10 settles pelvic floor disorders

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10 settles pelvic floor disorders

  1. 1. Pelvic Floor Dysfunction Diane M. Settles, MDAssistant Clinical Professor of Medicine IU Health Digestive & Liver Disorders
  2. 2. Roadmap• Pelvic Floor Anatomy• Risk Factors• Evaluation• Treatment• Prevention
  3. 3. Pelvic Floor Anatomy •Connective Tissue •Muscles •Neural Structures
  4. 4. Symptoms• Urinary Incontinence• Pelvic Organ Prolapse• Anal/Fecal Incontinence• Dypareunia• ?Dyssenergic Defecation
  5. 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. 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. 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. 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. 9. Risk Factors• Pregnancy versus Delivery• Parity• Age• Obesity• Smoking• Ethnicity?• Chronic Pulmonary Conditions• Menopause
  10. 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 riskfactor except for POP. This may be related to the smallamount of pts with POP.
  11. 11. ParityParity UI FI POP ≥1 PFD0 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. 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. 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. 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. 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. 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. 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
  18. 18. Mechanism of ContinenceRao CGH2010;8:910-9.
  19. 19. Evaluation• Examination – Detailed neurological examination – Perianal inspection – Detailed rectal examination • Resting and squeezing tone • Attempted defecation
  20. 20. 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.
  21. 21. High-Resolution Solid-StateAnorectal Manometry Catheter • 23 sensors – 20 4-quadrant sensors every cm for sphincter – 3 unidirectional sensors for rectum, balloon & reference
  22. 22. ARM: Resting Pressures
  23. 23. ARM: Squeeze Pressures
  24. 24. 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.
  25. 25. Pelvic MRI• Endoanal MRI – Recognition of EAS atrophy – Possible role in preoperative evaluation• Dynamic MRI – Possible replacement of defecography – Depends on radiologist’s expertise
  26. 26. Fecal IncontinenceDiarrhea Prolapse Obstetric/Surgical Neurological HxChronicDiarrhea Confirmed SuspectWorkup Surgery Imaging ARM and Imaging-Supportive Rx MRI or EUS Adapted from Rao et al.No improvement ACG Guidelines AJG 2004
  27. 27. Treatment• Lifestyle modifications• Medications• Kegel Exercises• Biofeedback• Surgery• Sacral Nerve Stimulation• Artificial sphincters
  28. 28. 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.
  29. 29. 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.
  30. 30. Biofeedback• Operant conditioning• Goals – Strengthen the anal sphincter muscle – Increase puborectalis tone – Improve rectal sensation – Eliminate sensory delay – Improve Recto-anal coordination
  31. 31. 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.
  32. 32. BF and Pelvic Exercise: EqualEfficacy?• 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.
  33. 33. Surgery • Sphincteroplasty – Short term improvement 70-85% – 5 years post op 50% failure • Postanal repair – Success 20-58%
  34. 34. Sphincteroplasty Failures-Stratification?• Clinical features possibly predictive of failure – Internal anal sphincter defect – Prolonged PNTML – Atrophy of EAS – IBS
  35. 35. Artificial sphincter
  36. 36. 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.
  37. 37. Prevention• Kegel exercises – Cochrane review- 15 trials: 6000pt – Antenatal and Postnatal – Decreased UI and FI – Minimial difference
  38. 38. Future Research• Pelvic Floor Disorder Network – BOOST Study- behavioral therapy versus usual care in women with anal sphincter tears and FI – ADAPTION Study
  39. 39. 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

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