Pelvic Floor,

Constipation and Bowel Incontinence

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The Pelvic Floor
Constipation

Bowel Incontinence
 

The Pelvic Floor

 

Muscles, tendons and bone within the pelvis not only act as support, but also provide vital function for the bladder and bowel.  With regard to bowel function, problems with stool expulsion can lead to constipation (obstructive defecation) or lack of control (faecal incontinence).

Constipation

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Many people will suffer from constipation at some time in their lives. In some people this may become a chronic and embarrassing condition associated with laxative dependency and prolonged toileting. Identification and treatment of these patients can be life changing.

 

What is chronic constipation?

Constipation occurs when bowel movements become less frequent. This may be because the bowel activity is reduced (true constipation) or because the rectum simply cannot expel its contents (obstructive defecation or ODS). This is an important distinction as if treatment is to be effective it must be directed to the underlying cause.

What is ODS?

This is a form of constipation which affects many people (particularly women) and may result in their having to plan their lives around their bowel movements. Often it is part of a more generalised weakening of pelvic support structures. In addition to infrequent bowel opening and the need for laxatives, clues to poor evacuation include:

  • Excessive straining

  • A sensation of incomplete evacuation

  • The need to apply pressure to the perineum or even to insert a finger in to either the front or back passage to expel the stool

 

How can ODS be treated?

This may involve:

  • An interview with a consultant.

  • A camera test of the bowel may be necessary as a check to see all is healthy

Thereafter most patients will respond to non-surgical measures such as dietary advice, specialist physiotherapy exercises and so on which would be tailored to the individual's requirement.

What if the ODS doesn't improve?

First line therapy for ODS is nearly always conservative. Many patients will respond to simple measures such as dietary change, exercise and weight reduction and possible laxatives. If these methods fail then specialised pelvic floor physiotherapy may be beneficial. In about a third of cases these methods fail to achieve the desired improvement and surgery may become an option. Careful anatomical assessment of the pelvic floor through clinical assessment and a special X ray called a defecating proctogram is required.

What is the STARR procedure?
A procedure called Stapled Transanal Rectal Resection (STARR) is one form of surgery that might be appropriate. This is a surgical procedure using stapling devices carried out through the anus with no external scaring. It is used to correct a low symptomatic bulge between the rectum and vagina called a rectocele together with a slipping of the rectum in on its self known as intussusception. The operation can be conducted as either a day case or with one night in hospital.  Careful selection and counselling is always essential to achieve optimal results in this operation.

What is Laparoscopic Ventral Mesh Rectopexy
A procedure called Laparoscopic Ventral Mesh Rectopexy  (Lap VMR) is a form of surgery when there is a more substantial weakness within the pelvic floor, the small bowel may flatten and push the rectum downward from above. This bulge is known as an enterocele. When the pelvic floor is very lax a combination of a deep enterocele and excessive Intussusception may result in the rectum being pushed out through the anal canal as a full thickness rectal prolapse. Symptomatic enteroceles and full thickness rectal prolapse need an operation from the abdomen to pull the pelvic floor structures back inside and in to correct alignment. The Lap VMR is a key hole operation that allows a piece of synthetic or biological material to be fixed between the rectum and vagina which is then lifted and anchored to a bone at the top of the pelvic inlet called the sacral promontory.

How long do these procedures take and what recovery time is involved?

Patients are typically in hospital for one to three days with minimal recovery time after leaving hospital.

 

Are there risks from surgery?

There are inevitably risks from both surgery and anaesthetics that would apply to all pelvic and abdominal surgery of this nature.

For both procedures recovery of function is never guaranteed.  Often further physiotherapy input post-operatively is required.

For the STARR procedure some patients have unpredictable function following the procedure.  Urgency to toilet is common, but in the vast majority this will settle with time.

For laparoscopic ventral mesh rectopexy it is estimated that between 1 and 3% of patients will, over time, experience mesh erosion; that is mesh protruding through the vagina or rectum.  This can be a devastating complication, is difficult to treat and may require mesh removal.  However two thirds of patients who have this surgery will report life changing improvement in their symptoms.  In addition the increasing use of biological meshes and dissolvable suture material appear to be minimising risks of erosion.  Patients are always carefully counselled before proceeding to surgery. 

A small minority of patients may suffer chronic pain as a consequence of their procedure.

Due to recent publicity regarding the use of mesh in women with pelvic organ prolapse and urinary incontinence, The Pelvic Floor Society has issued a consensus statement addressing the use of mesh for the treatment of constipation and rectal prolapse.  We recommend patients review this statement by following this link: http://thepelvicfloorsociety.co.uk/.

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Bowel Incontinence

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The involuntary loss of bowel motion is disabling and embarrassing for those affected. It can have devastating consequences on an individual’s quality of life. There are two broad categories which, more often than not, can occur together – soiling and loss of faecal material without the patient being aware (passive incontinence) or the inability to defer defecation leading to an incontinence episode (urgency). Severity of symptoms can vary but the condition is common and becomes more prevalent with increasing age. Childbirth is often causal and patients with a history of multiple births and obstetric trauma are more susceptible.

 

Treatment is usually one of escalation until symptomatic improvement is achieved and the majority of patients do not require surgery or indeed investigation. Conservative therapies including dietary manipulations and stool thickening agents often suffice.  In the event that these measures fail then pelvic floor assessment through X-ray, ultra-sound or pressure studies is used to guide to the most appropriate surgical treatment. Pathways are highly individualised and appropriately tailored to a patient’s requirement and circumstance. Operations are not necessarily major procedures, indeed with modern key-hole operations or electrical stimulation techniques for example, much is performed as a day-case or one night in hospital.

 

Please note that any change in bowel habit, stool consistency or rectal bleeding may indicate a pathology within the bowel including cancer and it is common for patients to be offered a test to be sure all is clear before embarking on any treatment of their incontinence.

Sacral neuromodulation

The pelvic floor muscles and structures within it are controlled by the nervous system.  A complex pathway of nerves both instruct activity, for example passing urine (motor) and receive information, for example when the bladder is full (sensory).  These processes are controlled by both reflexes within the pelvis and by higher centres in the brain.

 

Sacral neuromodulation is a day case procedure that involves placing fine wires adjacent to the very lower nerves that can modulate these pathways.

 

What is sacral neuromodulation?

In the pelvis are muscles and valves (sphincters) that impart control on the bladder and bowel functions. These not only receive instructions from the brain but report back to it, for example when the bowel or bladder is full. If this communication system fails then faecal or bladder incontinence may ensue. Sacral neuromodulation (SNS) is a procedure which can help improve such situation.

 

When might SNS be considered appropriate?

Various disorders can affect the pelvic floor:

  • bowel leakage from weakness in anal sphincter (passive)

  • urgency and frequency leading to faecal incontinence

  • urinary problems, overactive bladder, interstitial cystitis

 

First line treatment nearly always involves non-surgical methods. Simple dietary and lifestyle advice may be all that is required. Physiotherapists can dramatically improve symptoms with pelvic floor muscle training and toileting advice. However if the problem persists despite such treatment then SNS may be considered appropriate.

How does it work?

The technique simply involves a wire inserted in to the very lower back attached to an implanted device about the size of a watch. Once in place it stimulates, with varying degrees of intensity, the appropriate nerves in the pelvic area thus helping to restore coordination between the brain and this area of the body.

Will it work for you?

The likely efficacy of the device can be tested using a two stage technique:

 

1.  The trial phase.  A small soft wire is placed within a nerve root low down in the sacral area of the back.  This is away from the main spinal cord and cannot damage important nerves. The patient has an external controller to activate the stimulator and will test its efficacy over the trial period which is usually two weeks.  There is no implantable material other than the wire and all the equipment is external.  If this temporary device works then the patient is put forward for the permanent implant.

 

2.  For the permanent implant the procedure is repeated using a fully implantable wire and stimulating device.  This is subsequently programmed to maximise its efficacy.

 

Both procedures require a general anaesthetic, but are all performed on a day case basis.


How effective is it expected to be?

In a study carried out by the National Institute for Clinical Excellence (NICE) involving a series of tests complete continence was achieved for between 41 and 75% of those tested and 75-100% experienced a decrease of 50% or more in the number of incontinence episodes. Patients also reported a general improvement in their quality-of-life scores.

 

Can I use my mobile phone?

Using a mobile phone is not affected in any way.

 

Can I shower and bath?

During the temporary assessment a bath must be avoided, but a patient can shower after 48 hours.

There are no such restrictions for the permanent device.

Are sporting activities affected?

During the test phase you will have to restrict your physical activities due to the risk of the electrode moving from its initial position

With the permanent implant there are normally no restrictions to physical activities. You should avoid activities that involve sudden, excessive or repetitive bending, twisting, bouncing or stretching soon after the surgery. These movements could damage or move the electrode wire making it less effective

 

Can I have sexual intercourse?

During the test phase it is recommended that you avoid sexual intercourse in case the electrode moves from the correct position

With the permanent implant sexual activity is not restricted

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