GI Physiology - Investigating and treating
patients with pelvic floor dysfunction
Lynne Smith
Department of GI Physiology
NGH
Sheffield
Aims
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o
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To give an overview of lower GI
investigations
To demonstrate how these can be used to
aid understanding of the patient’s
defaecatory disorder
To describe how simple non-invasive
measures can provide effective
treatment
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Continence is a complex process which
depends on;
strength and integrity of the anal
sphincters
relationship between stool consistency,
local bowel and rectal function and
sensory awareness
psychological state.
Recto-anal inhibitory reflex
RAIR is an enteric reflex;
• Increase in rectal pressure
causes a reflex IAS
relaxation
Rectal
• neuromodulated
from
balloon
higher centres
Rectum
• preserved in spinal injury
IAS
EAS
rectum
Anorectal manometry
Recto-anal inhibitory reflex
pressure
balloon
inflation
b
a
d
c
time
Components
• a - time to maximum
decrease
• b - amplitude of
decrease (% of
resting pressure)
• c - duration of
decrease
• d - time to return to
base line
Recto-anal inhibitory reflex
Recto-anal
inhibitory reflex:
• rectal distension
induces a rapid
decrease in anal
canal resting
pressure, followed
by a gradual rise
back to base line
•
Rectal Distension
Rectal
balloon
Rectum
IAS
EAS
Anorectal manometry
Anorectal manometry
Anorectal manometry
Paradoxical contractions when
bearing down
Anorectal manometry
High Definition Anorectal Manometry
RAIR At Relaxation
Endoanal ultrasound
Endoanal ultrasound
Endoanal ultrasound
Endoanal ultrasound
Endoanal ultrasound
EAS disrupted
between 9 and 11
o’clock
Endoanal ultrasound
Endoanal ultrasound
Endoanal ultrasound
Endoanal ultrasound
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Patients who chronically strain (chronic constipation
or pelvic floor dysfunction) may develop lengthening
of the attachments of the rectum to the sacrum
leading to descending perineum syndrome.
The increased mobility allows for intussusception and
rectal prolapse.
Intussusception causes outlet obstruction because
the upper rectum moves away from the sacrum and
telescopes into the more distal rectum.
Investigations - Colonic Transit Study
Investigations - Colonic Transit Study
Investigations - Colonic Transit Study
Colonic Transit Study
Female with slow
transit
constipation –
temporary SNS
electrode in situ
“Biofeedback” ie bowel retraining
Describes a non-standardised package of
care;
to not only “retrain” the pelvic floor but to
help educate the patient to allow them to
gain more control of their distressing
symptoms.
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ePAQ
Diet and Bowel Habit Diary
Explanation of Anorectal Physiology and
ultrasound results in relation to symptoms
•
• Modification of dietary fibre, caffeine
and fluid intake
• Lifestyle changes – exercise and weight
loss
• Titration of loperamide
• Glycerine Suppositories
• Pelvic Floor exercises
• Relaxation techniques and toilet
positioning
• Deferment training
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Bowels respond best to regular habit, ideally 30 mins after a
meal, due to the gastro-colic reflex.
Encourage patients to find a toilet that they feel comfortable
to use and where they do not feel inhibited by lack of privacy
or time.
Teach them how to relax and position themselves on the toilet
Discourage patients from having a fixation of having to go the
toilet a certain number of times.
Discourage patients from deferring – studies have shown that
deferring over time slows colonic transit in normal group.
Re-education of the bowel to open at convenient times.
Percutaneous Tibial Nerve
Stimulation
•
Typically treated once per week for 30 minutes for a period of 12 weeks.
Posterior tibial nerve stimulation
o Impressive results for patients in UK hospitals
(60-80% positive response on treatment)
o Minimally-invasive
o Almost no side effects
o Stimulation to the sacral nerve plexus by
temporarily applying electrical impulses
o It can be given in an outpatient setting
o Safe and cost effective.
o Independent research shows that PTNS
creates significant reduction in the symptoms of
FI.
o Successfully implemented in over 20 NHS
centres in the UK.
Risks
associated with PTNS?
o Transient mild pain
o Skin inflammation at or near the stimulation
site.
Contraindications?
o Patients with pacemakers or implantable
defibrillators
o Patients prone to excessive bleeding
o Patients with nerve damage that could impact
either percutaneous tibial nerve or pelvic
floor function
o Patients who are pregnant or planning to
become pregnant during the treatment
STH Audit;
Is PTNS successful in alleviating
FI and does it have any other effects on pelvic
floor function?
o 27 out of 46 patients improved;
frequency, FI episodes, ability to defer
and quality of life all statistically
significant
o Dysuria improved in those with urinary
symptoms but other urinary symptoms eg
overactive bladder not improved (almost
certainly due to the study cohort)
o IBS, obstructive defaecation, vaginal
symptoms and sexual function were
unimproved
X2 Alzheimer’s patients have been
successfully treated
• Convinced the “scientist cynicism
within us”!
• Our surgeons are now more
convinced of efficacy
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We never give unreasonable
expectations before or during
treatment
We encourage maintenance of pelvic
floor exercise, dietary fibre
modification and use of titrated
loperamide.
Biofeedback gives symptomatic
improvement in >60% of patients
And
 Despite our initial cynicism, PTNS has
proved to be an effective treatment
for faecal urgency/incontinence.
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