PELVIC FLOOR DYSFUNCTION
What is pelvic floor dysfunction?
For most people, having a bowel movement is a seemingly automatic function. For some individuals, the process of evacuating stool may be difficult. Symptoms of pelvic floor dysfunction include constipation and the sensation of incomplete emptying of the rectum when having a bowel movement. Incomplete emptying may result in the individual feeling the need to attempt a bowel movement several times within a short period of time. Residual stool left in the rectum may slowly seep out of the rectum leading to reports of bowel incontinence.
The process of defecation (having a bowel movement) requires the coordinated effort of different muscles. The pelvic floor is made up of several muscles that support the rectum like a hammock. When an individual wants to have a bowel movement the pelvic floor muscles are supposed to relax allowing the rectum to empty. While the pelvic floor muscles are relaxing, muscles of the abdomen contract to help push the stool out of the rectum. Individuals with pelvic floor dysfunction have a tendency to contract instead of relax the pelvic floor muscles. When this happens during an attempted bowel movement, these individuals are effectively pushing against an unyielding muscular wall.
How is pelvic floor dysfunction diagnosed?
The diagnosis of pelvic floor disorder starts with a careful history regarding an individual’s symptoms, medical problems and a history of physical or emotional trauma that may be contributing to their problem. Next the physician examines the patient to identify any physical abnormality. A defecating proctogram is a study commonly used to demonstrate the functional problem in a person with pelvic floor dysfunction. During this study, the patient is given an enema of a thick liquid that can be detected with x-ray. A special x-ray video records the movement of the pelvic floor muscles and the rectum while the individual attempts to empty the liquid from the rectum. Normally the pelvic floor relaxes allowing the rectum to straighten and the liquid to pass out of the rectum. This study will demonstrate if the pelvic floor muscles are not relaxing appropriately and preventing passage of the liquid.
The defecating proctogram is also useful to show if the rectum is folding in on itself (rectal prolapse). Many women have outpouching of the rectum known as a rectocele. Usually a rectocele does not affect the passage of stool. In some instances, however, stool may become trapped in a rectocele causing symptoms of incomplete evacuation. The defecating proctogram helps to identify if liquid is getting trapped in a rectocele when the individual is trying to empty the rectum.
How is pelvic floor dysfunction treated?
Pelvic floor dysfunction due to non-relaxation of the pelvic floor muscles may be treated with specialized physical therapy known as biofeedback. With biofeedback, a therapist helps to improve a person’s rectal sensation and pelvic floor muscle coordination. There are various effective techniques used in biofeedback. Some therapists train patients by teaching them to expel a small balloon placed in the rectum. Another technique uses a small probe placed in the rectum or vagina or electrodes placed on the surface of the skin around the opening to the rectum (anus) and on the abdominal wall. These instruments detect when a muscle is contracting or relaxing and provide visual feedback of the muscle action. This visual feedback helps the individual to understand the muscle movement and aids in improving muscle coordination. Approximately 75% of individuals with pelvic floor dysfunction experience significant improvement with biofeedback.
Abnormalities identified with a defecating proctogram such as rectal prolapse and rectocele may be treated with a surgical procedure.
What is Rectal Prolapse?
Rectal prolapse is a condition in which the rectum (the lower end of the colon, located just above the anus) becomes stretched out and protrudes out of the anus. Weakness of the anal sphincter muscle is often associated with rectal prolapse at this stage, resulting in leakage of stool or mucus. While the condition occurs in both sexes, it is much more common in women than men.
Why does it occur?
Several factors may contribute to the development of rectal prolapse. It may come from a lifelong habit of straining to have bowel movements or as a late consequence of the childbirth process. Rarely, there may be a genetic predisposition. It seems to be a part of the aging process in many patients who experience stretching of the ligaments that support the rectum inside the pelvis as well as weakening of the anal sphincter muscle. Sometimes rectal prolapse results from generalized pelvic floor dysfunction, in association with urinary incontinence and pelvic organ prolapse as well. Neurological problems, such as spinal cord transection or spinal cord disease, can also lead to prolapse. In most cases, however, no single cause is identified.
Is rectal prolapse the same as hemorrhoids?
Some of the symptoms may be the same: bleeding and/or tissue that protrudes from the rectum. Rectal prolapse, however, involves a segment of the bowel located higher up within the body, while hemorrhoids develop near the anal opening.
How is rectal prolapse diagnosed?
A physician can often diagnose this condition with a careful history and a complete anorectal examination. To demonstrate the prolapse, patients may be asked to sit on a commode and "strain" as if having a bowel movement.
Occasionally, a rectal prolapse may be "hidden" or internal, making the diagnosis more difficult. In this situation, an x-ray examination called a videodefecogram may be helpful. This examination, which takes x-ray pictures while the patient is having a bowel movement, can also assist the physician in determining whether surgery may be beneficial and which operation may be appropriate. Anorectal manometry may also be used to evaluate the function of the muscles around the rectum as they relate to having a bowel movement.
How is rectal prolapse treated?
Although constipation and straining may contribute to the development of rectal prolapse, simply correcting these problems may not improve the prolapse once it has developed. There are many different ways to surgically correct rectal prolapse.
Abdominal or rectal surgery may be suggested. An abdominal repair may be approached laparoscopically in selected patients. The decision to recommend an abdominal or rectal surgery takes into account many factors, including age, physical condition, extent of prolapse and the results of various tests.
How successful is treatment?
A great majority of patients are completely relieved of symptoms, or are significantly helped, by the appropriate procedure. Success depends on many factors, including the status of a patient's anal sphincter muscle before surgery, whether the prolapse is internal or external, the overall condition of the patient. If the anal sphincter muscles have been weakened, either because of the rectal prolapse or for some other reason, they have the potential to regain strength after the rectal prolapse has been corrected. It may take up to a year to determine the ultimate impact of the surgery on bowel function. Chronic constipation and straining after surgical correction should be avoided.
What is a rectocele?
A rectocele is a bulging of the front wall of the rectum into the back wall of the vagina. Rectoceles are usually due to thinning of the rectovaginal septum (the tissue between the rectum and vagina) and weakening of the pelvic floor muscles. This is a very common defect; however, most women do not have symptoms. There can also be other pelvic organs that bulge into the vagina, leading to similar symptoms as rectocele, including the bladder (i.e., cystocele) and the small intestines (i.e. enterocele).
What can lead to developing a rectocele?
There are many things that can lead to weakening of the pelvic floor, resulting in a rectocele. These factors include: vaginal deliveries, birthing trauma during vaginal delivery (e.g. forceps delivery, vacuum delivery, tearing with a vaginal delivery, episiotomy during vaginal delivery), history of constipation, history of straining with bowel movements, and history of gynecological (hysterectomy) or rectal surgeries.
What are the symptoms associated with a rectocele?
Most people with a small rectocele do not have symptoms and it is often only discovered during routine physical examination. When the rectocele is large, it most commonly presents with a noticeable bulge into the vagina. Other rectal symptoms may include: difficulty with evacuation during a bowel movement, the need to press against the vagina and/or space between the rectum and the vagina in order to have a bowel movement, straining with bowel movements, constipation, the urge to have multiple bowel movements throughout the day, and rectal pain. Occasionally, the stool becomes stuck in the bulge of the rectum, which is why it is difficult to have a bowel movement. Vaginal symptoms can include: pain with sexual intercourse (dyspareunia), vaginal bleeding, and a sense of fullness in the vagina.
How can a rectocele be diagnosed?
A rectocele is usually found incidentally during a physical examination by your doctor. The evaluation of its severity, and potential relation to constipation symptoms, is hard to assess with physical examination alone. Further testing for a rectocele may include the use of a special x-ray study known as defecography (contrast material instilled into the rectum as an enema, followed by live x-ray imaging during a bowel movement). This study is very specific and can evaluate a rectocele’s size and ability to completely empty.
How can a rectocele be treated?
Rectoceles are not treated merely for their presence, but should only be addressed when they are associated with significant symptoms that interfere with quality of life. Prior to any treatment, there should be a thorough evaluation by your doctor to assess whether all of the complaints can be attributed to the presence of a rectocele alone. There are both medical and surgical treatment options for rectoceles. The majority of symptoms associated with a rectocele can be resolved with medical management; however, treatment depends on the severity of symptoms.
How can a rectocele be treated with medical management only?
It is very important to have a good bowel regimen in order to avoid constipation and straining with bowel movements. A high fiber diet, consisting of 25-30 grams of fiber daily, will help with this goal. This may be achieved with a fiber supplement, high fiber cereal, or high fiber bars. In addition to augmenting fiber intake, increased water intake (typically 6-8 glasses daily) is also highly recommended. This will allow for softer stools that do not require significant straining with bowel movements, thereby reducing your risk for having a bulge associated with a rectocele. Other treatments may include pelvic floor exercises such as Kegel exercises (i.e. biofeedback), stool softeners, hormone replacement therapy, and avoidance of straining with bowel movements. At times, it is also helpful to apply pressure to the back of the vagina during bowel movements.
How can a rectocele be treated with surgical management?
The surgical management of rectoceles should only be considered when symptoms continue despite the use of medical management and are significant enough that they interfere with activities of daily living. There are abdominal, rectal, and vaginal surgeries that can be performed for rectoceles. The choice of procedure depends on the size of the rectocele and its associated symptoms. Most surgeries aim to remove the extra tissue that makes up the rectocele and strengthening the wall between the rectum and vagina with surrounding tissue or use of a mesh (i.e. patch). Colorectal surgeons, as well as gynecologists, are trained in the diagnosis and treatment of this condition. The success rate of the surgery depends upon the specific symptoms and symptom duration. Some of the risks of surgical correction of the rectocele are bleeding, infection, pain during intercourse (dyspareunia), as well as a risk that the rectocele may recur or worsen.
author: Jennifer Speranza, MD, FACS, FASCRS, on behalf of the ASCRS Public Relations Committee