission test. Based on the results of the above tests, we need to analyze the evidence and make a comprehensive judgment, and finally give a three-level diagnosis: ①Specialist diagnosis: various subtypes of pelvic floor dystonia syndrome. pelvic floor dyslaxation (myogenic/neurogenic/mixed), pelvic floor dyslaxation comorbidity (rectal sensory dysfunction/cognitive or psychosomatic disorders/irritable bowel syndrome/pelvic floor pain/urinary dysfunction/development), pelvic floor dyslaxation combined with pelvic floor laxity (rectal prolapse/internal rectal overlap/perineal descent/intestinal hernia), etc.; (ii) psychological diagnosis: presence and extent of psychological or psychiatric disorders; (iii) TCM diagnosis: evidence, physical quality and quality of life [13]. 3. Comprehensive treatment is the key to improve the efficacy The complexity of pelvic floor dystocia syndrome determines the idea of comprehensive treatment. The treatment concept has also undergone a spiral leap from non-surgical – surgical – non-surgical. The main treatment methods include: pelvic floor biofeedback training [14], botulinum toxin injection [15], acupuncture [16], Chinese medicine and western medicine, and surgery. ① Biofeedback training: it is the first-line treatment of choice for pelvic floor dystonia syndrome and has been used since 1973, with an efficiency rate of 73%. The guarantee of efficacy is inseparable from patient selection, training protocol, therapist guidance and equipment. Before treatment, it is necessary to ensure that the patient has good cognition and communication, and the willingness to initiate treatment, mainly in patients with myogenic and some neurogenic disorders, together with home training reinforcement; the development of the training program requires training the stability of the pelvic floor type I muscles first rather than muscle strength, in addition to the interaction and encouragement of the therapist with the patient. ②Botulinum toxin type A injection: It can be injected at the puborectalis muscle ring under electromyography or ultrasound guidance, respectively at 3, 6 and 9 points in the truncal position. It can temporarily block the wrong conditioned reflex and reduce the anal canal tension. The best indications are those with high muscle tone, good muscle elasticity, and no concomitant rectal sensory hypoesthesia. It is often used in combination with biofeedback training to shorten the course of treatment and improve the long-term efficacy. (iii) Acupuncture treatment: by stimulating the low-level central regulation of defecation in the sacral plexus nerve, it promotes colorectal peristalsis and increases defecation dynamics, while regulating sympathetic and parasympathetic functions [16]. After practice, even though the patient’s symptoms improve but it is difficult to reverse the pelvic floor muscle motor uncoordinated state, so it is suitable for those with hyporectal sensory function and insufficient rectal propulsion, and can be used in combination with biofeedback training. ④Pharmacological treatment: Chinese medicine identification [17] mainly includes liver depression and spleen deficiency, spleen deficiency and dampness, liver and kidney yin deficiency and spleen and kidney yang deficiency, which need to be administered accordingly. Western medicine can be used to improve symptoms with laxatives, anti-anxiety or depressants, etc. ⑤ Surgical treatment: for the puborectalis muscle cut needs to be used with caution due to the risk of incontinence and poor long-term efficacy [18]. It should be said that the concept of pelvic floor failure syndrome is only a syndrome of symptoms, and the understanding of it is still the “tip of the iceberg”. With the continuous research on its etiology and diagnosis, it is a challenge for us to adopt comprehensive diagnostic ideas and individualized treatment plans. In the near future, we need to emphasize and standardize biofeedback treatment, conduct randomized controlled studies to compare different training protocols, combine Botox injections, acupuncture and Chinese medicine to improve efficiency, and regulate and evaluate various aspects such as physiology, psychology and health education to improve the quality of life of patients.