Treatment progression includes starting fiber, optimizing water intake, starting laxatives, ensuring thorough age-appropriate pelvic floor physical therapy, and screening for trauma history including sexual abuse with psychological intervention before proceeding to Botox
opinionPelvic floor dysfunction is underrecognized in pediatric patients↗
▶Ep 11 · 4:35
clinicalTesticular pain triggered by large hard bowel movements and anal penetrative sex are significant indicators of pelvic floor tightness↗
▶Ep 11 · 6:16
clinicalThere is a distinction between pelvic floor dysfunction and distal anismus, which is more external sphincter-related↗
▶Ep 11 · 6:26
clinicalWithholders are typically potty-training toddlers who are constipated↗
▶Ep 11 · 6:33
clinicalA subset of patients with behavioral considerations, delays, or nonverbality exert control through their anal sphincters, which are voluntary muscles↗
▶Ep 11 · 7:08
clinicalDysynergic contraction of puborectalis can be detected on digital rectal exam when asking the patient to bear down and feeling the puborectalis squeeze around the finger↗
▶Ep 11 · 7:16
quoteIf you, you ask them to bear down and you feel that puborectalis squeezing around your finger, that's dysynergia.↗
▶Ep 11 · 7:36
clinicalDefecography is not available at many pediatric institutions and patients must go to adult centers↗
▶Ep 11 · 9:14
clinicalIn SIS marker studies showing markers stacked against the puborectalis, this indicates outlet dysfunction at the pelvic floor level↗
▶Ep 11 · 9:19
quoteSee, all those markers are really stacked up against that puberretalis, that um Pelvic floor. So that is really helpful. This is really an outlet dysfunction.↗
▶Ep 11 · 9:57
quoteSo, instead of relaxing that puber rectalis, straightening the rectum and allowing a bowel movement, That pubertalis has tightened and increased the angle.↗
▶Ep 11 · 9:57
clinicalIn defecography for pelvic floor dysfunction, the anorectal angle paradoxically tightens during defecation instead of straightening, because the puborectalis tightens rather than relaxes↗
▶Ep 11 · 10:48
clinicalMost defecography studies are MRI-based these days↗
▶Ep 11 · 10:53
clinicalFor pelvic floor dysynergia defecography in children, vaginal filling and small bowel contrast are often not performed, which is acceptable since those components are not needed to evaluate for dysynergia↗
▶Ep 11 · 11:12
clinicalIf unable to get information from anal manometry or SIS marker study, already tried physical therapy without improvement, and strongly believe dysynergia is the problem, Botox the pelvic floor; if needing to prove it for insurance coverage, send for defecography↗
▶Ep 11 · 11:42
guidelineTreatment progression includes starting fiber, optimizing water intake, starting laxatives, ensuring thorough age-appropriate pelvic floor physical therapy, and screening for trauma history including sexual abuse with psychological intervention before proceeding to Botox↗
▶Ep 11 · 12:57
clinicalPelvic floor Botox technique uses 100 units diluted in 10 mL, divided into ten 1-mL aliquots, injected into the posterior puborectalis sling using a spinal needle↗
▶Ep 11 · 13:50
clinicalThe puborectalis does not come anteriorly; it fixates on the pubic symphysis↗
▶Ep 11 · 13:57
clinicalTo inject the puborectalis, palpate the muscle which should feel like a guitar string or violin string, place your finger below it, and inject with an angled spinal needle above your finger into the muscle belly↗
▶Ep 11 · 14:02
quoteYou feel your landmark and you bring your finger right Below it, and then you inject right above your finger, you feel that tenseness as you get into the muscle.↗
▶Ep 11 · 15:04
clinicalThe right side of the puborectalis is often tighter↗
▶Ep 11 · 15:12
clinicalSacral nerve stimulator is used for fecal incontinence and occasionally for constipation, but it fails most of the time for constipation↗
▶Ep 11 · 15:39
opinionNon-relaxing puborectalis should be called levator syndrome↗
▶Ep 11 · 15:45
clinicalPudendal neuropathy can present as weakness or as pain↗
▶Ep 11 · 15:55
clinicalPelvic floor dysfunction can present as significant deep aching pelvic pain precipitated by hard bowel movements trying to pass through tight puborectalis↗
▶Ep 11 · 16:25
clinicalDefecography helps identify the level of obstructive defecation↗
▶Ep 11 · 16:38
clinicalIn solitary rectal ulcer syndrome, failure to relax the puborectalis leads to continual valsalva that traumatizes the posterior wall, causing obliteration of the lamina propria at the level of the puborectalis↗
▶Ep 11 · 17:22
guidelineConstipation patients should be screened for urinary dysfunction and urinary dysfunction patients should be screened for constipation due to significant overlap between bowel and bladder dysfunction in the pelvic floor↗
▶Ep 11 · 17:35
clinicalA pelvic floor consortium is held annually in conjunction with the American Society of Colorectal Surgeons, American Urologic Association, and American College of Obstetrics and Gynecology↗
