An Introduction to Pelvic Floor Disorders - PowerPoint Presentation

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An Introduction to Pelvic Floor Disorders

Gaby Vargas, MD, MS, FACS, FASCRSColon and Rectal Surgeon

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Objectives

1. Participants will be able to understand the anatomy and function of the pelvic floor2. Participants will be able to recognize patients with pelvic floor disorders

3. Participants will be able to perform a basic pelvic floor examination4. Participants will be able to create an appropriate treatment plan for patients with common pelvic floor disorders

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General Anatomic Considerations

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General Anatomic Considerations

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Pelvic Floor in Women

Divided into three compartmentsAnterior compartmentBladder and urethra

Middle compartmentUterus and vagina

Posterior compartment

Rectum

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What Does The Pelvic Floor Do?

Supports the pelvic organsClosure of the urethral and anal sphincters

We need pelvic floor muscles that are responsive to intraabdominal pressures and postural

changes

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What Do We Mean By

“Pelvic Floor Dysfunction”?Urinary incontinenceStress

UrgeOveractive

Mixed

Pelvic pain

Sexual problems

Back pain

Fecal incontinence

Difficulty with defecation

Prolapse

Bladder

Vaginal

Uterine

Rectal

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Why is Recognizing Pelvic Floor Dysfunction Important?

PFD are commonPrevalence in US women of at least one PFD is estimated to be 24%

Prevalence more than doubles in women > 80 yrs. oldThe probability that a woman will undergo surgery for POP by age 80 is 1 in 5

Obstet Gynecol Clin North Am. 2016 Mar; 43(1): 1–13.

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Why is Recognizing Pelvic Floor Dysfunction Important?

Most women will suffer in silenceIn a sample of women 40 yrs. or older, the prevalence of UI was 41%, but only 25% of symptomatic women sought care

In a community based internet survey of women over 45 yrs., 19% reported FI but only 29% of those sought care

Minassian

VA, Yan XS,

Lichtenfeld

MJ, Sun H, Stewart WF. The iceberg of health care utilization in women with urinary incontinence. Int

Urogynecol

J. 2012;23(8):1087–1093

Brown HW, Wexner SD,

Lukacz

ES. Factors Associated With Care Seeking Among Women With Accidental Bowel Leakage. Female Pelvic Medicine & Reconstructive Surgery. 2013;19(2):66–71.

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Why is Recognizing Pelvic Floor Dysfunction Important?

Incontinence and POP are often accepted as ”normal” by patientsPFD are embarrassingPFD often leads to withdrawal from social and physical activities

Decrease in QOL and increase in depression/anxiety

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What Do We Mean By “Pelvic Floor Dysfunction”?

Urinary incontinenceStressUrge

MixedPelvic pain

Sexual problems

Back pain

Fecal incontinence

Difficulty with defecation

Prolapse

Bladder

Vaginal

Uterine

Rectal

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Risk Factors for Pelvic Floor Disorders

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Risk Factors for Pelvic Floor Disorders

Bump RC, Norton P. Epidemiology and Natural History of Pelvic Floor Dysfunction.

Obstetrics and Gynecology Clinics of NA. 1998;25(4):723–746

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Screening for Pelvic Floor Dysfunction

Several validated questionnairesNot particularly helpful in the clinical setting6 easy questions

Do you have pain/pressure in the pelvic region during any activity?Do you ever lose control of your bladder or bowels?

Do you have difficulty emptying your bowels or bladder?

Do you frequently wake up at night to urinate?

How often do you urinate during the day?

Do you have pain with sexual intercourse?

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What Do You Look For On Physical Exam?

Position patient for routine pelvic examination or prone jack knife positionVisually inspect the perineumPerform digital vaginal and rectal exam

One digit systematic circumferential palpationAsk patient to squeeze/pushObserve pelvic floor with Valsalva maneuver

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Documenting the Exam

Describe the position the patient was examined inRefrain from using clock hands to describe findings

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Documenting the Exam

Describe findings in the perineum and external inspection“The perineum was dry/soiled with a normal/abnormal appearing anal verge.”“Perineal body is thin/attenuated”

Describe digital exam findings”There were/were no appreciable masses, no blood.”

If there is an abnormal palpable finding note the location (name the quadrant)

Note the location of pain (name muscle if possible)

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Documenting the Exam

Describe digital rectal exam findingsWhat is rectal tone like (lax, normal, hypertonic)

When squeezing, is patient using accessory muscles (i.e. glutes)?

When performing Valsalva maneuver, are pelvic floor muscles relaxing or contracting?

Describe abnormal descent of pelvic organs

Bulging of vaginal walls or apex

Tissue protruding from the anus

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What Do Vaginal Bulges Mean?

Descent or bulging of the anterior vaginal wall = Cystocele

Descent or bulging of the cervix = uterine prolapse

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What Do Vaginal Bulges Mean?

Descent or bulging of the posterior vaginal wall = RectoceleDescent or bulging of the posterior vaginal wall= Enterocele/

sigmoidocele

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Pelvic Floor Defecatory Dysfunction

Typical complaints include:ConstipationFeeling of incomplete evacuation

Need to manually disimpact

Loitering on the commode

Adoption of usual poses to achieve defecation

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Pelvic Floor Defecatory Dysfunction

At rest, puborectalis muscle creates angling of the rectum. Normal continence mechanism

With Valsalva, puborectalis relaxes, anorectal angle straightens, and sphincters relax

At Rest

Straining

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Pelvic Floor Defecatory Dysfunction

Classified into several groupsFunctional outlet obstructionMechanical outlet obstruction

Defecatory force/directionColorectal compliance

Pelvic pain syndromes

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Pelvic Floor Defecatory Dysfunction

FIRST step is to rule out constipation from other causesDietary: low fiber, eating disorder, dieting (keto diet), low fluid intakeMetabolic: hypothyroidism, DM, hypercalcemia

Neurological: Parkinson’s, MS, spinal cord injuryIatrogenic: iron supplements, antacids, anti-emetics, OPIATES

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Pelvic Floor Defecatory Dysfunction

If stools are not normal

Start with dietary fiber/fluidOptimize all other medical issues

May need laxatives

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How much fiber should we recommend?

 

25-35 grams DAILY

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How much water should we be drinking?

6-8 eight ounce glasses

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Functional Outlet Obstruction

After managing constipation from other causesTreatment is primarily non surgical Pelvic floor physical therapy

Success is dependent on patient buy in and complianceIf patients do not have favorable results with PT, a diverting colostomy may be considered

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Mechanical Outlet Obstruction

Rectal ProlapseIntussusception of rectum through anus

Full Thickness

Circumferential

Symptoms

Pain

Bleeding

Mucoid discharge

Incontinence

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Rectal Prolapse

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Rectal Prolapse vs. Prolapsed Hemorrhoids

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Mechanical Outlet Obstruction

Rectal ProlapsePathology is in the pelvic floor support system NOT the rectum

Treatment

Reduction of prolapse

Fiber and water

Laxatives

Avoid straining and loitering

Surgery indicated but not urgent/emergent

Patients benefit from pelvic floor physical therapy to improve strength and coordination

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Abnormal Defecatory Force/Direction

Rectocele This is a variant of normal. Not all rectoceles represent pathology

Studies in volunteers without defecatory complaints

Rectocele in 17/20 nulliparous women

Rectocele up to 3.9 cm may be asymptomatic

Intrarectal intussusception also common (even grade III or IV asymptomatic)

Shorvon

, et al. Defecography in normal volunteers: results and implications. Gut 1989. Dec; 30 (12): 1737-49

Palit

, et al. Evacuation

proctography

: a reappraisal of normal variability. Colorectal Dis 2014. July; 16 (7): 538-46

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Abnormal Defecatory Force/Direction

Rectocele Treatment

If asymptomatic, NOTHING

Fiber and fluid

Patient education (Minimize straining)

+/- Laxatives

Pelvic floor physical therapy

Surgery

Poor correlation between surgical repair and improvement in symptoms

Vaginal splinting may be best predictor of who will respond well to surgery

Large rectoceles best repaired with transvaginal approach

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Fecal Incontinence

Can range from occasional leakage to complete loss of bowel controlBowel control is influenced by stool consistency, neurosensory function, muscle strength/coordination

Two types

Urge incontinence

Know you need to pass stool but cannot restrain it long enough to make it to the toilet

Passive incontinence

Passage of stool or mucus without sensation to defecate

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Fecal Incontinence

CausesDiarrhea/Constipation

Nerve or muscle damageSurgery

OB trauma

Neurological diseases

Parkinson’s disease

DM

Dementia

Stroke

MS

Causes

Loss of rectal compliance

Radiation

Inflammatory conditions

Rectal prolapse/prolapsing hemorrhoids

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Fecal Incontinence

TreatmentImprove stool consistency

Fiber/waterLaxatives or antidiarrheals

Pelvic floor physical therapy

Anal inserts (?)

Sacral Nerve Stimulator

Medtronic

Axonics

Colostomy (only curative option)

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Fecal Incontinence

Sacral neuromodulation indicationsUrge urinary incontinence

Urinary retentionFecal incontinence

Medtronic device FDA approval in the late 1990s for urinary symptoms

Medtronic device FDA approval for FI in 2011

New

Axonics

device received FDA approval in 2019

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Fecal Incontinence

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Fecal Incontinence

Placement is a two step processTrial phase to document efficacy

2 week periodPatient keeps bowel diary

Implant permanent device if 50% or greater improvement in symptoms

Compare pre and post trial diaries

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Fecal Incontinence

Medtronic dataRCT comparing SNS to optimal medical therapy (bulking agents/pelvic PT/dietary management)

At 12 months post implant, 66% of patients reported 75-100% improvement in incontinent episodes per week and 47% of patients achieved complete continence.

Five year efficacy data

89% of patient report 50% or greater improvement in symptoms (69% intent to treat)

36% reported complete continence

Several published questionnaire data show improvements in reported QOL

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Does Pelvic PT help?

Self help is not always the best approach> 30% of patients are not able to perform a Kegel exercise appropriately at first session

Failure is de-motivating

Not everyone needs Kegel exercises.

Pelvic floor doesn’t work in isolation

Think ”Trunk Mechanics”

Issues PT are trained to identify

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Does Pelvic PT help?

Pelvic PT is not just for womenEven if surgery is recommended, pelvic PT is an integral part of improving pelvic floor health

A skilled physical therapist is invaluable

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Questions?