Pelvic Floor Disorders and Constipation

Overview

• Pelvic floor disorders involve conditions affecting the colorectal, urologic, and gynecologic systems.
• Constipation is a dysfunction of colonic motility and the defecation process.
  • Can result from colon obstruction, pelvic floor diseases, or be functional.
  • Functional constipation requires differentiation from anatomical problems and may need surgical treatment if unresponsive to medical therapy.

Common Pelvic Floor Disorders

1. Rectal Prolapse (Procidentia)
   • Circumferential, full-thickness intussusception of the rectum.
2. Rectocele
   • Bulging of the rectum into the posterior wall of the vagina.
3. Cul-de-sac Hernia
   • Protrusion of the peritoneum between the rectum and vagina.
     • Enterocele: Contains small bowel.
     • Sigmoidocele: Contains sigmoid colon.
4. Anismus
   • Failure of the puborectalis and external anal sphincter to relax during defecation.
     • Can be due to nonrelaxation or paradoxical contraction.

Diagnosis: Testing and Evaluation

Anorectal Physiology Laboratory Tests

1. Anorectal Manometry

   • Evaluates anal canal pressures, including:
     • Resting pressure (due to internal sphincter).
     • Maximum voluntary pressure.
     • Squeeze pressure (due to external sphincter).
   • Normal resting pressure: 40–80 mm Hg.
   • Provides info on intrarectal pressures, reflexes, rectal sensation, and compliance.
   • High-resolution manometry offers greater detail and reduces artifacts.

   

2. Balloon Expulsion Test

   • Assesses ability to expel a balloon inflated with 50–60 cc of water/gas/air.
3. Pudendal Nerve Terminal Motor Latency
   • Measures conduction time from ischial spines to internal anal sphincter.
   • Normal latency: 2.0 ± 0.2 milliseconds.
   • Prolonged latency indicates nerve injury (e.g., obstetric trauma, diabetes).
4. Electromyography (EMG)
   • Records electrical activity of external sphincter and puborectalis muscle.
   • Identifies paradoxical contraction or lack of relaxation during defecation attempts.

Imaging Studies

1. Endoanal Ultrasound

   • Evaluates integrity, thickness, and abnormalities (scars, fistulas) of the anal sphincters.

   

2. Defecography

   • Dynamic study of anorectum and pelvic floor during defecation.
   • Identifies anatomic abnormalities (e.g., rectocele, prolapse) and functional disorders.
   • Uses fluoroscopy with contrast; patient is seated on a radiolucent commode.

   • MRI Defecography:

     • Provides high-quality images without radiation.
     • Limited by supine position, which may not reflect normal defecation.

     

3. Colonic Transit Time

   • Assesses colonic inertia.
   • Patient ingests 24 radio-opaque markers (Sitzmarks).
   • Progress tracked via abdominal x-rays over 7 days.
   • Normal: 80% of markers expelled by day 5.
   • Retention indicates slow transit constipation.

   

Rectal Prolapse (Procidentia)

Anatomy and Pathophysiology

• Definition: Full-thickness intussusception of the rectal wall.
• Types:
  • Internal (intrarrectal) prolapse.
  • Intra-anal prolapse.
  • External prolapse.

Epidemiology

• Occurs in ~0.5% of the population.
• Women >50 years are 6 times more likely than men.
• In men, typically presents <40 years old.
• Associated with psychiatric diseases and constipating medications in younger patients.

Risk Factors

• Age >40 years.
• Female gender.
• Prior pelvic surgery.
• Chronic straining and constipation.
• Chronic diarrhea.
• Vaginal delivery and multiparity (though one-third are nulliparous).
• Pelvic floor dysfunction.
• Neurologic diseases/injuries.
• Psychiatric conditions requiring constipating meds.

Symptoms

• Discomfort from prolapsed tissue.
• Fecal incontinence (50–75%):
  • Due to direct conduit, sphincter stretching, and rectoanal inhibitory reflex.
  • May involve pudendal neuropathy.
• Constipation or obstructed defecation (25–50%):
  • Feeling of incomplete evacuation.
  • Caused by bowel "telescoping" or associated rectocele.

Diagnosis and Differential Diagnosis

• Physical Examination:
  • Differentiate full-thickness prolapse (concentric folds) from prolapsed hemorrhoids (radial folds).
  • Look for patulous anus and lax sphincter.
  • Examination during straining; may request patient photos if not observable in-office.
• Proctoscopy:
  • Shows redundant tissue, possible anterior solitary rectal ulcer.
• Imaging:
  • Defecography or MRI defecography to confirm diagnosis and assess coexisting conditions.
• Colonoscopy:
  • Exclude colorectal cancer or other pathologies.
• Colonic Transit Study:
  • Differentiate between obstructed defecation and slow transit constipation.
• Endoanal Ultrasound:
  • May reveal thickened internal sphincter.

Management

Nonoperative Management

• Medical therapy for constipation and incontinence:
  • Increase fluid intake, fiber supplements, stool softeners.
  • Topical sugar or salt to reduce mucosal edema.
  • Use of enemas and suppositories.

Operative Repair

• Goals: Eliminate prolapse, correct anatomical and functional issues.
• Approaches:
  • Transabdominal (open, laparoscopic, robotic).
  • Transperineal.
• Decision factors: Patient's health, age, bowel function, surgeon's expertise.

Abdominal Procedures

• Rectopexy: Fixation of the rectum to presacral fascia.

  • Posterior Rectopexy:

    • Dissection and fixation with or without mesh.

    • Posterior Mesh Rectopexy:

      • Mesh attached to presacral fascia and rectum.
      • Improves fecal incontinence (20–60%).
      • Recurrence rate: 2–5%.

      

  • Ventral Mesh Rectopexy:

    • Anterior mobilization and mesh suspension to sacral promontory.
    • Advantages: Improves incontinence and constipation, low recurrence (3–5%).

    

• Mesh Complications:

  • Erosion, infection, bowel obstruction, mesh migration.
  • Biologic mesh may reduce infection risk but not significantly affect recurrence rates.

Perineal Procedures

• Preferred for elderly or high-risk patients.

• Altemeier Procedure (Perineal Proctectomy):

  • Transanal resection of prolapsed rectum and sigmoid.
  • Levatorplasty may reinforce pelvic floor.
  • Recurrence rate: ~10%.
• Delorme Procedure:
  • For short prolapses (<5 cm).
  • Mucosal stripping and muscle plication.
  • Lower complications, recurrence rates similar to other methods.
• Stapled Transanal Rectal Resection (STARR):
  • Not recommended due to high complication rates and poor outcomes.

Rectocele

Definition and Pathophysiology

• Rectocele: Bulging of anterior rectal wall into posterior vaginal wall.
• Risk Factors:
  • Advanced age.
  • Pregnancy and vaginal childbirth.
  • High BMI.
  • Chronic intraabdominal pressure.
  • History of hysterectomy.
• Causes:
  • Damage to rectovaginal septum (muscular/neurogenic).
  • Obstetric trauma.
  • Chronic straining affecting endopelvic fascia.

Symptoms

• Obstructed defecation: Difficulty emptying rectum.
• Need to press against vagina or perineum to defecate.
• Vaginal bulge sensation.
• Urinary and sexual dysfunction.
• Constipation.
• Fecal incontinence due to fecal trapping.

Diagnosis

• Physical Examination:
  • Digital vaginal and rectal exams reveal bulging during straining.
  • Check for other pelvic organ prolapses.
• Defecography:
  • Visualizes rectocele size and function.
  • Graded as:
    • Small: <2 cm.
    • Moderate: 2–4 cm.
    • Large: >4 cm.
• Limitations:
  • Anatomic distortion may not correlate with symptoms.
  • MRI limited by supine position.
• Balloon Expulsion Test:
  • Identifies inability to expel balloon within 4 minutes.

Management

• Asymptomatic rectoceles: No treatment needed.
• Symptomatic rectoceles:
  • Initial treatment: Bowel regimen, fiber supplements.
  • Surgery for unresponsive cases.

Surgical Approaches

1. Transvaginal Repair (Preferred by gynecologists)
   • Better access to levator muscles.
   • Fibromuscular layer is plicated.
   • Puborectalis may be reapproximated.
2. Endorectal Repair (Performed by colorectal surgeons)
   • Excision of excess rectal mucosa.
   • Muscularis layer plicated with sutures.
3. Transperineal Repair
   • Incision across perineal muscles.
   • Puborectalis muscles reapproximated.
   • Mesh may reinforce repair.
   • Suitable for patients with fecal incontinence.

Constipation

Overview

• Affects >50% of individuals over 65.
• Can occur in younger patients.
• Contributing factors:
  • Metabolic, endocrine, neurologic, psychiatric disorders.
  • Hypothyroidism.
  • Medications (e.g., opioids).

Evaluation

• Exclude serious causes:
  • Colorectal malignancies.
  • Colonic obstructions.
• Colonoscopy recommended for new-onset constipation.

Management

• Lifestyle changes:
  • Increase fluid intake (1.5–2 L/day).
  • Increase dietary fiber.
• Medications:
  • Osmotic laxatives (e.g., polyethylene glycol).
  • Probiotics.
  • Avoid long-term use of stimulant laxatives.
• Prescription options:
  • Lubiprostone (Amitiza): Chloride channel activator.
  • Linaclotide (Linzess): Guanylate cyclase agonist.
  • Prucalopride (Motegrity): Serotonin 5-HT4 agonist.

Functional Constipation (Rome IV Criteria)

• Diagnosis requires:
  1. At least two symptoms during ≥25% of defecations for ≥3 months:
     • Straining.
     • Lumpy or hard stools.
     • Sensation of incomplete evacuation.
     • Sensation of anorectal blockage.
     • Manual maneuvers to facilitate defecation.
     • Fewer than three spontaneous bowel movements per week.
  2. Loose stools rarely present without laxatives.
  3. Insufficient criteria for irritable bowel syndrome.

Further Investigation

• Obstructed Defecation Symptoms:
  • Defecography.
  • Anorectal manometry.
  • Balloon expulsion test.
  • Electromyography.
• Colonic Transit Time:
  • Radio-opaque markers (Sitzmarks).
  • Diagnoses slow transit constipation or colonic inertia.

Surgical Treatment

• For severe, refractory cases affecting quality of life.
• Abdominal Colectomy with Ileorectal Anastomosis (IRA)
  • Total abdominal colectomy (TAC-IRA) or colectomy with IRA (CIRA).
  • Minimally invasive techniques available.
  • Outcomes:
    • Postoperative diarrhea (5–15%).
    • Abdominal pain (30–50%).
    • Small bowel obstruction (10–20%).
    • Fecal incontinence.
    • Recurrence of constipation (10–30%).
  • High patient satisfaction despite potential complications.
• Segmental resections are not recommended.
• Permanent ostomy (ileostomy) as last resort for intractable cases.

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Note: Early diagnosis and tailored management of pelvic floor disorders and constipation are crucial for improving patient outcomes and quality of life.

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Pelvic Floor and Fecal Incontinence [ Anal Canal Sabiston]

Definition

• Fecal incontinence: Involuntary leakage of fecal material in individuals over the age of four.
  • Prevalence: up to 12%.
  • Most common cause: Obstetric injury.

Causes and Risk Factors

• Rectal sensation/compliance issues: Lead to urgency and loss of fecal control.
• Inflammatory conditions: (e.g., IBD) can result in urgency and incontinence.
• Medical conditions:
  • Diabetes
  • Diarrhea
  • Obesity
  • Neurologic diseases
  • Urinary incontinence

Comprehensive Evaluation

1. Bowel habits:
   • Consistency of stools and frequency of bowel movements.
   • Type of incontinence: Gas, liquid stool, solid stool, urge, passive, or postdefecation.
   • Presence of urgency and awareness of incontinence.
2. Associated factors:
   • Urinary incontinence.
   • Diet and medications.
   • Colorectal cancer: Rule out in cases of recent bowel habit changes or blood per rectum.
3. History:
   • Prior anal surgery.
   • Trauma.
   • Radiation therapy.
   • Systemic conditions: Diabetes, neurologic diseases.

Physical Examination

• Perineum and perianal region:
  • Evaluate musculature, perineal bulk, and skin condition.
  • Look for prolapsing tissue.
• Digital rectal exam:
  • Check resting tone and squeeze strength.

Pelvic Floor Physiologic Testing

• Anorectal physiology tests: Useful for patients not responding to medical management or being considered for surgery.

Initial Management

1. Dietary modification:
   • Fiber supplementation to bulk and firm stool consistency.
2. Medical therapy:
   • Antidiarrheal agents (e.g., loperamide) to reduce stool frequency and increase consistency.

Surgical Interventions

• Anal sphincter repair:
  • Beneficial for sphincter disruption from childbirth or anal surgery.
  • Long-term durability can be a challenge.
• Sacral nerve stimulation:
  • Decreases incontinence episodes and urgency.
  • Complications: Pain, infection, seroma formation, bleeding, and scarring.

Constipation

Prevalence

• Accounts for 8 million annual physician visits in the United States.

Causes

1. Primary motor disorders: Affecting the colon, rectum, or anus.
2. Defecation disorders.
3. Medication side effects.

Initial Management

1. Lifestyle changes:
   • Increased dietary fiber and fluid intake.
   • Regular exercise.
2. Medical treatments:
   • Polyethylene glycol solutions: Safe and effective.
   • Stimulant laxatives (e.g., senna, bisacodyl): Used cautiously.
   • Prokinetics and secretagogues: Reserved for patients unresponsive to simpler treatments.

Further Testing

• Indicated if medical treatment fails or if symptoms suggest severe slow transit or obstructed defecation.
• Barium or MRI proctography: Helps in diagnosing defecation disorders.
• Biofeedback therapy: Effective for dyssynergic defecation, related to the failure of puborectalis muscle relaxation.

Surgical Interventions

1. Sacral nerve stimulation: May alleviate constipation in selected patients.
2. Malone antegrade colonic enema (MACE):
   • Appendix stoma for colonic irrigation.
3. Colectomy with ileorectal anastomosis (IRA):
   • Reserved for severe colonic inertia with normal pelvic floor function.
4. Ventral mesh rectopexy:
   • Addresses rectocele and internal rectal intussusception.
   • Uses a mesh sling to suspend the rectum and pelvic floor muscles to the sacrum without dividing lateral ligaments.

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Key Takeaway: Management of pelvic floor disorders and constipation involves a combination of lifestyle modifications, medical therapy, and surgical interventions for refractory cases. Early diagnosis and appropriate treatment can significantly improve patient outcomes and quality of life.