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The pelvic floor contains a number of muscles that regulate defecation. Disorders of the pelvic floor include the following:
Prior trauma to the area can also damage the muscles of the pelvic floor and the surrounding structures. These disorders can often present with either constipation or fecal incontinence, and accurate diagnosis may require advanced testing by a specialist.[1,2]
Image courtesy of Wikimedia Commons.
Constipation is the dysfunction of colonic motility in the defecation process. It is one of the most common gastrointestinal (GI) complaints in the physicians' office, with a prevalence as high as 30% in select populations, and it can have a substantial impact on quality of life. Each year, this typically benign condition accounts for well over $1 billion worth of over-the-counter medications. According to the Rome III criteria, constipation is diagnosed when two or more of the following symptoms are present:
Image by Sam Shlomo Spaeth for Medscape.
An 84-year-old woman comes to the office with a complaint of mild, persistent abdominal pain for the past 6 months. She denies experiencing any rectal bleeding and is up to date on her screening colonoscopies. She takes medication for hypertension and hyperlipidemia but has had no recent changes in her health. Her abdomen is soft, with minimal diffuse tenderness to deep palpation. You decide to order an abdominal radiograph (shown).
Which of the following is not associated with an increased risk of constipation?
Image courtesy of David E Stein, MD.
Answer: D. Male sex.
Women are at higher risk for constipation than men are.[3] The causes of constipation are diverse and often multifactorial. Potential exacerbating factors include diet, dehydration, metabolic disorders, and neurologic diseases, as well as psychosocial issues. Multiple classes of medications can cause constipation, including opioids, antidepressants, anticholinergics, calcium-channel blockers, and calcium supplements. Initial management consists of medication review in conjunction with changes in diet (eg, increasing fiber and fluid intake). These conservative measures have a high success rate in patients without underlying pathology. In cases where they prove ineffective, referral to a specialist for further workup is warranted. The computed tomography (CT) scan in the slide shows a large stool burden in the transverse colon of a patient with constipation.
Image courtesy of David E Stein, MD.
A 54-year-old woman with a history of three vaginal deliveries presents with complaints of chronic constipation and a sensation of incomplete emptying of stool from her rectum. She also reports episodes of multiple small bowel movements in a short period. You are concerned about pelvic floor dysfunction as the possible cause of her constipation.
Which of the following is not an appropriate test to include in the workup of this patient?
Image courtesy of David E Stein, MD.
Answer: E. Positron emission tomography (PET)/CT.
All of these measures except PET/CT are standard components to be considered in the workup of pelvic floor dysfunction. Pelvic floor dysfunction gives rise to a wide range of patient presentations that can include problems with urination, disordered defecation, and chronic pain. The first step in the evaluation consists of a thorough but focused history and physical examination. After initial evaluation, consultation with a GI, colorectal, or urologic specialist is advised to guide further management and testing. Magnetic resonance imaging (MRI) of the pelvis (see slide 5) is helpful for evaluating the pelvic floor musculature and can identify anatomic lesions responsible for a patient's symptoms. Anorectal manometry (shown) can provide information about the functioning of the pelvic floor muscles.[4]
Images courtesy of David E Stein, MD (left) / Wikimedia Commons (top) / Medscape (bottom right).
A 65-year-old woman with a history of chronic constipation and previous obstetric trauma presents with worsening constipation and the sensation of vaginal fullness with bowel movements. She also reports that she feels unable to empty her rectum with bowel movements. After a bimanual pelvic examination, rectocele is the suspected diagnosis.
Which of the following is the ideal imaging examination to evaluate for rectocele?
Image courtesy of Medscape.
Answer: C. Defecography.
Rectocele is the bulging of the rectum into the posterior wall of the vagina, which is thought to be caused by weakened pelvic floor muscle and a thinning rectovaginal septum. When this condition is suspected, defecography is the imaging modality of choice. As many as 40% of patients with rectoceles may be asymptomatic. Treatment should be pursued only if patients are having significant symptoms that affect their quality of life. Medical therapy includes fiber supplementation, stool softeners and biofeedback. Surgical therapy (shown) should be reserved for patients who continue to experience severe symptoms despite optimal medical therapy.[5]
Image courtesy of Medscape.
A 45-year-old woman who underwent episiotomy to assist vaginal childbirth in the previous year presents with complaints of fecal incontinence. She has multiple episodes of incontinence each day and states that she feels unable to hold stool in her rectum when she has the urge to defecate.
After a thorough history and physical examination, which of the following tests would be most helpful in evaluating this patient's anal sphincter anatomy?
Image courtesy of Wikimedia Commons / Blausen.com staff.
Answer: A. EAUS.
EAUS allows visualization of the internal and external anal sphincter muscles. The image in the slide shows that both sphincter muscles are incomplete at the superior aspect, a finding related to the obstetric trauma sustained by the patient. Whereas the internal anal sphincter is an involuntary muscle, the external anal sphincter is under voluntary control, giving the patient the sensation of holding stool in despite an urge to defecate. Fecal incontinence can be caused by anatomic injury to the sphincter muscles, as well as by functional defects that develop despite a normal anatomy.
Image courtesy of David E Stein, MD.
Fecal incontinence (accidental bowel leakage) in an adult can have devastating effects on quality of life, which can result in significant disability. Continence relies on a complex relation between pelvic floor muscles, neurologic function, rectal reservoir function, and stool consistency. The workup begins with a thorough history and physical examination. Risk factors for fecal incontinence include the following:
Physical examination by a specialist would include a thorough external inspection, digital examination to assess sphincter tone, and anoscopy to inspect the anal canal. Clinical testing includes pelvic MRI, EAUS, anal manometry, and defecography.[6]
Image courtesy of David E Stein, MD.
Management of incontinence begins with dietary modification. Studies have shown that formal counseling regarding dietary habits, fluid management, bowel routines, and changes in medication can lead to improvement in 22-54% of patients with fecal incontinence. Medications used in this setting include antidiarrheal agents, tricyclic antidepressants, and opiates. When conservative measures fail or when obvious anatomic defects (eg, previous sphincter trauma) are present, surgical management (shown) may be indicated. Sphincteroplasty (sphincter repair) attempts to restore the integrity of the internal and external sphincters, as well as to provide resistance to stool passing through the anus. Sphincteroplasty for defects caused by pregnancy complications are associated with good-to-excellent results in as many as 85% of patients.
Image courtesy of David E Stein, MD.
A 65-year-old woman with a history of multiple vaginal childbirths and chronic constipation presents with a complaint of her "rectum falling out" (ie, rectal prolapse). She is able to push the prolapsed rectum back in. This is occurring more frequently and is associated with straining during bowel movements.
Which of the following is the most effective treatment for rectal prolapse?
Image courtesy of David E Stein, MD.
Answer: C. Abdominal operation.
Rectal prolapse (procidentia) is six times more common in women older than 50 years than it is in men. Although multiparity is commonly associated with this disease, one third of female patients are nulliparous. When rectal prolapse occurs in men, it is more likely to be a result of developmental delay or psychiatric comorbidities. It is common for patients to confuse rectal prolapse with prolapsing hemorrhoids. To identify rectal prolapse, after a thorough history is performed, it may be helpful to examine the patient while he or she is sitting or squatting, as well as to have the patient attempt to reproduce symptoms on the toilet. Diagnosis is aided by additional tests such as defecography, colonoscopy, and barium enema. Treatment of rectal prolapse is primarily surgical.[7] Operative repair via an abdominal approach is the most definitive treament (see the following slide).
Image courtesy of David E Stein, MD.
Medical comorbidities typically dictate which of the two primary surgical approaches is chosen. For healthier patients who are low-risk surgical candidates, an abdominal procedure (either open or laparoscopic) is performed. The abdominal approach has a recurrence rate four times lower than that of the perineal approach. The primary method of reducing recurrence is to affix the rectum to the retroperitoneal space (rectopexy). Removal of excess sigmoid colon can be helpful in patients with redundant colon or chronic constipation. If the patient cannot tolerate an abdominal operation, then a perineal rectosigmoidectomy (Altemeier procedure; shown) is performed. This procedure consists of a full-thickness resection of prolapsing or redundant rectum, followed by a transanal anastomosis.
Image courtesy of David E Stein, MD.
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