bowel and anorectal function and dysfunction and possible available physiotherapy options

1. BOWEL AND ANORECTAL
FUNCTION & DYSFUNCTION

2. PREVENTION
 Prevention is better than cure
 The bowels should be opened once a day
 Individual’s normal habit
 Education of parents
 Regular meals, a healthy diet
 Unhurried environment
 Availability of a private place to defecate
 Suitable defecation position
 some drugs are constipating(iron
supplements,opiates,anticholinergics and NSAIDS
 while some cause diarrhea i.e antibiotics

3. Normal bowel function
Food takes from 1 to 3 days to pass
through the gut. It is propelled through by
peristalsis and on the way digestion takes
place; nutrients are absorbed
into the bloodstream chiefly in the small
intestines.

5. STORAGE
-gastrocolic reflex-- produces mass movements
-anus is closed untill its closure pressure is greater
then the mass movements
-the initial sensation of presence of stool in the
rectum--at 11-68ml
-maximal sensation at 250-510ml
In those with normal compliance and sensation,
rectal pressure begins to increase at about 300
mL.

6.  resting pressure of IAS contributes 70-85% to
the total resting pressure at anus.
 the distension of rectum ,caused by waves of
rectal filling,elicits rectoanal inhibitory
reflex(RAIR) resulting in relaxation if IAS.
 anorectal angle- supported by puborectalis m/s
produces a flap valve(normal 60-105 degree)
 fecal material in rectum may increase this angle.

7. Factors effecting the maintenance
of anorectal incontinenece
 Resting pressure of internal anal sphincter
 Resting closure pressure of external anal sphincter
 Anorectal angle (60-105 degree)
 Vascular anal cushions
 Intact nerve supply
 Contact of moisture rectal wall
 Consistency of stool
 Diet
 Activity
 Absence of infection
 Cognitively intact
 Efficiently mobile

8. DEFECATION
 The act of emptying the rectum is called defecation or ‘opening the
bowels’.
 The normal frequency of defecation varies substantially between
individuals from three times a day to three times a week for 94%
of the population.
 Position of sitting( experts opinion recommends knees should be
apart & higher than the hip joints,this may require feet to be on a
support such as stool. trunk should be fwd flexed at the hips
supported on the forearm & with the neutral spinal curves
maintained.
 when possible heels should be raised.
 when individual is in the position,pelvic floor musculature relaxes
such that the floor descends 1-2cm to the plane of ischial
tuberosities.
 IAP+ peristalsis
 the raised intra-abdominal pressure is utilized to assist defaecation
is achieved by a complex co-ordination of trunk m/s called brace &
buldge.

10. Good & Bad position for defecation

11. Some important definitions
 Anal incontinenence
 Constipation
 Anismus
 Descending perineum syndrome
 Dyschezia
 Faecal incontinence
 Megacolon
 Megarectum
 Paradoxical puborectalis contraction
 Paradoxical anal sphincter contraction
 Passive soiling
 Pelvic floor dyssynergia

15. Prevelance
 PREVELANCE OF CONSTIPATION:
 in a large study of australian women by chiarelli
et al (2000),found a prevelance rate of 14.1% in
women aged 1-23 years,26.6% in women aged
45-50 years and 27% in women aged 70-75 years.
 PREVELANCE OF ANAL & FAECAL
INCONTINENCE:
 the prevelance of anal or faecal incontinence
is equally difficult to quantify because of the
reluctance of sufferers to admit.

16. Factors contributing to difficulties
in defecation
 Abnormal defecation techniques
 Abuse
 Eating disorders
 Food & drink
 Ignoring the call to stool/workplace constipation
 Irritable bowel syndrome
 Mega colon and mega rectum
 Menstruation
 Neurological conditions
 Pain associated with anal fissure
 Pregnancy and postpartum
 Prolapse
 Psychiatric disorders
 The elderly

17. Consequences of constipation
 Psychological problems
 Physical symptoms- m/s
tension,palpitation,churnining stomach and
fatigue
 Emotional symptoms- irritability,worry, less
enthusiastic
 Cognitive symptoms- poor concentration,
indecisiveness,memory changes
 Behavioral symptoms- agitation, lethargy, poor
sleep

18. Factors contributing anal
incontinence
 Age
 Anal sphincter dysfunction
 Child birth
 Surgery
 Accidents
 Trauma
 Habitual chronic straining at the stool
 Liquid stool
 Functional fecal incontinenece

19. Physical therapy assessment
 History
 Bowel habit diary
 Food diary
 Physical examination-should commence with
observation of the patient's gait & posture.
- lower back assessment
- abdominal examination
- neurological assessment
- anorectal examination


20. physical examination

21. neurological assessment

22.  Anorectal examination

24. Investigations
 Anorectal manometry
 Colonic transit studies
 Concentric needle EMG
 Defaecating proctogram(flouroscopic
evaluation)
 Endoanal ultrasonography (EAUS)
 Magnetic resonance imaging (MRI)
 Pudendal nerve terminal motor latency (PNTML)
 Real-time ultrasound
 Strength duration curves

25. TREATMENT FOR BOWEL AND ANORECTAL
DYSFUNCTION
 Diet
 Bowel Retraining( four stages holding on
programme)
 Medications
 Physical therapy treatment

26. Medications
Constipation Faecal incontinence
o Bulky agents
o Stimulants
o Osmotic laxatives
o Faecal softeners
o Antimotility drugs
o Absorbents
o Antispasmodics
o Topical agents
o Oestrogen replacement
therapy

27. Physiotherapy Treatment
(read book for detailed description)
 Defaecation technique
 Anal sphincter exercise
 Biofeedback for constipation
 Faecal incontinence
 Massage for constipation
 Neuromuscular stimulation
 Rectal sensitivity training
 Anal cones
 Skin care and body odours

28.  technique popularized by australian
physiotherapist -- brace ,open out and grunt
 pump brace technique