Colorectal Quiz: Episode 45 - Pelvic Floor Dyssynergia

Aaron Teeple is the only person in the United States with both pediatric surgery and adult colorectal surgery credentials

Mark Molota from Munich, Germany is also a pediatric surgeon and colorectal surgeon

Pediatric surgeons need to know more about pelvic floor dysfunction, while adult colorectal surgeons know this well

Pelvic floor dysfunction is underrecognized in pediatric patients

Urinary retention is extremely rare in an otherwise healthy young man and should raise red flags

Testicular pain triggered by large hard bowel movements and anal penetrative sex are significant indicators of pelvic floor tightness

Many patients with bad constipation have been treated with laxatives, Malone procedures, ileostomies, or stomas without anyone evaluating their sphincters

The majority of constipated patients without congenital reasons (excluding anorectal malformations and Hirschsprung disease) have pelvic floor dysfunction

There is a distinction between pelvic floor dysfunction and distal anismus, which is more external sphincter-related

Withholders are typically potty-training toddlers who are constipated

A subset of patients with behavioral considerations, delays, or nonverbality exert control through their anal sphincters, which are voluntary muscles

Dysynergic 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

Defecography is not available at many pediatric institutions and patients must go to adult centers

Taking a detailed history is important because reliable data from anorectal manometry is difficult to obtain in children

In a patient with gas retention who is distended all day but has a flat abdomen in the morning, this indicates successful gas passage during sleep when not thinking about it, suggesting behavioral impact

In SIS marker studies showing markers stacked against the puborectalis, this indicates outlet dysfunction at the pelvic floor level

In defecography for pelvic floor dysfunction, the anorectal angle paradoxically tightens during defecation instead of straightening, because the puborectalis tightens rather than relaxes

Most defecography studies are MRI-based these days

For 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

If 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

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

Pelvic 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

The puborectalis does not come anteriorly; it fixates on the pubic symphysis

To 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

The right side of the puborectalis is often tighter

Sacral nerve stimulator is used for fecal incontinence and occasionally for constipation, but it fails most of the time for constipation

Non-relaxing puborectalis should be called levator syndrome

Pudendal neuropathy can present as weakness or as pain

Pelvic floor dysfunction can present as significant deep aching pelvic pain precipitated by hard bowel movements trying to pass through tight puborectalis

Defecography helps identify the level of obstructive defecation

In 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

Constipation 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

A 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