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

2. Roadmap
• Pelvic Floor Anatomy
• Risk Factors
• Evaluation
• Treatment
• Prevention

3. Pelvic Floor Anatomy
•Connective Tissue
•Muscles
•Neural Structures

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

5. 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

6. 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

7. 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.

8. • 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.

9. Risk Factors
• Pregnancy versus Delivery
• Parity
• Age
• Obesity
• Smoking
• Ethnicity?
• Chronic Pulmonary Conditions
• Menopause

10. Age
Age 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.

11. Parity
Parity 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.

12. 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.

13. 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

14. • 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

15. 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

16. 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.

17. Elective Caesarean
• Cochrane Review
– 21 studies- total of 31,698 patients
Elective Caesarean
• 6028 Caesarean delivery
• 25170 Vaginal delivery
Cannot Bestudy- Term Breech Trial
• 1 randomized Recommended
• 1 Study illustrated benefit
• No difference in elective versus emergency
• Risk include adhesions(83% by third
pregnancy), infertility, bleeding
Cochrane Review 2010

19. Mechanism of Continence
Rao CGH
2010;8:910-
9.

20. Evaluation
• Examination
– Detailed neurological examination
– Perianal inspection
– Detailed rectal examination
• Resting and squeezing tone
• Attempted defecation

21. Physiologic Testing
Clinical Utility of ARM in Fecal
• Manometry and Sensory Testing
Incontience
– Functional weakness 95%
Diagnosis Confirmed EAS and IAS
– Abnormal rectal sensation
New Information 98%
– Grade B evidence
Influenced Treatment 84%
Normal Study 2%
Not Helpful 14%
Rao et el. AJG 92:460-
75.

22. High-Resolution Solid-State
Anorectal Manometry Catheter
• 23 sensors
– 20 4-quadrant
sensors every
cm for sphincter
– 3 unidirectional
sensors for
rectum, balloon &
reference

23. ARM: Resting Pressures

24. ARM: Squeeze Pressures

25. 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
Enck et al. AJG 91:2539-
fecal incontinence 43.

26. Pelvic MRI
• Endoanal MRI
– Recognition of EAS atrophy
– Possible role in preoperative evaluation
• Dynamic MRI
– Possible replacement of defecography
– Depends on radiologist’s expertise

27. Fecal Incontinence
Diarrhea Prolapse
Obstetric/Surgical
Neurological Hx
Chronic
Diarrhea Confirmed Suspect
Workup Surgery Imaging
ARM and Imaging-
Supportive Rx MRI or EUS
Adapted from Rao et al.
No improvement ACG Guidelines AJG 2004

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

29. Antidiarrheals
• Loperamide
– Reduce frequency of incontinence
– Improve stool urgency
– Increase colonic transit time
– Increase anal resting sphincter pressure
– Reduce stool weight
Sun et al. Scan J
• Lomotil Gastro 32:34-8.
Hallgren Dig Dis Sci
• Codeine 39:2612-8.

30. 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.

31. Biofeedback
• Operant conditioning
• Goals
– Strengthen the anal sphincter muscle
– Increase puborectalis tone
– Improve rectal sensation
– Eliminate sensory delay
– Improve Recto-anal coordination

33. 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.

34. 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.

35. Surgery
• Sphincteroplasty
– Short term
improvement
70-85%
– 5 years post op
50% failure
• Postanal repair
– Success 20-58%

36. Sphincteroplasty Failures-
Stratification?
• Clinical features possibly predictive of failure
– Internal anal sphincter defect
– Prolonged PNTML
– Atrophy of EAS
– IBS

37. Artificial sphincter

38. 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.

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

40. Future Research
• Pelvic Floor Disorder Network
– BOOST Study- behavioral therapy versus
usual care in women with anal sphincter tears
and FI
– ADAPTION Study

41. 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