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 also holds both credentials.

Pelvic floor dysfunction is underrecognized in pediatric surgery and requires consideration of sexual, urinary, and bowel dysfunction together.

Urinary retention in an otherwise healthy young man is extremely rare 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 constipated patients 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.

Pelvic floor dysfunction differs from distal anismus, which involves the external sphincter; withholding behavior in potty-training toddlers represents one pattern, while patients with behavioral considerations or developmental delays may exert control through voluntary anal sphincter contraction.

Digital rectal exam can mimic anal manometry by asking the patient to squeeze and bear down; feeling puborectalis squeeze during bearing down indicates dysynergia.

Defecography is not available in many pediatric institutions; in Philadelphia it goes through adult centers, and at MedStar defecographies are obtained at the adult center.

History-taking is important for diagnosing pelvic floor dysfunction because anorectal manometry data is often unreliable in children.

A patient with external sphincter tightness and gas retention had a flat abdomen every morning after passing gas successfully during sleep, demonstrating behavioral impact on sphincter control.

When SIS markers stack up against the puborectalis and pelvic floor, this indicates outlet dysfunction.

In defecography, the vagina and anus are retrograde filled and the patient takes contrast to visualize enterocele or sigmoidocele and assess pelvic floor function.

In pelvic floor dysynergia, the puborectalis tightens during defecation, increasing the anorectal angle instead of relaxing and straightening the rectum.

Most defecography studies are MRI-based these days; pediatric patients typically do not need vaginal filling or small bowel filling when evaluating for pelvic floor dysynergia.

If anal manometry and SIS marker study cannot provide diagnostic information, physical therapy has failed, and dysynergia is suspected, Botox of the pelvic floor can be both diagnostic and therapeutic; defecography can be obtained if proof is needed for insurance coverage.

Initial treatment for pelvic floor dysfunction includes fiber, optimized water intake, laxatives, thorough age-appropriate pelvic floor physical therapy, and screening for trauma history including sexual abuse with psychological intervention.

After optimization with diet, fiber, water, laxatives, and psychological/psychiatric intervention, the next step is pelvic floor Botox injection.

Pelvic floor Botox technique: 100 units diluted in 10 mL, divided into ten 1-mL aliquots; using an operative anal scope or nasal speculum for smaller children, palpate the puborectalis sling digitally, then inject each 1-mL aliquot with a spinal needle into the posterior puborectalis sling just above the palpating finger.

The puborectalis should feel like a guitar string or violin string; if it cannot be felt, it is probably not a tight pelvic floor.

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

During Botox injection, the needle is sunk into the belly of the puborectalis muscle, which can be felt as tenseness; the technique involves hooking the muscle with a finger, creating an indent with bulging muscle above, then injecting above the finger.

Often the right side of the puborectalis is tighter.

Sacral nerve stimulator is used for fecal incontinence and occasionally for constipation, but it fails most of the time for constipation; it has not been seen used for non-relaxing puborectalis.

Terminology creates confusion: levator syndrome should be called non-relaxing puborectalis; pudendal neuropathy can present as weakness or pain.

Non-relaxing puborectalis can present as significant deep aching pelvic pain precipitated by hard bowel movements trying to pass the tight puborectalis.

Defecography helps identify the level of obstructive defecation when it is unclear whether the problem is poor motility or outlet obstruction.

Solitary rectal ulcer syndrome occurs when failure to relax the puborectalis causes continual valsalva to traumatize the posterior rectal wall, leading to 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.