Evaluation and Management of Pelvic Floor Disorders

Educational Objectives

The goal of this program is to improve treatment of pelvic floor disorders. After hearing and assimilating this program, the clinician will be better able to:

1. Explain the symptoms and etiology of functional defecatory disorders.

Summary

Pelvic floor dysfunction: it is more common in women; symptoms may include lower urinary tract symptoms, sexual dysfunction or pain, prolapse or bowel symptoms; ≤76% of women present with urinary tract symptoms; a study has shown that ≈82% of patients with defecatory disorders also had ≥2 urinary symptoms; ≈57% had ≥4 symptoms of voiding

Causes: can be due to overly relaxed muscles or muscles not relaxing enough; with overly relaxed muscles patients complain of incontinence, urinary or fecal, pelvic organ prolapse; this category is easily identified; in cases of muscles that are not relaxed enough, the symptoms are difficult to ascertain; in cases of overly relaxed muscles, specific to bowel, patients describe diarrhea, when they actually mean urgency or fecal incontinence; for muscles that are not relaxed, patients describe constipation or bloating, having difficulty in evacuating stool or sense of incomplete evacuation, or straining in bowel movements

Constipation: primary type constipation involves slower than normal transit constipation; secondary type constipation occurs because of lifestyle issues such as getting too much or no fiber, medications, including opioids, calcium channel blockers, glucagon-like peptide-1 (GLP-1) agonists; almost everyone during travel gets constipated; associated with excessive perineal descent, prolapse or rectocele and possible obstruction, scarring because of a prior surgery; it can be functional as in dyssynergic defecation or inadequate propulsive forces

Functional defecatory disorders: they have no structural basis; not neurologic and no anatomic defect; frequently associated with maladaptive learning, associated with holding, eg, seen in flight attendants, some clinicians; also, association with physical and sexual abuse is seen; sometimes patients might have this after an acute severe bout of constipation; often times associated with anxiety

Physical examination: involves rectal examination, when patients present with bleeding, rectal pain or hemorrhoids; however, it is critical to do examination in constipation too; inspect perineum, assess for perineal descent, hemorrhoids, or other obstructive situation; with digital examination, anal spasms are checked; patients describe knife-like pain with rectal examination

Work-up: a thorough history and physical examination; metabolic causes can be checked based on baseline laboratory testing; patients talk about basic issues such as physical activity; medications should be review for associated constipation; enough hydration (up to 64 oz of water in some patients); discuss with patients ways to improve their stool consistency with fiber intake

Kiwi use in constipation: study in American Journal of Gastroenterology (Chey et al [2021]) assessed 80 patients who had constipation; were randomized to 2 kiwis/day, prunes, or psyllium; all groups had an improvement in their spontaneous bowel movement; stool consistency was better with kiwis and prunes; with kiwi there was much less bloating and adverse effects were fewer

Improving bowel motions: attempt for bowel movement first thing in morning; drinking a large glass of water followed by exercise; drinking a warm beverage, preferably caffeinated (eg, coffee), eating (to have a gastrocolic reflex) helpful; responding to the urge within 6 min preferable; sit up tall; taking deep breaths helpful; 10 min maximum on toilet

Other measures: if conservative measures fail, guidelines recommend next step as anorectal manometry with balloon expulsion test

Biofeedback and pelvic floor retraining: education and instrument-based behavior training shown to be effective; 50% to 90% success is seen; use simulated defecation training with feedback on the rectal balloon to tighten the abdominal wall muscles to help lower the diaphragm and to push stool; there is a visual feedback with anal canal pressure with electromyograph and therapist helps remind the patient to relax the pelvic floor, increase their abdominal pressure, and concentrate on sensations produced by balloon passage

Readings

Chey SW, Chey WD, Jackson K, et al. Exploratory comparative effectiveness trial of green kiwifruit, psyllium, or prunes in US patients with chronic constipation. J Am Coll of Gastroenterol ACG. 2021; 116:1304-1312; Davila GW, Ghoniem GM, Wexner SD. Pelvic floor dysfunction. Springer-Verlag London Limited. 2006; Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. InMayo Clin Proc. 2012; 87:187-193; Rao SS. Dyssynergic defecation. Gastroenterol Clin North Am. 2001; 30:97-114; Talley NJ. Definitions, epidemiology, and impact of chronic constipation. Rev Gastroenterol Disord. 2004; 4:S3-10.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Moleski was recorded at the 40th Annual Advances in Gastroenterology Conference, held June 18, 2022, in Atlantic City, NJ, and presented by the Sidney Kimmel Medical College at Thomas Jefferson University. For more information about upcoming CME activities from this presenter, please visit https://jefferson.edu. Audio Digest thanks the speakers and the Sidney Kimmel Medical College at Thomas Jefferson University, for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GE370103

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.