Pelvic floor dysfunction involves a range of disorders causing abnormalities of bowel storage, bowel emptying, and sometimes pelvic pain. Patients should be aware that a systematic approach to evaluate their symptoms can lead to appropriate diagnosis and treatment for what often is a chronic and frustrating problem.
Pelvic floor dysfunction can be caused by a number of specific conditions. These include:
- Pelvic organ prolapse
- Paradoxical puborectalis contraction or nonrelaxation
- Pelvic pain syndromes:
- Levator Syndrome
- Coccydynia
- Proctalgia Fugax
- Pudendal Neuralgia
This pamphlet will focus on paradoxical puborectalis contraction which is also known as nonrelaxing puborectalis or pelvic floor dyssynergia.
WHAT IS THE PELVIC FLOOR?
The pelvic floor is a muscular sheet through which the rectum passes to form the anal canal. Surrounding the anal canal is the anal sphincter complex, comprised of both internal and external components. Many of the disorders associated with pelvic floor dysfunction stem from improper functioning of these muscles. The primary component of the pelvic floor is the levator ani muscle also known as the pelvic diaphragm. This muscle consists of 3 individual muscles – the iliococcygeus, pubococcygeus, and puborectalis. The puborectalis is a U-shaped muscle that attaches to the pubic bone and encircles the rectum. During normal everyday life, this muscle remains contracted to maintain a bend in the rectum, aiding in stool continence. When bearing down to pass a bowel movement, typically this muscle relaxes, allowing the rectum to straighten. Additionally, in females, the urethra, (which carries urine from the bladder to the outside of the body) and the vagina also pass through the front portion of the pelvic floor.
HOW IS PELVIC FLOOR DYSFUNCTION EVALUATED?
The most important part of evaluating a patient suspected of pelvic floor dysfunction involves a thorough medical history and physical examination, including a thorough pelvic floor assessment. In women, an essential part of the medical history is a detailed obstetrical history, focusing on potential factors such as difficult deliveries. It is also crucial to understand the patient’s bowel habits as well as prior anorectal surgeries.
Following the office examination, various tests may be conducted, depending on the patient’s symptoms and the physician’s diagnostic suspicions. While these tests can occasionally cause discomfort or be somewhat embarrassing for the patient, they offer valuable information that aids in identifying the patient’s symptoms and help provide effective relief.
ENDOANAL/ENDORECTAL ULTRASOUND:
This test utilizes sound waves to create anatomic images of the anus, sphincter muscles, and rectal wall. It typically involves inserting a thin ultrasound probe which is no bigger in diameter than an index finger into the anus and/or rectum. Prior to the procedure, patients are often asked to perform an enema to ensure the anus and rectum are empty. Sedation is not given, and the procedure typically lasts only a few minutes.
ANORECTAL MANOMETRY TESTING:
This test provides the physician with detailed information regarding the function of the anal sphincter muscles, sensation of the anus and rectum, and the compliance (distensibility) of the rectal wall. This test provides information explaining how the rectum reacts to stool entering the rectum as well as reflexes necessary for stool passage. The procedure involves inserting a small flexible catheter (about the diameter of a pencil) with a small balloon on the end into the rectum. The test only requires an enema for preparation, and the patient remains awake during the procedure to respond to commands.
BALLOON EXPULSION TEST:
This test involves inserting a small rubber balloon into the rectum, which is then filled with water. The patient is then asked to sit on a commode or toilet and expel the balloon. Typically, patients are able to expel the balloon within a minute. Difficulty in doing so may indicate some degree of obstructed defecation.
PRUDENDAL NERVE MOTOR LATENCY TESTING:
This test evaluates the function of the nerves that control the pelvic floor and anal sphincters. It involves stimulating the pudendal nerve from inside the anus by inserting an electrode attached to the examiner’s finger. During the procedure, nerve stimulation induces muscle contractions, which may cause mild discomfort for the patient. The test measures the conduction of signals through the nerve to determine whether the nerve is conducting signals to the muscles at a normal rate or if there is a delay.
ELECTROMYOGRAPHY (EMG):
EMG is another method used to evaluate the function of nerves and muscles in the anal sphincter and pelvic floor. There are various approaches to conducting this test, including the placement of small needles into the muscles or using a plug inserted into the anal canal. While these procedures may cause more temporary discomfort compared to other tests, it provides valuable information in certain situations.
VIDEO DEFECOGRAPHY:
During this procedure, the patient is administered an enema of thickened liquid (“contrast”) that is visible on x-rays. Specialized x-ray equipment captures video pictures while the patient sits on a commode and evacuates the contrast from the rectum. This method mimics an actual bowel movement, providing valuable information about the coordination of pelvic muscle movements during a bowel movement. An alternative to traditional video defecography is dynamic MRI defecography, where images are obtained using MRI instead of conventional x-rays. This newer technique is performed only in specialized centers.
COLONIC TRANSIT STUDY:
This test, often referred to as a Sitz marker study, is useful for evaluating severe constipation to determine if the cause of constipation is slow transit of the colon. The procedure involves swallowing a small gelatin capsule containing tiny rings that are visible on an x-ray. Once swallowed, the capsule dissolves and releases the rings into the intestinal tract. X-rays of the abdomen are then taken at specified intervals to monitor the movement of these rings through the colon. Normally, most rings should have exited the body in bowel movements by day 5. If any rings remain, their number, pattern, and location are observed on the x-ray images.
WHAT IS PARADOXICAL PUBORECTALIS SYNDROME?
The puborectalis muscle is a sling-like structure that wraps around the lower rectum as it passes through the pelvic floor. It plays a crucial role in maintaining fecal continence and is also vital during bowel movements. At rest, the puborectalis muscle is contracted, pulling the rectum forward and creating a sharp angle in the rectum that helps prevent passive stool leakage. During normal defecation, as one bears down to pass stool, the puborectalis muscle reflexively relaxes and straightens the angle. This allows stool to pass more easily from the rectum into the anal canal. In cases of paradoxical puborectalis syndrome, the muscle fails to relax and sometimes contracts harder during defecation. This has the effect of further sharpening the angle in the rectum and making it difficult to empty the rectum, a condition sometimes referred to as obstructed defecation. Patients often describe the sensation as “pushing against a closed door” and may have a history of needing enemas to have a bowel movement.
WHAT CAUSES IT?
The exact cause of paradoxical puborectalis syndrome is unclear, but it is believed to be due to a combination of factors, including improper functioning of the nerves and/or muscles of the pelvic floor. Psychological mechanisms may also play a role. Patients often have concurrent diagnoses of anxiety, depression, or history of sexual trauma.
HOW IS IT DIAGNOSED?
This condition is typically diagnosed through a combination of persistent difficulty with bowel movements and various diagnostic tests. These tests include manometry, EMG, and defecography, which reveal the puborectalis muscle fails to relax during a bowel movement. Additionally, patients often show an abnormal result on a balloon expulsion test.
HOW IS IT TREATED?
Management of paradoxical (non-relaxing) puborectalis syndrome is primarily non-surgical. The primary treatment is biofeedback therapy, where patients engage in specialized pelvic floor physical therapy. During these sessions, patients can often view EMG or manometry tracings from sensors placed in the rectum. This allows them to visualize the results of their efforts in order to properly relax the pelvic floor. Portable biofeedback units are also available for home use. The success rate of biofeedback for this condition ranges from 40% to 90% with most failures due to patients not keeping up with or incorrectly performing their exercises.
For severe cases where these treatments are ineffective, surgical creation of a colostomy, through which the patient passes stool into a bag on the abdominal wall, may be considered as a last resort, though this is rarely needed.
ABOUT COLON AND RECTAL SPECIALISTS
Colon and Rectal Specialists was founded in 1913. We are a group of dedicated fellowship-trained colorectal surgeons. We are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. Our surgeons have all completed advanced surgical training in the treatment of these diseases in addition to full general surgical training. We are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.
ABOUT C.A.R.E.S. CENTER
Colon and Rectal Endoscopy and Surgery (CARES) Center is our state-of-the-art Ambulatory Surgery Center. Our center has been accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) and has been given Medicare Deemed Status by CMS. We perform a variety of services including: screening colonoscopies, hemorrhoidectomy, abscess and fistula surgery, fissure surgery, pilonidal surgery, and surgery to treat fecal incontinence. Learn more about us at www.crspecialists.com.
