Pelvic Floor Disorders Amir Darakhshan MD FRCS (Gen Surg) Consultant Colorectal and General Surgeon What is Pelvic Floor Disorder • Surgical perspective “ symptoms of RED, FI or prolapse on the background of PF failure ” What is Pelvic Floor Disorder • Pelvic Floor Failure = Structural – Perineal descent – Rectocoele, enterocoele, cystocoele, poor bladder neck support – Uterine, vaginal vault prolapse • Rectal Evacuatory Difficulties (RED) – ODS, RI, rectocoele, anismus, poor effort • Incontinence – FI, UI • Dysmotility – Constipation, diarrhoea, IBS Stress MRI What is Pelvic Floor Disorder • Pelvic Floor Failure – Perineal descent – Rectocoele, enterocoele, cystocoele, poor bladder neck support – Uterine, vaginal vault prolapse • Rectal Evacuatory Difficulties (RED) – ODS( descent, RI, rectocoele), anismus, poor effort • Incontinence – FI, UI • Dysmotility – Constipation, diarrhoea, IBS What is Pelvic Floor Disorder • Pelvic Floor Failure – Perineal descent – Rectocoele, enterocoele, cystocoele, poor bladder neck support – Uterine, vaginal vault prolapse • Rectal Evacuatory Difficulties (RED) – ODS, RI, rectocoele, anismus, poor effort • Incontinence – FI (urge, passive), UI • Dysmotility – Constipation, diarrhoea, IBS What is Pelvic Floor Disorder • Pelvic Floor Failure – Perineal descent – Rectocoele, enterocoele, cystocoele, poor bladder neck support – Uterine, vaginal vault prolapse • Rectal Evacuatory Difficulties (RED) – ODS, RI, rectocoele, anismus, poor effort • Incontinence – FI (urge, passive), UI • Dysmotility – Constipation, diarrhoea, IBS Patient Assessment -1 • History and examination • Are symptoms primarily • • • • pan –enteric/colonic dysmotility RED Incontinence (+/- urinary) All of above Patient Assessment -2 • Bowel habit • constipation, abdo distension/pain, nausea • straining, perineal support, digitation, prolapse, fragmented defaecation, difficulty wiping • Obstetric • number, 2nd stage labour, forceps, tears • Urinary symptoms Patient Assessment -3 • Investigations – U&Es, TFT, Ca2+ – Colonic transit marker study, colonoscopy – EAUS, Total Pelvic Floor US – Anorectal physiology – Video proctography – Stress MRI – Urodynamic studies (urogynaecology) Transit Marker Study Anatomy EAUS Transverse perineii External sphincter Internal sphincter Video Proctogram Sacrum Small bowel Rectum Femur Stress MRI - Straining Multi-compartment failure RED • • • • • • Poor propulsive effort Perineal descent Rectocoele Rectal mucosal Intussusception Rectal prolapse Anismus Rectocoele Rectal intussusception Rectocoele FI - Normal Anus • Diarrhoea – – – – – Infection Inflammatory Bowel Small Bowel Resection Tumours Entero-enteric fistula • Rectum – Reduced Sensation – Reduced Capacity • Fibrosis • Radiotherapy • Resection, Proctitis – Tumour – Poor emptying • Faecal impaction • ODS • Poor technique FI – Abnormal Anus • Passive – Reduced resting tone – IAS atrophy – Neurologic Dysfunction • Urge – Trauma – Obstetric anal injury – Iatrogenic • Stretch • Fistula • Haemorrhoidectomy – Impalement – Military EAUS External sphincter Internal sphincter Management of RED Non-operative • Diet, fluid intake optimisation – Soft, bulky stool • Exercise • Biofeedback – Correct toilet technique – Perineal/vaginal splinting – Pelvic floor exercises, balloon expulsion Management of FI Non operative • Diet fluid intake optimisation • Medication – Loperamide, codeine, colestyramine – Suppostories, Enemas – Anal plug – Biofeedback – Rectal irrigation: Peristeen, Qufora Biofeedback Balloon expulsion Biofeedback Anal Plug Rectal Irrigation Management of RED Operative • Rectocoele repair • Rectopexy – Ventral mesh – Posterior • STARR Rectocoele repair Rectocoele repair Rectocoele repair Rectal Intussusception Lindsey et al Oxford Rectal Prolapse Grade Rectal Prolapse Surgical options • Abdominal – Effective – Low recurrence rates – Better improvement in FI – Anterior/posterior – Open or lap – Constipation • Perineal – – – – – – Frail/elderly Avoid laparotomy/GA High recurrence Higher FI Low morbidity Lower constipation Rectopexy Results Post Rectopexy • Improvement in continence 80-90% • Severe post-op constipation 50% – “denervation inertia” – Kinking of rectosigmoid – Resection? • Recurrence <5% at 5 years • (c/f perineal procedure 18-30%) Results Ventral Rectopexy • • • • Lead point of intussusception = anterior No postero-lat mobilisation Resolution of constipation 80% Avoids worsening of constipation – supports denervation inertia – refutes kinking • Long term function unclear – Decreases at 12 months STARR for ODS STARR Management of FI Operative • Restore anatomy – Anterior sphincter repair +/- perineum repair – Correct prolapse/intussusception • Rectopexy, intra-anal Delormes, STARR – Repair rectocoele • Transvaginal, STARR – Bulking agents • IAS defect, keyhole deformity STARR - Outcome • Improvement ODS and structure in >90% of patients • European STARR registry – 2,224 patients, 12-month follow-up – significant improvement • obstructive defaecation score (15.8 vs. 5.8, P<0.001) • symptom severity score (15.1 vs. 3.6, P<0.001) • quality of life Jayne DG et al. Stapled transanal rectal resection for obstructed defecation syndrome: one year results of the European STARR Registry. Dis Colon Rectum 2009 July;52(7):1205-12. STARR - Complications • Overall - 36% – – – – – – – – Urgency Bleeding Sepsis Staple line complications Incontinence Pain rectal necrosis rectovaginal fistula 20% 5% 4.4% 3.5% % <2% <1% <1% Management of FI Operative • Restore anal function – Artificial Anal Sphincter, Graciloplasty • Neuromodulation – SNS, PTNS Anterior Anal Sphincter Repair Anterior Anal Sphincter Repair - 2 Sacral Nerve Stimulation SNS • Minimally invasive • Urinary incontinence – FI/Constipation • • • • Implantable electrode Electrical stimulation sacral nerve Neuromodulation Sub-threshold stimulation Sacral Nerve Stimulation • 2 stage – Temporary/trial – Bowel diary – Improvement • • • • • 50-75% fully continent >75% pts incontinence episodes halved Improved ability to defer defaecation Increased bowel movements Reduced abdominal pain and bloating SNS Permanent • • • • • • If temporary SNS successful Fully implantable Tined/barbed leads IPG Stimulation parameters Hand-held patient controller Sacral Nerve Stimulation Injectable Bulking Agents • For passive soiling/FI – Into intersphincteric space/IAS – Biomaterials • PTQ • carbon-coated beads (Durasphere(R) • dextranomer in stabilised hyaluronic acid (NASHA Dx) • The Gatekeeper(™) prosthesis: solid polyacrylonitrile cylinder Injectable Bulking Agents Outcomes • Improved continence scores at 6 months • <50% maintained improvement at 12 months • Better results with >2 sites injected • May require repeat treatment • SE: Pain mainly, infection Restore anal function
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