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

2. 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

3. 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

4. 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.

5. 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

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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. Anorectal manometry

16. Anorectal manometry

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

18. 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

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

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

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

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

23. 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

24. 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

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

26. References
Schey R, et al. Medical and surgical management of pelvic floor disorders affecting defecation. Am J Gastroenterol 2012;107(11):
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):

27. Acknowledgement
Dr. Oswens Lo Siu Hung

28. Thank You!

30. 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

31. 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)

32. 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

33. 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

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

35. 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

36. 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

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

38. 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.

39. 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

40. 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