Evaluation and Treatment of Pelvic Floor Disorders

□ Review □

대한대장항문학회지 2007;23:206-220

Evaluation and Treatment of Pelvic Floor Disorders Department of Surgery, Chungbuk National University School of Medicine, Cheongju, Korea

Sang-Jeon Lee, M.D.

Pelvic floor disorders are of interest to many surgeons who specialize in organ system s within this region. Colorectal surgeons are especially interested in disorders of the posterior compartm ent, which may broadly be divided into defecation disorders and fecal incontinence. These disorders distress patients socially and psychologically and greatly impair their quality of life. The underlying anatom ical and pathophysiological changes are com plex, are often incom pletely understood, and cannot always be determined. However, over the past decades, advances in the understanding of these disorders, together with rational methods of evaluation in anorectal physiology laboratories, radiology studies, and new surgical techniques, have led to promising results. This review summarizes the evaluation and treatment strategies, as well as the recent updates on the clinical and the therapeutic aspects of pelvic floor disorders. J Korean Soc C oloproctol 2007;23:206-220

diaphragm floor and may be divided into three muscles: the puborectalis, the iliococcygeus, and the pubococcygeus. The puborectalis arises and inserts on the parasymphyseal portion of the pubic rami. It extends posteriorly to form a sling around the rectum, which serves two purposes: (1) the orifices of the pelvic floor are kept closed and (2) the bladder neck is elevated and compressed against pubic symphysis. The iliococcygeus provides a physical barrier to organ descent and is the major support of the posterior compartment. Both muscles help to maintain a stable position of the pelvic organs, as well as fecal and urinary continence. The pelvic organs are also supported by a series of fascial condensations called

Key W ords: Pelvic floor disorders, Defecation disorders, Fecal incontinence

ligaments. Laxity of the supporting muscles and stretching or tearing of the fascial supports lead to pelvic floor

󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

relaxation. These deficits become greater in the middleaged and elderly. Tears in the rectovaginal fascia lead to

INTRODUCTION

the formation of rectoceles and enteroceles and, occasionally, rectal intussusceptions. These women may present

The pelvic diaphragm supports the pelvic organs, con-

with constipation or a feeling of incomplete defecation.

tracts during increased abdominal pressure (coughing,

The motor supply of the puborectalis muscle remains

straining), and has an important coordinated role during

controversial: direct pelvic branches of S3 and S4, the

defecation. The pelvic floor can be divided into three

inferior rectal branch of the pudendal nerve, or a

compartments: (1) the anterior compartment, which con-

combination of the two. The pubococcygeus and il-

tains the bladder and the urethra, (2) the middle com-

iococcygeus muscles are supplied on their superior

partment, which contains the vagina, the cervix, and the

aspects by S4 and on their inferior aspects by perineal

uterus, and (3) the posterior compartment, which contains

branches of pudendal nerves. Damage to the innervation

the rectum. The levator ani forms the posterior pelvic

can also lead to laxity of the supporting muscles and pelvic floor relaxation. The rectum serves as a storage organ and as a conduit

Correspondence to: Sang-Jeon Lee, Department of Surgery, Chungbuk National University School of Medicine, 12, Gaeshindong, Heungduk-gu, Cheongju 361-763, Korea. Tel: +82-43-269-6360, Fax: +82-43-266-6037 E-mail: [email protected] This work was supported by the research grant of the Chungbuk National University in 2006.

from the colon to the anal canal. The anal canal is defined proximally by the levator ani muscles, which form part of the pelvic floor, and includes the puborectalis muscle, which creates the anorectal angle. Both continence and defecation rely heavily on the appropriate functioning of

206

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이상전. 골반저 질환의 평가와 치료

the puborectalis muscle, internal anal sphincter (IAS), and

atation proximal to the non-relaxing, non-propulsive

external anal sphincter (EAS), but other factors also play

segment of the distal bowel. Intramural ganglion cells of

important roles. These include stool consistency, volume

the submucosal and myenteric plexuses are absent in the

and delivery of colon contents to the anorectum, rectal

affected segment of the distal bowel as a result of failure

storage capacity, anal and rectal sensations, and cognitive

of migration of ganglion cell precursors from the neural

and behavioral influences. Pelvic floor disorders in which

crest into the hindgut during fetal development.

3

colorectal surgeons are usually interested are conditions

A rectocele, an outpocketing of the rectovaginal wall

causing constipation due to pelvic outlet obstruction: non-

into the lumen of the vagina, is frequently found when

relaxation or paradoxical contraction of the puborectalis,

4 patients are investigated for constipation. It can cause

rectoceles, enterocele/sigmoidoceles, rectal intussusception/

anorectal symptoms, such as incomplete evacuation

prolapse, solitary rectal ulcer syndrome (SRUS), descend-

necessitating rectal or vaginal digitation, perineal support

ing perineum syndrome, etc., or fecal incontinence.

maneuvers, or perineal pressure or the sensation of a pouch in the vagina. The rectovaginal septum can

DEFECATION DISORDERS 1) Pathophysiology Two major paradigms, which are not mutually exclusive in a given patient are currently used to explain 1

attenuate with increasing age and parity in women, allowing the rectum to protrude into the vagina during evacuatory efforts. Childbirth and excessive straining at defecation are known risk factors.

5

Other suggested

associated conditions are post-menopausal status, con-

constipation. The first of these is slow transit con-

nective tissue disorders, and a hysterectomy. The rela-

stipation, in which there is failure of coordinated motor

tionship between rectoceles and pre-existing defecatory

activity to move luminal contents through the colon. The

dysfunction is unknown, that is, whether prolonged

alternative mechanism involves disorders of the ano-

straining results in a rectocoele which, when it reaches

rectum and pelvic floor, causing obstructed defecation

a critical size, results in stool trapping and prolonged

(pelvic outlet obstruction). In this paradigm, the primary

straining. What is clear is that most rectoceles are

failure is an inability to adequately evacuate contents

asymptomatic, but that defecation difficulties may arise

from the rectum. Two different conditions can produce

when expulsive forces are misdirected into a large pouch.

pelvic outlet obstruction. The first is functional obstruction:

There are three levels of a rectocele-high, mid, and low.

non-relaxation or paradoxical contraction of the pubo-

A high rectocele is usually due to a stretching or

rectalis (anismus, pelvic floor dyssynergia), Hirschsprung's

disruption of the upper third of the vaginal wall and the

disease, and descending perineum syndrome. The second

cardinal or uterosacral ligaments and is frequently asso-

is anatomic obstruction: rectocele, enterocele/sigmoidocele,

ciated with a sigmoidocele, cystocele, and uterine pro-

and rectal intussusception/prolapse. Other rare causes

lapse. A mid-level rectocele is the most frequently seen.

include rectal hyposensitivity (blunted rectum), an idio-

It is caused by the loss of pelvic floor support and is

pathic megarectum, hereditary internal sphincter myopathy,

influenced by parturition. Low-level rectoceles are usually

and a nutcracker anus.

the consequence of perineal body defects secondary to an

6

Non-relaxation or paradoxical contraction of the

inadequately repaired major obstetric injury or an overdis-

puborectalis appears to be an acquired disorder of

tention during childbirth. Rectoceles may also be clas-

defecation. Most patients show an inability to coordinate

sified according to their size:

the abdominal, rectoanal, and pelvic floor muscles during

(2～4 cm), and big (＞4 cm); the clinical severity of the

2

7,8

small (＜2 cm), medium

attempted defecation. Additionally, two thirds of patients

bulge (the International Continence Society) may be

may exhibit impaired rectal sensation.

classified as Stage I, the most distal portion of the

Hirschsprung's disease is a classic example of outlet

rectocele is ＞1 cm above the level of the hymen; Stage

obstruction. It is a congenital disorder characterized by

II, ≤1 cm proximal or distal to the plane of the hymen;

obstipation from birth and is associated with colonic dil-

Stage III, ＞1 cm below the plane of the hymen. The

9

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Journal of the Korean Society of Coloproctology: Vol. 23, No. 3, 2007 10

clinical relevance of rectoceles is questionable.

Recto-

sigmoid colon. It is frequently associated with rectal 12

The

celes less than 2 cm usually are accepted as a normal

intussusception (55%) or a rectal prolapse (38%).

finding whereas lesions greater than 2 cm in diameter can

suggested mechanism of pelvic outlet obstruction caused

11

cause symptoms.

Rectoceles present on defecography in 12

81% of asymptomatic women.

by a sigmoidocele is collapse of the rectal wall as a result of extrinsic compression of the hernia contents and stasis

Rectoanal intussusception (internal rectal prolapse) is an infolding of the rectum into. But not beyond, the anal verge, and this is usually a normal finding. It can be

of the sigmoid loop. 2) Evaluation

associated with SRUS, an uncommon benign condition

The first step is taking the history to make sure that

characterized by rectal bleeding, copious mucus dis-

the patient does, in fact, suffer from chronic constipation

charge, pain, and difficult evacuation.

from a defecation disorder. Obstructed defecation is usu-

An enterocele is defined as a peritoneum-lined sac

ally defined on the basis of symptoms and physiologic

herniating down between the vagina and the rectum and

and radiologic studies. Symptoms include a feeling of

13

is filled with abdominal content, often the small bowel.

incomplete evacuation and rectal obstruction, passage of

Concomitant abnormal findings, such as perineal descent,

hard stools, rectal or vaginal digitation, and excessive

rectoceles, and rectal intussusception, are frequently en-

straining.

14

The characteristic symptoms resulting from

The physical examination and screening tests, if deemed

an enterocele are not well understood. In general, females

appropriate, should also eliminate diseases to which con-

with an enterocele may express a feeling of pelvic

stipation is secondary. It is mandatory to perform a

heaviness and a bearing-down sensation, especially when

detailed physical examination; extracolonic and structural

standing. Pelvic pain may occur because the pull of

disorders should be excluded. Colonoscopy or flexible

gravity stretches the mesentery of the contents of the sac.

sigmoidoscopy with a contrast barium enema is the

It is controversial whether an enterocele causes evacuation

optimal study to exclude intraluminal pathology. A

countered.

difficulty.

15

barium enema is also useful when screening for structural

A sigmoidocele is a protrusion of the peritoneum

abnormalities, such as a megacolon/megarectum, and for

between the rectum and the vagina that contains the

demonstrating the aganglionic distal bowel segment seen

Fig. 1. Treatment algorithm for obstructed defecation (Adapted from Khaikin M, Wexner SD. Treatment strategies in obstructed defecation and fecal incontinence. World J Gastroenterol 2006;12:3168-73.).

Lee S-J. Evaluation and Treatment of Pelvic Floor Disorders 209

in classic Hirschsprung's disease.

observations possible with these techniques, the most

A proctological examination confined to a perineal/

relevant are (1) the failure of the anorectal angle to open

rectal examination is advisable, and it is comprised of a

during defecation and (2) the degree of pelvic floor

visual inspection of the pelvic floor, as well as a digital

descent during defecation. Decreased descent is a com-

rectal examination at rest and during straining and

ponent of impaired pelvic floor relaxation; conversely,

squeezing. Proctoscopy should also be performed at rest

excessive descent (descending perineum syndrome) can

and at straining. These allow the recognition of rectoceles,

also be a pathophysiologic mechanism of constipation. In

pelvic floor descent, non-relaxation or paradoxical con-

this instance, excessive straining, internal intussusception,

traction of the puborectalis/external anal sphincter, and

solitary rectal ulcers, and prolapse may also occur.

internal/external rectal prolapse. A number of diagnostic

scintigraphic method has also been described. Evacuation

tests more sensitive than a proctological examination may

scintigraphy evaluates anorectal angulation and pelvic

be used to evaluate patients with possible defecation

floor descent during evacuation and can quantify the

disorders (Fig. 1). These include defecography, electro-

22 evacuation of artificial stools. Its advantage is simplicity

myography, anorectal manometry, the balloon expulsion

and minimal radiation exposure; the disadvantage is that

test, dynamic pelvic magnetic resonance imaging (MRI),

anatomic defects may not be seen as well as with barium

etc. (Table 1).

16,17

18-21

A

defecography.

(1) Defecography: Defecography can be performed

(2) Sphincter electromyography: Sphincter electromyo-

either in conjunction with a standard barium enema (for

graphy may identify inappropriate activity of the pubo-

structural evaluation of the whole colon) or introducion of

rectalis or external sphincter (or both) during attempted

barium thickened to a consistency approximating stool

defecation.

into the rectum. Evacuation of the barium is monitored

features consistent with pelvic outlet obstruction.

23

Failure to relax and increased activity are 24

by fluoroscopy or videotape while the patient sits on a

(3) Anorectal manometry: Measurements of anal

specially constructed commode. Defecography provides a

canal pressures and anal sphincter responses are obtained

two-dimensional quantification of rectal parameters; thus,

in anorectal manometry, which has an important role in

an anatomic/functional evaluation of defecation can be

the assessment of internal and external anal sphincter tone

performed at the same time. Still radiographs are taken

and rectal function, although experienced surgeons would

to allow features such as anorectal angle, anal canal

derive comparable information from a careful digital

length, puborectalis length, and perineal descent to be

rectal examination. This test also provides information on

measured. Fluoroscopy detects anorectal intussusception,

rectal sensation and compliance, reflexive relaxation of

rectoceles, sigmoidoceles, and perineal descent. Of the

the IAS, and manometric patterns produced on attempted expulsion of the balloon apparatus. The presence of IAS

Table 1. Suggested physiology laboratories for evaluation of pelvic floor disorders 󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚 Diagnosis Studies 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 Constipation Manometry, EMG-S, defecography, BET Fecal incontinence Obstetric Manometry, EMG-L, endoanal USG Uncertain etiology Manometry, EMG-L, endoanal USG, defecography Prolapse Manometry, EMG-L, defecography, dynamic pelvic MRI 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 EMG-S = sphincter EMG; EMG-L = measurement of PNTML; BET = balloon expulsion test.

relaxation following rectal distension excludes Hirs3

chsprung's disease from consideration. Clinical practice suggests the greatest value is in (1) excluding Hirschsprung's disease by the presence of a normal rectoanal inhibitory reflex and (2) providing supportive data for clinical or physiologic suggestions of pelvic floor dysfunction. For example, high basal sphincter pressures with relatively little voluntary augmentation suggest paradoxical contraction of the puborectalis. (4) Balloon expulsion test: The balloon test quantifies the ability of a patient to evacuate a water-filled (usually 50～60 ml) balloon. It can be performed easily in conjunction with anorectal manometry and can be quantified

210

대한대장항문학회지: 제 23 권 제 3 호, 2007

by noting the magnitude of additional passive forces

assess complex prolapses involving more than one pelvic

needed to expel the balloon if spontaneous evacuation is

compartment. Prolapse of the various pelvic compart-

not possible. Although never evaluated systematically, it is

ments is detected with respect to organ position relative

a simple, useful screening test for major dysfunctions of

to the pubococcygeal line during dynamic phases.

25

evacuation

and can serve as a functional marker for

biofeedback programs of pelvic floor retraining.

26

3) Treatment

Paradoxical contraction of the puborectalis is associated

Obstructed defecation is a common subtype of con-

with the contour of the puborectalis muscle increasing or

stipation. The common treatment for chronic constipation

the anorectal angle decreasing in defecography. In

is high dietary fiber and laxatives. However, some patients

addition, the suspicion of impaired defecation may be

are unresponsive to these measures, which has led the use

confirmed by the patient's inability to expel a rectal

of alternative treatments, such as biofeedback training.

balloon. Paradoxically, increased anal pressure in manom-

Failure of the pelvic floor and anal sphincter muscles to

etry or electromyographic activity in a sphincter EMG

relax during straining seems to be the mast common cause

during straining is also readily detected.

of obstructed defecation. Biofeedback to teach patients to

In approximately two-thirds of patients with rectoceles,

inhibit this paradoxical behavior has been proposed as an

physical examination alone can be diagnostic, but is not

effective treatment, but the mechanisms of action are still

adequate to assess emptying ability accurately. Defeco-

unclear, and controlled studies are lacking (Fig. 1).

graphy has been shown to be the most useful physiologic

In patients with rectoceles, surgical treatment should be

test for this purpose. Co-existing causes of constipation,

restricted to patients in whom clinical, physical, and

such as rectoanal intussusception, non-relaxation or para-

physiologic findings confirm the rectocele primary cause

doxical contraction of the puborectalis, and sigmoidoceles,

of the symptoms. Treatment of a rectocele is usually

are commonly observed. These associated conditions may

indicated when a herniation of the anterior rectal wall is

be predictors of a poor outcome after surgical rectocele

greater than 3 cm with significant clinical symptoms or

repair because the rectocele may be only a secondary

with a non-emptying rectocele on defecography. However,

condition.

there is no correlation between the severity of symptoms,

Colonic transit studies using radio-opaque markers are

contrast material retention, the depth of a rectocele, and 27

useful in patients with complaints of infrequent or

success of the repair.

difficult defecation. They are particularly useful when a

conservative therapy fails and includes transvaginal pos-

pattern of slow transit with outlet delay is present, as this

terior colporrhaphy, and transrectal or transperineal repair.

raises the possibility of a defecation disorder. Neither the

The success rates of the three techniques seem com-

presence of normal colonic transit nor the delay of marker

parable. Careful patient selection is very important for a

passage through the proximal colon excludes a defecation

successful outcome. Two new techniques include the

disorder.

double stapled trans-anal rectal resection (STARR) and

Surgery is considered when

Patients with a chronic idiopathic megacolon or me-

single stapled trans-anal prolapsectomy with perineal

garectum have increased rectal compliance and elasticity,

levatorplasty (STAPL) for the management of obstructed

blunted rectal sensation, and increased thresholds and

defecation associated with a rectocele or intussusception.

smaller degrees of relaxation of the IAS in response to

These methods use one or two circular staplers to perform

rectal distension. In this disorder, propulsive forces are

mucosal

diminished, and sensory signals that normally alert the

resection of the distal rectum. In their randomized study

individual to rectal filling are blunted.

Boccasanta et al.

(5) Dynamic magnetic resonance imaging: Compared with clinical examination, dynamic magnetic resonance

or

full-thickness 28

circumferential

transanal

reported significant symptomatic

improvement after a STARR and a STAPL in 88% and 76%, respectively, at approximately 2 years.

imaging appears to be especially invaluable in the

Approximately half of the patients with rectoanal

posterior compartments (peritoneal and digestive) and to

intussusception present with clinical symptoms of ob-


structed defecation, while in 29% of the cases, it is seen 29

211

feedback training may be added to the first-line therapy.

If it is found

There is a paucity of controlled trials showing the true

in isolation, the first option should be medical treatment

effectiveness of this behavioral treatment. Furthermore,

consisting of adequate fiber intake, judicious use of

there is no single factor that can predict a favorable

laxatives and enemas to facilitate evacuation, and possibly

outcome with this treatment. The three main biofeedback

biofeedback therapy. Surgery is reserved only for patients

techniques used to treat paradoxical contraction of the

with combined pathology, usually fecal incontinence as a

puborectalis are sensory training, electromyographic feed-

result of EAS defects or pudendal neuropathy, or, if the

back, and manometric feedback.

intussusception progresses to full thickness, rectal prolapse.

additional sensory retraining to lower defecation threshold

Solitary rectal ulcer syndrome may be associated with

by means of progressively reducing the distension volume

on defecography in asymptomatic patients.

32

31

Some authors provide

The use of rectal sensory retraining

paradoxical contraction of the puborectalis, rectoanal in-

of a rectal balloon.

tussusception, rectal prolapse, and descending perineal

33 is well standardized in fecal incontinence, but its clinical

syndrome. The treatment of SRUS should start with a trial

relevance in constipation is not yet confirmed.

of medical therapy, including high fiber and biofeedback.

Sensory training was the first biofeedback technique to

Local excision is not recommended because this pro-

be used in clinical practice. It entails simulated defecation

cedure does not address the underlying pathophysiology,

by means of a water-filled balloon introduced in the

and the lesions tend to recur. Only symptomatic ulcers

rectum; this is then slowly withdrawn while patients are

should be treated by surgery after medical treatment has

asked to concentrate on the sensations evoked by the

failed. Many of these patients have a co-existant paradox-

balloon and to try to ease its passage.

ical puborectalis contraction, for which biofeedback

technique involve defecation of a balloon or simulated

therapy can be successful.

stools to improve defecatory dynamics.

34

Variations of this 35

Descending perineum syndrome is abnormal perineal

Electromyography consists of recording a patient's

descent, possibly as a result of consistently prolonged

averaged electromyographic activity from the pelvic floor

straining with defecation, as defined on defecography.

muscles for training.

Medical therapy with a high fiber diet, laxatives, enemas,

from intraluminal probes or from surface electrodes taped

and biofeedback is the main treatment for these patients;

to the perianal skin. By watching the recording, the

no viable surgical option exists.

patient first learns to relax the pelvic floor muscles during

36

Measurements may be obtained

Sigmoidoceles are classified into three degrees by the

attempts to defecate and then gradually increases straining

position on defecography of the lowest loop of the

efforts to increase intra-abdominal pressure while keeping

sigmoid during evacuatory effort: first degree, above the

the pelvic floor muscles relaxed.

31

pubococcygeal line; second degree, between the pubo-

Manometric training is almost identical in procedure to

coccygeal and the ischiococcygeal lines; and third degree,

those described above for electromyographic training. The

below the ischiococcygeal line.

30

Although a first-degree

or second-degree sigmoidocele is probably a normal anatomic variant, a non-emptying sigmoidocele can be the

anal canal pressure is measured to detect contraction and relaxation of the pelvic floor muscles.

31

No differences were reported between electromyographic 37

cause of a sensation of incomplete evacuation. Patients

biofeedback and simulated defecation in one study

with first-degree and second-degree sigmoidoceles can

whereas a recent meta-analysis showed that the mean

undergo biofeedback therapy with an expectation of

success rate with manometric biofeedback was superior to

success in approximately 50% of the cases. Third-degree

that with electromyographic biofeedback (78% vs. 70%).

sigmoidoceles may benefit from a sigmoid resection.

The few studies with long-term follow-up data are

Co-existing significant rectoanal intussusception can be

uncontrolled and often include patients with various

treated with a rectopexy at the time of sigmoidectomy.

subtypes of constipation. Most studies on biofeedback

(1) Biofeedback training: For patients who cannot

training report good short-term efficacy, mirrored by an

relax their pelvic floor muscles during straining, bio-

38

improved psychological state and quality of life,

39

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Journal of the Korean Society of Coloproctology: Vol. 23, No. 3, 2007

Table 2. Causes of fecal incontinence 󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚 Congenital Imperforate anus Rectal agenesis Cloacal defects Myelomeningocele Meningocele Anatomical Obstetric injury, vaginal delivery Anorectal surgery Sphincter-sparing bowel resection Pelvic fracture Anal impalement Neurological Diabetes mellitus Multiple sclerosis Stroke Dementia CNS tumor, infection, trauma Spina bifida Pudendal neuropathy Functional Psychiatric disorder Malabsorption Inflammatory bowel disease Radiation proctitis Hypersecretory tumors Rectal intussusception, prolapse Fecal impaction Physical disabilities 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 Adapted from Madoff RD, Parker SC, Varma MG, Lowry AC. Faecal incontinence in adults. Lancet 2004;364:621-32.

whereas the few follow-up studies indicate a fading effect 40

over time.

However, a certain percentage of patients (up

to 50% and more) continue to report satisfaction even at 12～44 months after treatment.

41

FECAL INCONTINENCE 1) Pathophysiology Continence is a complex function of multiple anatomic, physiologic, and psychologic factors: bowel motility, stool consistency, rectal reservoir function, anorectal reflexes and sensation, anal sphincter function, pelvic floor muscles and nerves, and mental function. If one or more of these mechanisms are disturbed, incontinence may result (Table 2, 3). 2) Evaluation A systematic evaluation of the patient should reveal the underlying pathophysiology and lead to the most appropriate therapy. The first step is a detailed clinical examination, including a history and a physical examination. A detailed bowel history is most important for identifying the frequency and the degree of incontinence and its effect on quality of life and may provide some first hints about the cause of the incontinence. Because it is important to identify the daily circumstances during which symptoms occur, symptom diaries are most useful.

Table 3. Symptoms of fecal incontinence and possible underlying dysfunctions 󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚 Characterization of fecal incontinence Suspected dysfunction 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 Urge incontinence Impaired motor control Muscle defect Involuntary loss of stool during the day Autonomic neuropathy Cerebral dysfunction Rectal prolapse Involuntary loss of stool at night Autonomic neuropathy (eg, diabetes) Soiling the underwear Rectocele Mucosal prolapse Scars in the anal canal No differentiation of stool and gas Sensory incontinence (prolapse, scars) Involuntary loss of flatus Weak internal anal sphincter Stress incontinence Impaired innervation (pudendal nerve, spinal, central) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 Adapted from Enck P, Musial F. Biofeedback in pelvic floor disorders. In: Pemberton J, Swash M, Henry MM, editors. The Pelvic Floor. London: WB Saunders; 1999.


The patient should also be asked about the presence and

influenced by physicians' beliefs and the availability of

the nature of urinary incontinence symptoms because

diagnostic studies. Colonoscopy may be employed to

fecal and urinary incontinence are frequently associated.

detect inflammation of the colon and rectum and to

The use of a standardized incontinence score and a

identify possible causes of a recent change in bowel

detailed questionnaire is advisable.

42,43

habits. In addition to this modality, the tests of greatest

Information should distinguish between passive soiling

clinical utility are anorectal manometry and endoanal

(sensory incontinence) urge incontinence (fecal urgency:

ultrasonography (USG)(Table 1, Fig. 2). Patients with

loss of stool despite attempts to prevent evacuation) and

isolated IAS abnormalities are characterized by decreased

soiling the underwear after defecation. Sensory incontinence

anal canal tone. Characteristically, they have fecal soiling

is often seen with IAS malfunction whereas urge

in the presence of normal bowel habits. Endoanal USG

incontinence is normally associated with EAS motor

can demonstrate disruptions of the anal sphincters. A new

dysfunction, but also with liquid stools and impaired

and potentially important technique is static and dynamic

rectal reservoir function. Soiling after defecation may

pelvic MRI.

44,45

occur after incomplete defecation caused by a rectal

Pelvic MRI provides superior characterization of the

prolapse or a rectocele. It is also seen with hemorrhoids

EAS and the puborectalis muscle compared with endoanal

or a weak IAS.

USG, and the detection of EAS atrophy is a good

A surgical history report is necessary for all anorectal,

predictor of poor results after repair of EAS defects. Only

abdominal, and gynecologic operations or trauma. In

MRI can identify external sphincter atrophy whereas

women, a detailed obstetric history is important because

ultrasound is more sensitive for internal sphincter im-

in postpartum women, fecal incontinence is often as-

aging.

sociated with sphincter impairment or pudendal nerve damage.

Dynamic MRI provides excellent imaging of pelvic floor structures during squeeze and expulsion maneuvers

A careful physical examination can identify structural

to characterize perineal descent, dyssynergia, and pelvic

defects (prolapse or rectocele) and systemic or local

organ prolapse. The precise role of this new imaging

diseases that may cause anorectal dysfunction. First the

modality in clinical practice remains to be determined.

perianal area should be inspected visually for reddening,

Other rests that are less helpful or of uncertain utility

scars, fistulas, hemorrhoids, a gaping anus, or a keyhole

include defecography and pudendal nerve terminal motor

defect. The perianal sensation should be examined by skin

latency (PNTML) measurements. Injuries to the pudendal

stimulation. With some experience, a digital examination

nerve innervating the EAS and resulting in a weak

can provide information about the squeeze and the resting

sphincter place patients at risk for fecal incontinence. A

pressure, the presence of a rectocele, anal reflex con-

normally innervated sphincter muscle may also produce

traction, and pelvic floor descent during an attempt to

inadequate squeeze pressures if there is an anatomic

defecate. Digital examination can also identify fecal

separation of the muscle as may occur during childbirth.

impaction in most cases.

In deciding on treatment, it may be important to

Further steps are basic anorectal physiologic tests and

distinguish between muscle weakness due to pudendal

anorectal imaging procedures. Various diagnostic tests

nerve injury and muscle weakness due to muscle injury.

that which may provide insights into the pathophysiology

However, PNTML may not predict improvement or

of fecal incontinence are available to assess anorectal

failure after surgical repair of anal sphincter defects.

structures and functions. In general, these tests are most

(1) Pudendal nerve terminal motor latency: Measure-

useful when the etiology of incontinence is uncertain after

ment of PNTML is operator dependent and requires

the initial clinical evaluation or when making therapeutic

accurate placement of the examining finger as close as

decisions for which such information may affect the

possible to the pudendal nerve as it courses around the

outcome. The evidence to support this approach is

pelvic rim, thereby obtaining the shortest latency possible.

sometimes contentious, and the choice of testing is often

The latency measured reflects the function of the fastest

214


Faecal incontinence

Diarrhoea?

History and physical examination

Yes

Assess/treat aetiology of diarrhoea: colitis, hypersecretory tumour, radiation, overflow Medical treatment: fibre, dietary, barrier cream, antidiarrhoeal agent, bowel regimen

Does not resolve

lmproves

No

Anorectal physiology testing " Anorectal manometry " Pudendal nerve testing " Endoanal ultrasonography " Defecography (optional)

Sphincter defect?

Yes

Major defect? Yes

No

No

Biofeedback

Overlapping sphincteroplasty Improves

Improves

Fails

Endoanal ultrasonography: persistent sphincter defect? Yes

Fails

Consider indications, age, comorbidities, technical issues

No

Repeat sphincteroplasty with or without biofeedback

Improves

Dynamic graciloplasty Artifical sphincter Sacral stimulation

Fails

Stoma

Fig. 2. Algorithm for evaluation and treatment of fecal incontinence (Adapted from Madoff RD, Parker SC, Varma MG, Lowry AC. Faecal incontinence in adults. Lancet 2004;364:62132.).

conducting nerve fibers. Although interesting from a

PNTML increases with age independently of continence

research point of view, the clinical usefulness of this test

status, and this was not controlled in most studies and (2)

is controversial. The test lacks sensitivity and specificity

PNTML measures only the fastest conducting fibers in the

for detection of EAS muscle weakness caused by

pudendal nerve, with the result that a damaged nerve may,

46

found that

nevertheless, show a normal conduction time as long as

approximately half of patients with prolonged PNTML

some fast-conducting fibers remain. Although early

had normal anal canal squeeze pressures. Many patients

studies suggested that patients with prolonged pudendal

with prolonged pudendal latencies have subsequently been

nerve latencies fared less well with anterior EAS repair,

shown by endoanal USG to have structural sphincter

recent studies that also used endosonography found that

damage, and this finding appears to be more important

pudendal nerve function was not predictive of surgical

in determining functional impairment and symptom

results.

pudendal nerve damage. Wexner et al.

47

development.

48,49

Other studies

have similarly failed to

find an association between delays in PNTML and

50

51

Pudendal nerve testing is also not predictive of

the results of postanal repair for neurogenic incon52

tinence.

48

decreased anal canal squeeze pressures. Cheong et al.

suggest that this lack of agreement between PNTML and squeeze pressures may occur for technical reasons: (1)

3) Treatment The management of fecal incontinence encompasses a

215


modification of stool consistency and delivery using

been plagued by methodological inadequacies, few long-

dietary and pharmacological modalities, behavioral in-

term follow-up studies, and the absence of consistent and

terventions, and surgery to correct underlying abnormal-

validated outcomes. A recent Cochrane review concluded

ities. An innovative technique involving the stimulation of

that there was insufficient evidence from trials of bio-

sacral nerve roots appears to be promising and may soon

feedback and exercises for fecal incontinence to determine

become clinically available for selected patients (Fig. 2).

whether such treatments are effective.

60

(1) Medical treatment: When incontinence is as-

(3) Surgery: Surgical procedures for fecal incontinence

sociated with decreased colonic and rectal storage

may be classified as those that repair a damaged sphinc-

capacity or with chronic diarrhea, treatment is directed

ter, those that create a neosphincter by using nearby

towards reversing the underlying inflammation or, if not

muscles or implantation of artificial material and, as a last

an option, modifying the stool volume, consistency and

resort, diversion of the fecal stream.

delivery. It is often beneficial to reduce dietary fiber

① Sphincteroplasty; Repairing sphincter defects is the

intake in combination with anti-diarrheal drugs which

cornerstone of surgery for incontinence. At the time of

slow colonic transit. Of the anti-diarrheal agents available,

a recognized obstetric injury, immediate direct repair is

loperamide is preferred as it has no central nervous

advocated, yet persistent defects are common.

system effects. It prolongs the whole-gut transit time with

immediate repair is not attempted, patients should wait at

decreased stool weight and reduces the sensitivity of the

least 3 months before surgery so that the magnitude of

anorectum.

53

It has been shown to improve the resting 54

anal canal pressure.

64,65

If

the functional deficit can be defined, a physiological assessment can be done, and local tissue inflammation

(2) Biofeedback training: Both pelvic floor training

and edema can resolve.

and biofeedback, the latter based on the principles of

Most series report that 60～88% of patients achieve an

55

operant conditioning first enunciated by Engel et al,

excellent or good outcome, defined as perfect continence

have been reported to be effective in many patients with

or as incontinence to flatus with minor staining.

fecal incontinence associated with impaired functioning of

15～20% experience no change or a worse outcome.

the puborectalis muscle and the EAS. In contrast with

However, several studies have shown that the results of

pelvic floor retraining, which is directed exclusively at

a sphincteroplasty deteriorate substantially with time.

66-69

About

70-74

re-educating weakened or impaired muscles, biofeedback

Suggested predictive factors for treatment failure

often includes techniques to alter rectal sensation and

include the presence of an IAS defect, prolongation of

sphincter muscle responsiveness to intrarectal stimuli,

PNTML, atrophy of the EAS, as demonstrated by pelvic

such as balloon distension. Some investigators have

MRI,

emphasized the enhancement of the responsiveness of the

inance.

56

75

and the presence of IBS with diarrhea predom-

while others have focused on

Patients for whom sphincteroplasty fails should undergo

increasing the force and the duration of EAS contrac-

follow-up endosonography to ensure that the muscle wrap

EAS to rectal distensions 57,58

tions;

59,60

others have attempted to modify both.

There

is intact; patients with persisting defects can undergo 76,77

Biofeedback can be

appears to be a general consensus that improvement of

repeat repair after 6～12 months.

the thresholds of the perception of rectal sensation and

an effective salvage therapy for patients with sub-optimum

synchronization of EAS contractions to rectal stimulation

results after a sphincteroplasty.

61,62

78

In

In the absence of demonstrable anal sphincter defects,

contrast, increased striated muscle strength and endurance

the efficacy of surgical approaches designed to correct

after biofeedback training have not been shown con-

abnormalities of the pelvic floor, such as anterior

are important factors associated with improvement.

62

There is widespread agreement that biofeed-

levatorplasty, post-anal repair, and total pelvic floor repair,

back is effective in approximately 75% of patients who

is unproven. These procedures cannot be recommended

fulfill the entry criteria and has no adverse conse-

for patients with neurogenic incontinence or in the

sistently.

quences.

63

Unfortunately, the biofeedback literature has

absence of structural defects.

216


② Other surgical approaches; Replacement of a

Most studies of sacral nerve stimulation have shown

damaged or non-functioning anal sphincter complex has

increases in both resting and squeeze pressures, increased

been reported using nearby muscles (dynamic graciloplasty)

squeeze durations, decreased thresholds of rectal sen-

79

or an artificial implanted sphincter,

88

Recent reviews of

and increased time of retention of a saline load.

sation,

both procedures have suggested that improved continence

The mechanism by which these effects are mediated

occurs in over 50% of patients, but this is tempered by

remains uncertain, though many researchers believe that

significant morbidity, including infections, device mal-

sacral nerve stimulation works by modulating local sacral

80-82

functions,

and, in the case of the artificial sphincter,

reflexes and sacral parasympathetic nerves, thereby al-

a high percentage of explantation of the device. For those

tering rectal contractile activity and rectal sensitivity.

with severe refractory incontinence, a diverting colostomy

The mechanism could well be multifactorial. It has

may provide improvement, although no formal assessment

been hypothesized that there may be possible trans-

of the quality of life has been published.

formation of type-II fast-twitch muscles to slow-twitch

(4) Innovations: Sacral spinal nerve stimulation (SNS)

type-I fibers that are more resistant to fatigue, although

is a new therapeutic approach for patients with fecal

there is little evidence to support this.

incontinence associated with structurally intact anal sphinc83,84

Sacral stimulation has also been successfully applied

SNS is a unique and highly precise technique

for the treatment of constipation and chronic pelvic pain,

because it is comprised of two diagnostic stages followed

and in patients with complete spinal cord injuries, for the

by a third therapeutic implantation stage. The diagnostic

modulation of bowel and bladder control.

ters.

stages are the acute and sub-chronic stages of peripheral

Recent work has investigated novel minimally invasive

nerve evaluation (PNE). If PNE shows good results in

approaches to fecal incontinence. One option is the

improving fecal incontinence, a permanent implant can be

addition of a bulking agent to the anal canal to augment

considered, as the success rate for SNS then is more

resting tone.

84

89

After success with the use of bulking

Indications have evolved with time, and

agents to close down the bladder neck for treatment of

patients with fecal incontinence caused by idiopathic

urinary incontinence, it was a natural progression to try

sphincter degeneration, iatrogenic internal sphincter damage,

bulking agents in patients with a weak, but intact, IAS.

partial spinal cord injury, scleroderma, rectal prolapse

The successful uses of implantable microballoons,

likely (Fig. 3).

90

91

repair, and low anterior resection of the rectum have all

carbon-coated beads,

been reported to benefit from SNS. Success rates after

collagen

94

85

92

autologous fat,

93

silicone,

and

have each been reported in small series with

short-term stimulation approach 90%. The great majority

low morbidities. However, both the magnitude and the

of patients for whom test stimulation is successful remain

durability of improvement have varied with such tech-

continent after permanent implantation.

86,87

95

However,

niques.

infection and lead displacement remain challenging in up to 25% of patients.

A second investigational approach is radio-

frequency energy delivery to the anal canal, known as the

88

Secca procedure. In this procedures energy is used to

Acute and subchronic PNE

Temporary electrode

Poor response Abandon SNS

Tined lead

Good response

Good response

Permanent implant with neurostimulator

Poor response Consider open approach with foramen electrode

Fig. 3. Algorithm of sacral nerve stimulation. PNE = peripheral nerve evaluation (Adapted from Tjandra JJ, Lim JF, Matzel K. Sacral nerve stimulation: an emerging treatment for faecal incontinence. ANZ J Surg 2004; 74:1098-106.).


apply a series of small submucosal burns at multiple sites on the anal canal with resultant scarring.

96

SUMMARY Pelvic floor disorders, such as defecation difficulty and fecal incontinence, are commonly encountered in the practices of colorectal surgeons. The evaluation of these disorders should include a detailed history and a physical examination, which are supplemented by appropriate diagnostic studies in selected patients. These diagnostic tests include tests at anorectal physiology laboratories and radiology studies, such as manometry, defecography, electromyography, endoanal ultrasound, and static and dynamic pelvic MRI. In patients with defecation difficulty, successful treatment is contingent upon appropriate diagnosis. Although a history and a physical examination are important, anorectal and colonic physiologic investigations are essential in order to appropriately categorize the type of constipation into pelvic outlet obstruction, colonic inertia, or a combined outlet obstruction and inertia. Conservative therapy is successful for many cases of mild incontinence, but more severe cases should be formally assessed before treatment is undertaken. Repairing sphincter defects is the cornerstone of surgery for incontinence. Recent advances have provided new therapeutic options for patients with refractory incontinence.

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국문 초록 골반저 질환의 평가와 치료 충북대학교 의과대학 외과학교실 이

상

전

골반저 질환은 이 영역의 장기를 전공하는 많은 외과 계 의사의 관심의 대상이 되고 있다. 대장항문 외과의 는 특히 골반의 후방 구획에 발생하는 질환에 관심이 있는데 이에 속하는 질환은 대별하여 배변곤란과 변 실금이 있다. 이러한 환자들은 사회적으로나 심리적으 로 고통을 받고 삶의 질이 손상된다. 배경이 되는 해부 학 및 병리생리학적 변화는 복합적이어서 때로는 이 해가 불완전하여 확실히 알 수 없는 경우도 있다. 하지 만 근래에 들어 생리학적 검사와 방사선학적 검사로 합리적인 평가를 할 수 있게 되어 이러한 질환을 좀 더 깊이 이해할 수 있게 되었으며, 새로운 외과적 기법 이 도입되어 희망적인 결과를 얻게 되었다. 이 종설에 서는 골반저 질환에 대한 평가와 치료 전략을 요약해 보고 최근에 진전된 부분도 살펴보고자 한다. 중심단어: 골반저 질환, 배변 곤란, 변실금