Colorectal Quiz: Episode 45 - Pelvic Floor Dyssynergia
With Dr. Jason Fisher & Dr. Mark Levitt & Dr. Aaron Teeple · hosted by Dr. Thomas Xu
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Aaron Teeple is the only person in the United States with both pediatric surgery and adult colorectal surgery credentials, with Mark Malota from Munich, Germany being another surgeon with both credentials.
Pelvic floor dysfunction is underrecognized in pediatric surgery and pediatric surgeons need to know more about it.
Testicular pain triggered by hard bowel movements and anal penetrative sex are significant indicators of pelvic floor tightness.
Many patients with severe constipation receive aggressive interventions (laxatives, Malone procedures, cecostomies, stomas) without proper evaluation of their sphincters.
The majority of pediatric constipation patients (excluding those with anorectal malformations and Hirschsprung disease) have pelvic floor dysfunction.
There is a distinction between pelvic floor dysfunction and distal anismus (external sphincter dysfunction).
Withholding toddlers during potty training represent one subset of patients, while another subset includes patients with behavioral considerations, delays, or nonverbality who exert control through their voluntary anal sphincters.
Dyssynergic contraction of the puborectalis can be assessed during digital rectal exam by asking the patient to bear down; if the puborectalis squeezes around the examining finger, that indicates dysynergia.
Defecography is not widely available in pediatric institutions; in Philadelphia it goes through adult centers, and at MedStar defecographies are performed at the adult center.
History-taking is important in diagnosing pelvic floor dysfunction because anorectal manometry data is often unreliable in children.
A patient with external sphincter tightness who is gassy and has a colon filled with air may pass gas successfully during sleep when not consciously controlling it, indicating behavioral impact.
In SIS marker studies showing pelvic floor dysfunction, markers stack up against the puborectalis and pelvic floor, indicating outlet dysfunction.
In defecography of patients with pelvic floor dysfunction, the anorectal angle paradoxically tightens during defecation instead of straightening; at rest the rectum is more straight than during defecation.
Most defecography studies are now MRI-based rather than fluoroscopic.
For pediatric patients undergoing defecography at adult institutions, vaginal filling is typically not performed, and small bowel filling is often omitted, which is acceptable when evaluating for pelvic floor dysynergia.
If a patient has failed physical therapy and dysynergia is strongly suspected but needs to be proven (for insurance coverage), defecography should be obtained before proceeding to Botox.
Initial treatment for pelvic floor dysfunction includes fiber, optimized water intake, laxatives, and thorough age-appropriate pelvic floor physical therapy.
Adults with pelvic floor dysfunction may have trauma backgrounds including sexual abuse or other abuse, and should be screened and connected with psychological services.
After optimization with diet, fiber, water, laxatives, and psychological/psychiatric intervention, the next treatment step is pelvic floor Botox injection.
Most pediatric surgeons inject Botox into the sphincter rather than the pelvic floor.
For pelvic floor Botox injection, 100 units are diluted in 10 mL and divided into ten 1-mL aliquots, which are injected into the posterior puborectalis sling using a spinal needle.
The puborectalis should feel like a guitar string or violin string on palpation; if it cannot be felt, it is probably not a tight pelvic floor.
The puborectalis does not extend anteriorly; it fixates on the pubis.
During Botox injection of the puborectalis, the examining finger is placed below the muscle, creating an indent with bulging of the muscle above it, and the angled spinal needle is inserted above the finger into the belly of the muscle.
The right side of the puborectalis is often tighter than the left.
Sacral nerve stimulator is used for fecal incontinence and occasionally for constipation, but it fails most of the time for constipation and is not typically used for non-relaxing puborectalis.
Terminology creates confusion in pelvic floor disorders; levator syndrome should be called non-relaxing puborectalis.
Pudendal neuropathy can present as weakness or as pain.
Pelvic floor dysfunction can present as significant deep aching pelvic pain that can be precipitated by hard bowel movements trying to pass through a tight puborectalis.
Obstructive defecation is tricky to diagnose because the level of obstruction is unclear and it may be difficult to determine whether poor motility or another problem is the cause.
Defecography helps identify the level of obstructive defecation.
Solitary rectal ulcer syndrome occurs when failure to relax the puborectalis leads to continual trauma to the posterior rectal wall during valsalva, causing obliteration of the lamina propria at the level of the puborectalis.
Constipation patients should be screened for urinary dysfunction and urinary dysfunction patients should be screened for constipation because there is significant overlap between bowel and bladder dysfunction, some of which is in the pelvic floor itself.
The 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 as a joint effort among specialists invested in pelvic floor disease care.
Botox and pelvic floor physical therapy can help improve constipation in patients with pelvic floor dysfunction.
Anal manometry in children is difficult because getting a child to hold a balloon in their bottom is often unsuccessful at certain ages and not a reliable measure of sphincter tone.