Pelvic Floor Disorder Affecting Defaecation Joint Hospital Surgical Grand Round CY Cheung Queen Mary Hospital

Constipation : common disorder. 10-15% of population Slow transit Obstructive defaecation ->> pelvic floor disorder Standard therapy: fibre, water intake, timed bowel opening, exercise, +- laxatives Some failed to standard therapy -? Further investigation and management

Constipation Common complaint Rome III criteria for constipation 2 or more of the following Straining ≧25% Lumpy or hard stools ≧ 25% Sensation of incomplete evacuation ≧ 25% Sensation of anorectal obstruction / blockage ≧ 25% Manual maneuvers ≧ 25% <3 defaecations per week Loose stool rarely present without use of laxatives ≧3days / month in past 3 months Symptom onset ≧ 6months prior to diagnosis Not fulfilling IBS criteria Alame AM et al. Clin Colon Rectal Surg 2012

Causes of constipation Slow transit constipation Young adult Laxative dependent Megacolon / Megarectum Elderly Assosciated with neurological conditions Obstructed defaecation syndrome Dyssynergic defaecation Rectal prolapse Rectocoele Secondary causes Drugs, neurological conditions, hypothyroidism etc.

Physiology of defaecation (detailed explanation of diagram) Th e superfi cial layers include the internal anal sphincter (IAS) and external anal sphincter (EAS), perineal body, and transverse perinei muscles ( 2 ). Th e deeper pelvic muscles, also known as levator ani, consist of the pubococcygeus, ileococcygeus, and puborectalis. Th e pelvic fl oor receives nerve supply from the pudendal and perineal nerves and sympathetic and parasympathetic nerves. Branches from the sacral nerve roots of S2, S3, and S4 innervate the pelvic fl oor muscles. Th e puborectalis muscle (middle layer of pelvic fl oor muscle) is actually innervated by the pudendal nerve and the deep muscles (pubococcygeus, ileococcygeus, and coccygeus) are innervated by the direct branches of sacral nerve roots S3 and S4 ( 3 ). During normal defecation, the voluntary eff ort of bearing down increases the intraabdominal pressure, together with the contraction of the rectum and perineal muscles. Simultaneously, the anal sphincters and puborectalis relax, the anorectal angle widens, and the perineum descends. Th ese sequential movements facilitate the movement of stool from the rectum, resulting in stool evacuation ( Schey R, et al. Am J Gastroenterol 2012;107

Pelvic floor disorder affecting constipation Functional Dyssynergic defaecation Structural Rectocele Rectal prolapse Descending perineum syndrome Common pelvic floor disorder

Dyssynergic defaecation Paradoxical anal contraction, inadequate anal relaxation +/- impaired push effort due to incoordination of abdominal, rectal and anal muscles In about 50% of patients with chronic constipation Also known as pelvic floor dyssynergia, obstructed defaecation, outlet obstruction, or animus Rao SS, et al. J Clin Gastroenterol 2004;38

Dyssynergic defaecation Diagnostic criteria Rome III criteria for chronic constipation Paradoxical increase of anal sphicter pressure / <20% relaxation of the resting pressure during defaecation At least 2 of the followings: Failed balloon expulsion test >50% retention of barium during defaecography Retention of >5 markers in colonic transit study Rao SS, et al. J Clin Gastroenterol 2004;38

Schey R, et al. Am J Gastroenterol 2012;107 Outline of management Schey R, et al. Am J Gastroenterol 2012;107

History Frequency Consistency Straining Sense of incomplete emptying or obstruction Use of manual maneuvers Constitutional symptoms Alternating bowel habit Passage of blood / mucus Other medical history Drug history

Physical examination Abdominal examination Digital rectal examination Inspection Perineal sensation PR exam Stricture, mass, blood, impacted stool Resting tone, spasm Squeeze Anal sphincter and puborectalis muscle Bear down Relaxation of EAS +/- puborectalis muscle Perineal descent 77% sensitivity, 87% specificity for diagnosing dyssynergic defaecation Inspect – fissure fistula, haemorrhoid, skin tag, SCC Tantiphlachiva K, et al. Clin Gastroenterol Hepatol 2010;8

Investigations Colonoscopy and blood tests Anorectal manometry Balloon expulsion test Colonic transit study Colonic transit scintigraphy Wireless motility capsule test Barium defaecography MR defaecography Pudendal nerve terminal motor latency Specific investigations for pelvic floor disorder

Anorectal manometry Water-perfused anorectal manometry 3cm-interval sideholes High-resolution anorectal manometry Used in oesophageal motility study 36-channel catheter with sensors spaced at 1cm intervals Provides greater anatomical details Jones MP, et al. Am J Gastroenterol 2007

Anorectal manometry

Anorectal manometry

Anorectal manometry Healthy adults Rao SS, et al. Am J Gastroenterol 1999;94

High-resolution anorectal manometry Healthy Brief explanation of the healthy and abnormal HRM image High resolution manometer (HRM) image. ( a ) HRM image of a healthy control showing manometric and topographic features during an attempted defecation maneuver. The upper part of the panel shows pressure changes from the rectum indicating that subject generated a good push effort. The lower part of the panel shows topographic images from the entire anal canal and puborectalis showing that both the anal sphincter and puborectalis relaxed normally with a signifi cant drop in pressure. The location of sensors from the anal verge and the pressure gauge as represented by the various colors are also shown. ( b ) HRM image of a patient with constipation showing manometric and topographic features during two attempted defecation maneuver. The upper part of the panel shows pressure changes from the rectum indicating that patient generated a good push effort. The lower part of the panel shows topographic images sphincter and puborectalis exhibited paradoxical anal contraction, typical of dyssynergic defecation. Abnormal Schey R, et al. Am J Gastroenterol 2012

Balloon expulsion test 50ml water filled balloon Normal expulsion time 1 minute Simple screening test High specificity but low sensitivity

Colonic transit study >5 / 24 markers (>20%) present after 5 days Slow transit constipation coexist in 2/3 of patients with dyssynergic defaecation

Wireless motility capsule test SmartPill ® Wireless pH, temperature and pressure recording capsule Assess regional (stomach, SB, colon) and whole gut transit time No radiation

MR defaecography Visualizes the pelvic viscera during the defaecation phase Rectal prolapse Rectocele Descending perineum syndrome Enterocoele Add video of MRD

MR defaecography Closed vs open configuration Mid-sagital slice chosen and repeated at 2- second intervals 4 phases Rest Maximal sphincter contraction Maximal strain Defaecation Size of pelvic visera descent, rectocoele Degree and thickness of rectal prolapse Fiaschetti V, et al. Radiol Med 2011;116

Pudendal nerve terminal motor latency Time from stimulation of the pudendal nerve to muscular contraction of the external anal sphincter Normal latency = 2.1 milliseconds±0.2 milliseconds Gurland B etal. Clin Colon Rectal Surg 2008

Schey R, et al. Am J Gastroenterol 2012;107 Outline of management Schey R, et al. Am J Gastroenterol 2012;107

References Schey R, et al. Medical and surgical management of pelvic floor disorders affecting defecation. Am J Gastroenterol 2012;107(11):1624-33. Raizada V, et al. Pelvic floor anatomy and applied physiology. Gastroenterol Clin North Am 2008;37:493,509,vii. Jones MP, et al. High-resolution manometry in the evaluation of anorectal disorders: a simultaneous comparison with water-perfused manometry. Am J Gastroenterol 2007;102(4):850-5. Rao SS, et al. Dyssynergic defecation: demographics, symptoms, stool patterns, and quality of life. J Clin Gastroenterol 2004;38: 680–5. Tantiphlachiva K, et al. Digital rectal examination is a useful tool for identifying patients with dyssynergia. Clin Gastroenterol Hepatol 2010;8: 955–60. Rao SS, et al. Manometric tests of anorectal function in healthy adults. Am J Gastroenterol 1999;94:773–83. Fiaschetti V, et al. Dynamic MR defecography with an open-configuration, low-field, tilting MR system in patients with pelvic floor disorders. Radiol Med 2011;116:620–33. Alame MA et al. Evaluation of consipation. Clin Colon Rectal Surg 2012;25:5-11. Gurland B et al. Transrectal Ultrasound, Manometry, and Pudendal Nerve Terminal Latency Studies in the Evaluation of Sphincter Injuries. Clin Colon Rectal Surg 2008;21(3):157-66.

Acknowledgement Dr. Oswens Lo Siu Hung

Thank You!

Extracolonic constipation Diet Drugs Anticholinergics, Antidepressants, Antiparkinsonian Antacids,Diuretics, Hypotensives, Opiates Ganglionic Blockers, MAO Inhibitors, Hematinics (Iron) Metals (Arsenic), Paralytic Agents, etc Neurological Spinal: Meningocele, Trauma, Paraplegia Cerebral: Parkinson, Tumor Peripheral: Autonomic Neuropathy, MS Endocrine/Metabolic Hypothyroidism, DBT, Uremia Hyperkalemla, Pregnancy Psychological Depression Anorexia Nervosa

Colonic consipation Structural Anatomic Pelvic Etiology Anatomic Colonic Etiology: Tumors Megabowel Hirschprung’s Disease Chagas’ Disease Anatomic Pelvic Etiology Rectocele, Sigmoidocele Intussusception/Perineum Sx Anal Stenosis/Anal Tumor Colonic Dismotility Colonic Inertia Physiologic Outlet Obstruction Paradoxical Puborectalis Contraction Anismus (Spastic Pelvic Floor)

Dyssynergic defaecation Biofeedback therapy Correct underlying dyssynergia Improve rectal sensory perception How? Manometric probe into rectum to provide instant feedback to the patient Attempts to expel artificial stool Advice and feedback provided to improve defaecatory effort Rao SS. Gastroenterol Clin North Am 2008;37

Dyssynergic defaecation Biofeedback therapy Shown to be effective and superior than standard therapy or laxatives in RCTs Not effective in isolated slow transit constipation Shown in different RCTs Rao SS, et al. Am J Gastroenterol 2010;105 Chiarioni G, et al. Gastroenterology 2006;130 Heymen S, et al. Dis Colon Rectum 2007;50

Rectocele Abnormal sac-like protrusion of the rectal wall either towards the vagina or rarely toward the sacrum Apparent during defaecation

Rectocele Mostly asymptomatic and <2cm Multiple vaginal deliveries Chronic constipation with excessive straining Ass. with dyssynergic defaecation Clinical significant if >3cm with retention of barium or stool

Treatment Medical therapy Biofeedback therapy if DD coexist Surgery for large size after failure of medical therapy Transanal approach Transperineal approach Surgery need tailor made for patient. ?uterovaginal prolapse,rectal prolapse Transperineal approach generally better Transanal stapled resection of redundant anterior / posterior rectal wall  ideal for rectocele and DD. But some study showed high long term relapse rate

Rectal prolapse Abnormal protrusion of rectal wall through anus Excessive straining Pudendal neuropathy Anal protrusion Rectal bleeding Symptoms of obstructed defaecation Faecal incontinence

Rectal prolapse Grade 1 - 2 Grade 3 - 4 Medical therapy Biofeedback therapy Grade 3 - 4 Surgery Abdominal approach Sacral fixation by mesh rectopexy / posterior suture +/- resection of redundant sigmoid colon Perineal approach Perineal proctosigmoidectomy +/- Transperineal levatoroplasty Abd approach higher risk. Recurrence rates for transabdominal rectopexy are low (0 – 8 % ); however, aft er posterior rectopexy 50 % of patients complain of severe constipation ( 47 ). Perineal procedures have a recurrence rate of 5 – 21 % with similar incidence of constipation.

Descending perineum syndrome Ballooning and excessive descent of perineum during straining below the bony outlet of the pelvis >4cm descent during maximal push effort Pubococcygeal line

Descending perineum syndrome Painful defaecation Excessive straining Sense of incomplete evacuation Faecal incontinence Treatment Correct excessive straining Artificial perineum supporting device (defecom) Biofeedback therapy Retro-anal levator plate myorrhaphy for isolated DPS Defecom + biofeedback -> improve symptoms in 50% of patient