Gaby Vargas MD MS FACS FASCRS Colon and Rectal Surgeon Objectives 1 Participants will be able to understand the anatomy and function of the pelvic floor 2 Participants will be able to recognize patients with pelvic floor disorders ID: 928878
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Slide1
An Introduction to Pelvic Floor Disorders
Gaby Vargas, MD, MS, FACS, FASCRSColon and Rectal Surgeon
Slide2Objectives
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
Slide3General Anatomic Considerations
Slide4General Anatomic Considerations
Slide5Pelvic Floor in Women
Divided into three compartmentsAnterior compartmentBladder and urethra
Middle compartmentUterus and vagina
Posterior compartment
Rectum
Slide6What 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
Slide7What 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
Slide8Why 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.
Slide9Why 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.
Slide10Why 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
Slide11What 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
Slide12Risk Factors for Pelvic Floor Disorders
Slide13Risk 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
Slide14Screening 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?
Slide15What 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
Slide16Documenting the Exam
Describe the position the patient was examined inRefrain from using clock hands to describe findings
Slide17Documenting 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)
Slide18Documenting 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
Slide19What Do Vaginal Bulges Mean?
Descent or bulging of the anterior vaginal wall = Cystocele
Descent or bulging of the cervix = uterine prolapse
Slide20What Do Vaginal Bulges Mean?
Descent or bulging of the posterior vaginal wall = RectoceleDescent or bulging of the posterior vaginal wall= Enterocele/
sigmoidocele
Slide21Pelvic 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
Slide22Pelvic 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
Slide23Pelvic Floor Defecatory Dysfunction
Classified into several groupsFunctional outlet obstructionMechanical outlet obstruction
Defecatory force/directionColorectal compliance
Pelvic pain syndromes
Slide24Pelvic 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
Slide25Pelvic Floor Defecatory Dysfunction
If stools are not normal
Start with dietary fiber/fluidOptimize all other medical issues
May need laxatives
Slide26How much fiber should we recommend?
25-35 grams DAILY
Slide27How much water should we be drinking?
6-8 eight ounce glasses
Slide28Functional 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
Slide29Mechanical Outlet Obstruction
Rectal ProlapseIntussusception of rectum through anus
Full Thickness
Circumferential
Symptoms
Pain
Bleeding
Mucoid discharge
Incontinence
Slide30Rectal Prolapse
Slide31Rectal Prolapse vs. Prolapsed Hemorrhoids
Slide32Mechanical 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
Slide33Abnormal 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
Slide34Abnormal 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
Slide35Fecal 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
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
Slide37Fecal Incontinence
TreatmentImprove stool consistency
Fiber/waterLaxatives or antidiarrheals
Pelvic floor physical therapy
Anal inserts (?)
Sacral Nerve Stimulator
Medtronic
Axonics
Colostomy (only curative option)
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
Slide39Fecal Incontinence
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
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
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
Slide43Does 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
Slide44Questions?