10 settles pelvic floor disorders
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TRANSCRIPT
Pelvic Floor Dysfunction
Diane M. Settles, MDAssistant Clinical Professor of Medicine
IU Health Digestive & Liver Disorders
Roadmap
• Pelvic Floor Anatomy• Risk Factors • Evaluation • Treatment• Prevention
Pelvic Floor Anatomy•Connective Tissue
•Muscles
•Neural Structures
Symptoms
• Urinary Incontinence• Pelvic Organ Prolapse• Anal/Fecal Incontinence• Dypareunia• ?Dyssenergic Defecation
Prevalence
• Varies greatly in the literature• UI 17-45%• FI 1.9-11.3%• Prolapse 2-25%
• Reasons for variation– Lack of standardized definitions– Use of surrogate markers; ie surgical history
NHANES 05-06 Data
• 3440 women >20 years old selected• 2489 agreed to participate• 528 patients excluded- 1961remaining
– UI defined using a 2 item incontinence severity index
– FI defined as at least monthly leakage of solid, liquid, or mucous stool• Validated fecal incontinence severity index
– POP- experience bulging or something falling out that you can see or feel
NHANES
• 23.7% (21.2-26.2) ≥ 1 PFD• 15.7% (13.2-18.2) UI• 9% (7.3-10.7) FI• 2.9% (2.1-3.7) POP
Nygaard, et al. JAMA 300(11): 1311-6.
• 2008- 38.6 million adults > 65 years old• 2010- 28.1 million women with 1 PFD• 2050- projected to double to 88.5 million
– 43.8 million women with 1 PFD
• Kaiser consultation for PFD from 2000-2030– Consultations for 2000 618,165– Projections for 2030 954,397
Wu et al. Ob&Gyn 114(6): 1278-83.
Risk Factors
• Pregnancy versus Delivery• Parity• Age• Obesity• Smoking• Ethnicity?• Chronic Pulmonary Conditions• Menopause
AgeAge UI (n=331) FI (n=176) POP (n=58) ≥1 PFD (n=470)
20-39 6.9(4.9-9.0) 2.9(1.9-3.9) 1.6(0.6-2.6) 9.7 (7.8-11.7)
40-59 17.2(13.9-20.5) 9.9(7.4-12.5) 3.8(2.0-5.7) 26.5(23-29.9)
60-79 23.3(17-29.7) 14.4(10.4-18.3) 3(0.9-5.1) 36.8(32-41.6)
≥80 31.7(22.3-41.2) 21.6(12.8-30.4) 4.1(1.1-7.1) 49.7(40.3-59.1)
NHANES data demonstrated age as a clinical significant risk factor except for POP. This may be related to the small amount of pts with POP.
ParityParity UI FI POP ≥1 PFD
0 6.5(4.2-8.9) 6.3(2.9-9.6) 0.6(0-1.5) 12.8(9-16.6)
1 9.7(6.4-13) 8.8(4.3-13.3) 2.5(0.2-4.9) 18.4(12.9-23.9)
2 16.3(12.3-20.3) 8.4(5.8-11) 3.7(1.7-5.6) 24.6(19.5-29.8)
>3 23.9(20.1-27.7) 11.5(8.7-14.3) 3.8(2.1-5.4) 32.4(27.8-37.1)
Parity was not a stastically significant risk factor for FI. The greatest damage occurs during the first pregancy.
Sphincter Defects and Parity
• Anal sphincter defects are associated with first delivery– Primiparas: Before 0% After 35%– Multiparas: Before 40% After 44%
Sultan et al. NEJM 325:1905.
Pregnancy and Childbirth
• PFD are more common among women who have delivered @ least 1 child
• Premenopausal women- parous women have higher prevalence of SUI and UI
• Postmenopausal women parity has little effect on UI– WHI: History of at least one delivery
associated with 2x risk of POP
• UI and FI are common during pregnancy– UI reported by 7-60% of pregnant women– FI 6% – 70% UI symptoms during pregnancy resolve
postpartum
• Conflicting data regarding vaginal delivery and increased rates on incontinence
Pregnancy & Childbirth: Mechanisms of Injury
• Neural Injury– Operative delivery– Prolonged second stage of labor– High birth weight
• Anal sphincter disruption– Gross and occult injuries– Role and risk of episiotomy– Maternal birth position– Epidural
Mode of Delivery
• Australian Cross-sectional Study
Method of Delivery Odds Ratio
Caesarean only 2.5(1.5-4.3)
Vaginal only 3.4(2.4-4.9)
At least one forceps 4.3(2.8-6.6)
Both vaginal and caesarean 4.7(2.3-9.3)
MacLennan et al. Br J Obstet Gynae 107:1460-1470.
Elective Caesarean
• Cochrane Review– 21 studies- total of 31,698 patients
• 6028 Caesarean delivery• 25170 Vaginal delivery• 1 randomized study- Term Breech Trial• 1 Study illustrated benefit• No difference in elective versus emergency• Risk include adhesions(83% by third
pregnancy), infertility, bleedingCochrane Review 2010
Elective Caesarean Cannot Be Recommended
Mechanism of ContinenceRao CGH 2010;8:910-9.
Evaluation
• Examination– Detailed neurological examination– Perianal inspection– Detailed rectal examination
• Resting and squeezing tone• Attempted defecation
Physiologic Testing
• Manometry and Sensory Testing– Functional weakness EAS and IAS– Abnormal rectal sensation– Grade B evidence
Clinical Utility of ARM in Fecal Incontience
Diagnosis Confirmed 95%
New Information 98%
Influenced Treatment 84%
Normal Study 2%
Not Helpful 14%
Rao et el. AJG 92:460-75.
High-Resolution Solid-State Anorectal Manometry Catheter
• 23 sensors– 20 4-quadrant
sensors every cm for sphincter
– 3 unidirectional sensors for rectum, balloon & reference
ARM: Resting Pressures
ARM: Squeeze Pressures
Anal Endosonography
• Assessment of integrity and thickness of sphincters
• Sphincter thickness does not correlate with manometry findings
• EUS vs. EMG mapping– High concordance for identifying sphincter
defects
• Low specificity for demonstrating etiology of fecal incontinence Enck et al. AJG 91:2539-
43.
Pelvic MRI
• Endoanal MRI– Recognition of EAS atrophy– Possible role in preoperative evaluation
• Dynamic MRI– Possible replacement of defecography– Depends on radiologist’s expertise
Fecal IncontinenceFecal Incontinence
DiarrheaDiarrhea Obstetric/SurgicalNeurological HxObstetric/SurgicalNeurological Hx
ProlapseProlapse
ARM and Imaging- MRI or EUSARM and Imaging- MRI or EUS
Chronic Diarrhea Workup
Chronic Diarrhea Workup
Supportive RxSupportive Rx
ConfirmedSurgeryConfirmedSurgery
SuspectImagingSuspectImaging
No improvementNo improvementAdapted from Rao et al. ACG Guidelines AJG 2004
Treatment
• Lifestyle modifications• Medications• Kegel Exercises• Biofeedback• Surgery• Sacral Nerve Stimulation• Artificial sphincters
Antidiarrheals
• Loperamide– Reduce frequency of incontinence– Improve stool urgency– Increase colonic transit time– Increase anal resting sphincter pressure– Reduce stool weight
• Lomotil• Codeine
Sun et al. Scan J Gastro 32:34-8.Hallgren Dig Dis Sci 39:2612-8.
Hormone Replacement Therapy
• Prospective observational study– 25% asymptomatic after 6 months of
treatment– 65% symptom improvement– Anal resting and squeeze pressures
significantly increased– Anal canal sensitivity and PNTML unchanged
Donnelly et al. Br J Ob Gyn 104:311-5.
Biofeedback
• Operant conditioning• Goals
– Strengthen the anal sphincter muscle– Increase puborectalis tone– Improve rectal sensation– Eliminate sensory delay– Improve Recto-anal coordination
Biofeedback: Effective Treatment?
• Subjective treatment 40-85% in uncontrolled studies
• Norton et al- RCT of 171 patients – Outcomes- Immediate and 1 year post
intervention– 60% of patients had improvement– No difference between treatment arms
Norton et al Gastro 125:1320-9.
BF and Pelvic Exercise: Equal Efficacy?
• Heyman et al- RCT of 108 pts– Run-in/Education Period- 21% of patients
reported adequate control– Biofeedback group
• Greater reduction in FISI• Fewer episodes of FI• 44% complete continence• 3 months- 76% reported adequate response• Greater increase in anal squeeze pressure
Heyman et al. Dis Col Rect 2009:1730-7.
Surgery• Sphincteroplasty
– Short term improvement 70-85%
– 5 years post op 50% failure
• Postanal repair– Success 20-58%
Sphincteroplasty Failures- Stratification?
• Clinical features possibly predictive of failure– Internal anal sphincter defect– Prolonged PNTML– Atrophy of EAS– IBS
Artificial sphincter
Sacral Nerve Stimulation
• Approved for urinary incontinence• Full restoration of continence in 37-74% @
24 months• Objective changes
– Increase in resting and squeeze pressure– Increase squeeze duration– Improved perception of rectal sensation
Ganio et al. Dis Col Rectum 44:1261-7.Jarrett et al Br J Surg 91:1559-69.
Prevention
• Kegel exercises– Cochrane review- 15 trials: 6000pt– Antenatal and Postnatal– Decreased UI and FI– Minimial difference
Future Research
• Pelvic Floor Disorder Network– BOOST Study- behavioral therapy versus
usual care in women with anal sphincter tears and FI
– ADAPTION Study
Take Home Points
• FI is common• Unclear whether pregnancy or delivery
causative; multifactorial causes• History, exam, and testing are
complementary in diagnosis• Biofeedback is the mainstay of therapy in
patients who failed to respond to supportive Rx