PELVIC FLOOR

DYSFUNCTION

AND SRU

Reza Ansari

Associate professor of Medicine

DDRC

TUMS

PELVIC FLOOR ANATOMY The pelvic floor has superficial and deep muscle

The superficial layers include the internal anal

sphincter (IAS) and external anal sphincter (EAS),

perineal body, and transverse perinei muscles

The puborectalis maintains anorectal angulation and

creates a mechanical barrier for stool flow and

maintains pelvic floor integrity

Mechanisms of Defecation

1. Stool enters the rectum rectal distention

2. Reflex relaxation of the internal anal sphincter

3. Anorectal angle is voluntarily straightened (squatting)

abdominal pressure is increased (straining)

4. Descent of the pelvic floor

Contraction of the rectum

Voluntary inhibition of

external anal sphincter

5. Evacuation of rectal contents

Physiology of defecation

Functional Defecation Disorder Symptoms:

Prolonged excessive straining (85%)

Feeling of incomplete evacuation (75%)

May have soft stool

Require digital evacuation (66%)

Do not respond well to standard laxatives

Pelvic floor dyssynergia

It is multifactorial and thought to be an acquired, learned dysfunction rather than an organic disease and 31% begins during childhood, 29% after a specific event (pregnancy,trauma),40% the precipitating event is unknown

Structure and function Barium defcography MR (magnetic resonance) defecography

Functional only :

- Balloon expulsion - Manometry (HRM) - Colonic transit time - Anal sphincter EMG

DX Balloon expulsion test

This provides information regarding the ability to

expel a 50-ml water-filled balloon placed in the

rectum. Normal expulsion time is 1 min

It has 80– 90% specificity and 97 % negative

predictive value for identifying dyssynergia

Sensitivity 50 %

Colonic transit study Slow transit constipation can coexist in two-thirds of

patients with DD, and it is imperative to differentiate

between patients with isolated DD or mixed with

slow transit constipation.

Anorectal manometry Type I : adequate push effort with paradoxical anal

contraction

type II : impaired push effort with paradoxical anal

contraction,

type III : impaired anal relaxation with adequate

push

Effort

type IV : impaired push effort with impaired anal

relaxation.

Defecation normally involves the coordinated relaxation of the puborectalis and external anal sphincter muscles as pressure is building in the rectum (control panel, left). However, in patients with dyssynergic defecation (patient panel, right), ineffective defecation is associated with a failure to relax, or inappropriate contraction of, the puborectalis and external anal sphincter muscles as pressure increases in the rectu

MR (magnetic resonance) defecography

It is not widely available and can be performed with a

closed or open system:

Open magnetic resonance imaging (MRI) acquires

images in a sitting position, simulating true

defecation

Closed-configuration MRI system, images are

acquired in the supine position

SRU The annual incidence is 1– 3.6/ 100,000

80% of patients are < 50 years of age ,with slightly

higher prevalence in females

Rectal intussusception is often present and

evacuation is delayed

SRU Patients present with rectal bleeding and / or pain,

mucus discharge, straining and tenesmus, and a

feeling of incomplete evacuation

A majority of these patients use digital maneuvers

but rarely admit

In some patients, an underlying psychologic

disorder, such as obsessive – compulsive disorder,

may be present

SRU

Approximately 55 %with constipation

20– 40% with diarrhea

25% of the patients, asymptomatic

25 % are treated as IBD

Histology of solitary rectal ulcer Thickened mucosal layer with distortion of the crypt

architecture

The lamina propria is replaced with smooth muscle

and collagen (fibromuscular obliteration)

Collagen infiltration of the lamina propria can be

helpful for distinguishing solitary rectal ulcer

syndrome from IBD and chronic ischemic colitis

DX Defecography may show other abnormalities such as

rectal mucosal intussusception in 45– 80% of subjects

Barium enema is unreliable

Anorectal manometry does not help in establishing the diagnosis or predicting therapeutic response

Ultrasonography may show marked thickening of the IAS, submucosa, and EAS, as well as rectal wall and muscularis propria

SRU, DX Sigmoidoscopy may reveal a small, shallow ulcer

with a white slough or hyperemic mucosa on the

anterior wall of the rectum

Th e lesions can be multiple (30 % ), ulcerated

(57 % ), polypoid (25 % ), or with patches of

hyperemic mucosa (18 % )

It is usually found on the anterior or anterolateral

wall of the rectum, over a rectal fold, ~ 5 – 10 cm

from anus

Management

Reminding patients that :

The levatory is not the

Library

Management Behavioral therapy remains the mainstay of

treatment

Reducing excessive straining, spending < 5 min during evacuation, and discontinuing the use of digital maneuvers

These recommendations, together with biofeedback therapy, improved symptoms in 67 % of patients

A high-fiber diet showed a variable response rate of 19 – 70 % , suggesting that although diet helps by itself, it is insufficient.

Management Local treatment with topical steroids and

sulphasalazine is generally ineffective

There are limited data for sucralfate

A recent study suggests that Argon plasma

coagulation may be useful in controlling bleeding

and improving healing of ulcers, but controlled

studies are lacking

Botulinum toxin

An open label trial reported that injections of 60 to

100 units of type A botulinum toxin into both sides of

the puborectalis muscle under ultrasound guidance

was effective in patients with defecatory dysfunction

Repeat injections may be necessary to maintain

benefits

Biofeedback therapy

A prospective study of 11 patients with refractory

SRUS showed that biofeedback therapy improved

straining effort and stool frequency, digital

maneuvers were discontinued in 45 % , and bleeding

ceased in 56 % of patients

Ulcer healing was reported in 10 patients: 4 had

complete healing, 2 had > 50% healing, and 4 had <

50% healing

Surgery Appropriate for patients with full-thickness or mucosal rectal

prolapse, or with symptoms unresponsive to conservative management

Surgical options include local excision, diversion, or rectopexy

Outcomes of surgery are often disappointing, because of either persistent symptoms, postoperative bleeding, or sexual dysfunction

New methode laparoscopic mesh rectopexy a minimally invasive option for selected patients

Classification of Constipation:

Slow Transit Constipation (STC): “colonic inertia”; characterized by prolonged delay in the transit of stool through the colon due to neuromuscular dysfunction of the colon

Constipation-predominant irritable bowel syndrome:

subtype of constipation associated with abdominal discomfort

Functional Defecation Disorder (Pelvic Floor

Dysfunction): difficulty or inability to expel stool from the anorectum due to neuromuscular dysfunction of the defecation unit

3.

Colectomy in constipation ? At least five criteria should be met prior to consideration of surgery:

The patient has chronic, severe, and disabling symptoms from constipation that are unresponsive to medical therapy

The patient has slow colonic transit of the inertia pattern

The patient does not have intestinal pseudoobstruction, as demonstrated by radiologic or manometric studies

The patient does not have pelvic floor dysfunction based on anorectal manometry

The patient does not have abdominal pain as a prominent symptom.

Misoprostol A prostaglandin analog which has been used

successfully to treat some patients with severe constipation

Anecdotal experience suggests that misoprostol (200 mcg every other day and increased by 200 mcg every other day and can be increased as tolerated

Act more better when use with PEG

Misoprostol should not be used in women who could become pregnant since it induces labor and can lead to loss of the fetus. It can also increase menstrual bleeding

Linaclotide Agonist of the guanylate cyclase-C receptor that

stimulates intestinal fluid secretion and transit

Linaclotide has been approved by FDA for the

treatment of chronic idiopathic constipation at a dose

of 145 micrograms daily

However, the role of linaclotide in treating chronic

constipation and the long-term risks and benefits

remain to be determined

Lubiprostone A locally acting chloride channel activator

Its approval was based upon two placebo-controlled

trials that included a total of 479 patients (either 24 or

48 mcg daily)

Its long-term safety is not yet established

Reserved for patients with severe constipation in

whom other approaches have been unsuccessful

Prucalopride this 5HT4 prokinetic agent in a dose of 1 to 4 mg

once daily has been shown to be superior to placebo

in 4 to 12-week trials, and safe and well tolerated in

patients age 65 or older

The improvement in quality of life scores seen at the

end of the 12-week trials was maintained for up to 18

months

Colchicine May be effective for the treatment of chronic

constipation

It is effective with 1 mg daily

It should not be used in patients with renal

insufficiency

The drug can induce a myopathy