10 settles pelvic floor disorders

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Pelvic Floor Dysfunction Diane M. Settles, MD Assistant Clinical Professor of Medicine IU Health Digestive & Liver Disorders

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Page 1: 10 settles pelvic floor disorders

Pelvic Floor Dysfunction

Diane M. Settles, MDAssistant Clinical Professor of Medicine

IU Health Digestive & Liver Disorders

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Roadmap

• Pelvic Floor Anatomy• Risk Factors • Evaluation • Treatment• Prevention

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Pelvic Floor Anatomy•Connective Tissue

•Muscles

•Neural Structures

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Symptoms

• Urinary Incontinence• Pelvic Organ Prolapse• Anal/Fecal Incontinence• Dypareunia• ?Dyssenergic Defecation

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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

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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

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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.

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• 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.

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Risk Factors

• Pregnancy versus Delivery• Parity• Age• Obesity• Smoking• Ethnicity?• Chronic Pulmonary Conditions• Menopause

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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.

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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.

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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.

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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

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• 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

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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

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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.

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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

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Mechanism of ContinenceRao CGH 2010;8:910-9.

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Evaluation

• Examination– Detailed neurological examination– Perianal inspection– Detailed rectal examination

• Resting and squeezing tone• Attempted defecation

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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.

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High-Resolution Solid-State Anorectal Manometry Catheter

• 23 sensors– 20 4-quadrant

sensors every cm for sphincter

– 3 unidirectional sensors for rectum, balloon & reference

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ARM: Resting Pressures

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ARM: Squeeze Pressures

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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.

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Pelvic MRI

• Endoanal MRI– Recognition of EAS atrophy– Possible role in preoperative evaluation

• Dynamic MRI– Possible replacement of defecography– Depends on radiologist’s expertise

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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

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Treatment

• Lifestyle modifications• Medications• Kegel Exercises• Biofeedback• Surgery• Sacral Nerve Stimulation• Artificial sphincters

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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.

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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.

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Biofeedback

• Operant conditioning• Goals

– Strengthen the anal sphincter muscle– Increase puborectalis tone– Improve rectal sensation– Eliminate sensory delay– Improve Recto-anal coordination

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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.

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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.

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Surgery• Sphincteroplasty

– Short term improvement 70-85%

– 5 years post op 50% failure

• Postanal repair– Success 20-58%

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Sphincteroplasty Failures- Stratification?

• Clinical features possibly predictive of failure– Internal anal sphincter defect– Prolonged PNTML– Atrophy of EAS– IBS

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Artificial sphincter

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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.

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Prevention

• Kegel exercises– Cochrane review- 15 trials: 6000pt– Antenatal and Postnatal– Decreased UI and FI– Minimial difference

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Future Research

• Pelvic Floor Disorder Network– BOOST Study- behavioral therapy versus

usual care in women with anal sphincter tears and FI

– ADAPTION Study

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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