49
Pelvic Floor Disorders
Frank J. Harford and Linda Brubaker
687 Pelvic floor disorders are relatively common entities in clini-
cal practice. These disorders can include abnormalities of bowel storage, bowel emptying, regional pain, and anatomic abnormalities. This chapter will review the anatomic abnor- mality of rectocele and the group of regional anorectal pain disorders.
Rectoceles
Rectoceles are a nonpainful, poorly understood disorder with- out a gold standard for diagnosis. Rectoceles occur almost exclusively in women, particularly women who are vaginally parous. The relationship between anatomy and function in the distal rectovaginal region has not been studied adequately and there are significant gaps in medical and surgical knowledge.
A common clinical definition of rectocele is abnormal rec- tovaginal anatomy that allows the rectum to be in direct con- tact with the vaginal serosa without an intervening layer.
Usually, rectoceles are diagnosed when rectovaginal support abnormalities are observed during physical examination.
There may be protrusion of the posterior vaginal wall beyond the hymen with or without strain effort. Using the interna- tionally validated staging system for pelvic organ prolapse,1 the distal-most posterior vaginal wall is 3 cm from the hymen.
In rectocele formation, this normal anatomy is lost and the distal posterior vaginal wall moves closer toward the hymen or may protrude outside the hymen.
The differential diagnosis for this physical finding includes other abnormalities of vaginal attachment, usually the vaginal apex (with or without the uterus). Differences in physical examination techniques affect the degree of prolapse that is detected. The side-lying or prone jackknife examination that is favored by many colon and rectal surgeons is sufficient to detect some forms of prolapse; however, the standing strain- ing vaginal examination provides the best opportunity to determine the full extent of anatomic abnormalities.
Gynecologic surgeons have placed more focus on repair of the vaginal apex, which then provides secondary resolution of
the distal vaginal support defect for many women. Another important differential diagnosis includes abnormalities in per- ineal support, including severe atrophy or denervation of the levator muscles. Abnormalities in these muscles allow the genital hiatus to widen significantly, causing the vaginal opening to appear larger. This is often referred to as a pseudo- rectocele.
Some specialists use fluoroscopy as an aid to physical diag- nosis (Figure 49-1). There is little literature regarding these techniques, the lack of a “gold standard” diagnosis has limited progress in this field. It is clear, however, that the finding of
“rectocele” in asymptomatic women during fluoroscopic examination should not prompt surgical repair. Moreover, review of fluoroscopically recorded defecation has demon- strated significant variability in the movement of the distal rectovaginal wall in normal women. The promptness and completeness of defecation are probably more important than the maximum excursion of the anterior rectal wall.
Isolated rectoceles are distinctly uncommon and virtually always occur in the presence of a significant defecation disor- der. The decision to surgically readdress rectocele must be carefully considered after a full evaluation of the symptoms that are being attributed to the abnormal anatomy.
The symptoms of rectocele are believed to be stool trap- ping, difficult defecation, and vaginal protrusion of the poste- rior vaginal wall. Rectoceles are not painful and reports of pain should prompt the physician to seek other diagnoses. It is widely appreciated that many women with relatively large
“rectoceles” have no symptoms attributable to this finding.
They are able to conduct all pelvic functions without diffi- culty, including sexual function, and bowel storage and emp- tying. Other women with minimal abnormalities on physical examination may report great bother from difficult defecation and stool trapping. In the absence of severe symptoms or find- ings, the recommended primary intervention is generally attention to optimize stool consistency. For many affected women, this requires appropriate amounts of fiber, adequate hydration, and improved toileting habits. In certain centers, allied health professionals such as nurses and/or occupational
or physical therapists can assist the surgeon with these impor- tant behavioral changes. Biofeedback to establish pelvic floor outlet relaxation during defecation may be helpful.
When symptoms are persistent despite appropriate atten- tion to stool consistency, surgical treatment may be consid- ered. The goal of the surgery should be clearly stated by the surgeon and clearly understood by the patient. Mismatch of goals in this area of poorly understood physiology are com- mon. For example, a patient may not mind the bulge at all, but she is greatly bothered by the need to manually assist her defecation with her hand. Although surgery may be quite effective at relieving her abnormal anatomy, the symptom res- olution for hand-assisted defecation is much lower. The planned surgery will not be considered successful by the patient (and therefore by the surgeon) unless the bothersome symptom that prompted the surgery is finally relieved. Honest surgeons will recognize that surgery has significant limita- tions in relief of certain forms of defecation disorders, but is reasonably effective at normalizing anatomy.
Preoperative testing should include age and risk-appropriate cancer screening (e.g. colonoscopy). Pudendal terminal motor latency testing has no role in selection of patients for rectocele surgery. Defecography may be helpful in documenting failure of the puborectalis muscle to relax during attempted defeca- tion and to establish the presence or absence of internal intus- susception as a cause of outlet obstruction of the rectum.
A variety of surgical options are available. The surgeon’s belief about the etiology of the rectocele typically determines the technique selected. Gynecologists favor an approach aimed at reinforcement and perineal reattachment of the nor- mal intervening layer of rectovaginal tissue. There are only two randomized surgical trials.2,3Both of these studies report that the transvaginal approach is superior to the transanal route. Whereas some have argued that there is a distinct fascia,4others refute this. More recently, gynecologists have begun supplementing this tissue with a wide variety of graft materials, although no materials have been proven superior to repair without graft.
Colon and rectal surgeons may approach rectocele from a transanal approach, focusing attention on the capacious rectal vault, and reducing it with pursestring or placating sutures.
Sehapayak5reported a case series of 355 patients who had a transanal rectocele repair treated with a technique similar to mucosal prolapse. Symptoms attributable to the rectocele were recorded pre- and postoperatively. This technique focuses on abnormalities within the bowel wall itself. A similar tech- nique, described by Khubchandani et al.,6also includes exci- sion of the mucosa. Validated outcome assessment of this technique is pending. Block7has described a frequently used approach, restricted to midlevel or midvaginal rectocele. The technique in this case series has not yet been tested in a ran- domized surgical trial. Transanal stapled reduction of the ante- rior rectocele has recently been evaluated for safety and feasibility but efficacy in a randomized trial is pending.
There is a paucity of literature addressing the symptoms that are appropriately attributed to rectocele, indications for rectocele surgery, the optimal outcome measures after sur- gery, and the durability of optimal surgical outcomes. This is regrettable given the frequency with which this surgery is performed in American women.8
Unsuccessful rectocele repair can occur when either anatomy or symptoms are not corrected. Additional problems may occur when new symptoms arise. One very troubling postoperative complication can be dyspareunia, which in some women can completely preclude sexual activity and destroy intimacy. All operations in the distal posterior vagina and per- ineum may cause new-onset dyspareunia, and this risk should be disclosed to patients during the negotiation of the informed consent. Recurrent anatomic problems that do not seem to be triggered by abnormal bowel function may be attributable to a widespread abnormality of pelvic support, such as vaginal api- cal prolapse (with or without a uterus). Physical examination of vaginal supports in the standing straining position is essen- tial and strongly recommended even before a first surgery.
A combined gynecologic-colorectal-urologic approach is sometimes needed to address the combination of issues.
Patients who experience initial resolution of anatomy and symptoms may experience relapse if the behavioral program to optimize stool consistency and toileting is not followed.
Severe constipation is not a distal rectovaginal problem and it is not reasonable to expect rectocele repair to resolve this symptom. Continued attention to underlying disorders, such as severe constipation, is necessary to preserve optimal recto- cele repair.
Pelvic Pain Syndromes
Epidemiology
Chronic pelvic pain is not an infrequent cause for medical consultation. The prevalence of chronic pelvic pain in the female population is estimated to be 3.8%. This is similar to FIGURE49-1. This is a typical fluoroscopic appearance for a rectocele
(R). The protrusion is distal with a normal anal opening and proximal rectum. Other support abnormalities are also seen in the bladder (B).
the prevalence of back pain or asthma. It accounts for about 10% of all visits to gynecologists.9 A North Carolina survey of primary care practices found that 39% of women complain of pelvic pain.10 In a telephone toll of about 18,000 United States households, the Gallop Organization reported that 16%
of women surveyed complained of chronic pelvic pain.11 Although pelvic pain is more common in women, it is cer- tainly not confined to the female gender. In a United States survey of functional gastrointestinal disorders, the prevalence of functional anorectal pain was 11.1% of the male and 12.1%
of the female respondents to the survey.12 In a United States survey of physician visits between 1990 and 1994, there were two million healthcare visits per year associated with the diagnosis of prostatitis.13 Ninety percent of patients with the diagnosis of prostatitis do not have bacterial prostatitis. In 1998, a National Institutes of Health consensus conference designated a new term to encompass these patients—Type III chronic prostatitis/chronic pelvic pain syndrome.14 In a study of patients with CPPSIII, they were found to have significant differences in muscle spasm, increased tone, and pain on pal- pation of the muscles of the pelvic diaphragm.15
The role of the specialist in the care of these patients is to eliminate intrinsic disorders of the genitourinary and gas- trointestinal organs in the pelvis and, if none are found, to
treat the pain. The more common pain syndromes are described below. An algorithm for the management of these patients is depicted in Figure 49-2.
Levator Syndrome
Levator syndrome is but one of the symptom complexes in the broader category of chronic pelvic pain or chronic idiopathic rectal pain. It is a pattern that was recognized and described in the 1930s and will be discussed as a separate entity. The rigor with which the syndrome is defined varies greatly and thus leads to some confusion. Simpson16reported the symp- tom complex first in 1859, but Thiele,17in 1936, described it in more detail and attributed the symptoms to spasm of the pelvic floor musculature.
The term coccygodynia has been applied to this symptom complex in the early descriptions. It has also been referred to as piriformis syndrome, puborectalis syndrome, diaphragma pelvis spastica, and pelvic tension myalgia. Grant et al.,18in one of the largest modern series of cases, described it as pain, pressure, or discomfort in the region of the rectum, sacrum, and coccyx that may be associated with pain in the gluteal region and thighs. They made the observation that pressure on the coccyx was rarely painful and regarded the label of
History & Physical Exam Endoscopy, Ultrasound MRI, Defecography as Clinically Indicated
Symptoms Suggestive of Pudendal Nerve Entrapment
Symptomatic Treatment Myofascial Pelvic Floor Physical Therapy
Relief No Relief
Relief No Relief Repeat PRN
Pudendal Nerve Block
Consider Neurolysis
Symptomatic Treatment
Symptomatic Treatment Levator Syndrome
Massage/Myofascial Pelvic Floor Physical Therapy
Relief No Relief Relief No Relief
Relief No Relief
Relief No Relief
Relief No Relief
Repeat PRN Repeat PRN
Repeat PRN
Repeat PRN
Repeat PRN PR Trigger Point
Steroid Injection Operative
Manipulation & Injection
Galvanic Stimulation Coccygodynia
Steroid Injection
Rare
Coccygectomy
FIGURE49-2. Algorithm for management of chronic anorectal pain.
coccygodynia as incorrect. Other observers have noted the radiation of the pain to the vagina in women and the associa- tion with the feeling of incomplete evacuation.19
The prevalence of this symptom complex in the general population is approximately 6%.12 It is more common in women. The Committee on Functional Anal/Rectal Disorders at a conference to develop diagnostic criteria for Functional Gastrointestinal Disease (Rome II)20 described the pain of levator syndrome as a vague, dull ache or pressure sensation high in the rectum, often worse with sitting or lying down, that lasts for hours to days. They differentiated between a
“highly likely” diagnosis in patients with these symptoms in which posterior traction on the puborectalis reveals a tight levator ani musculature and tenderness or pain, and a “possi- ble” diagnosis if only the symptoms are present. These diagnoses should be entertained only after the presence of alternative diseases are excluded with careful physical examination, endoscopy, and ancillary studies such as defecography, ultrasound, computed tomography, or mag- netic resonance imaging (MRI).
The utility of electromyography, anal manometry, and pudendal nerve studies has not been established. No consis- tent abnormalities in any of these tests have been demon- strated in the majority of patients.21,22
A wide variety of treatments have been described. Thiel first recommended digital massage. The massage was given daily for 5 or 6 days. Grant et al.18used two to three massages 2–3 weeks apart, combined with heat and diazepam, and had good results in 68% of the patients and moderate improve- ment in 19%. Poor results were obtained in 13%. A small number of these patients were salvaged with injection of methylprednisolone and lidocaine into the puborectalis sling or “rectal divulsion under anesthesia.” (Manual dilation of the anal sphincter, a procedure no longer recommended by this group). (Salvati EP, personal communication.)
Kang et al.23described a series of 104 patients in which transanal injection of triamcinolone rendered 37% of patients pain free. Thirty-five percent experienced a greater than 50%
reduction in pain. Several investigators have tested electrogal- vanic stimulation of the levator muscles via a transrectal probe. The electrical stimulation induces fasciculation and eventual fatigue in the spastic muscles. There is quite a bit of variance in the schedule of treatments as well as length of follow-up in the reported series. The percentage of patients with excellent or good results varies from 19% to 91%.19,24–29 Biofeedback has been used with some success. Both Grimaud et al.30 and Heah et al.31 reported small series of patients who had excellent results with biofeedback. Gilliland et al.32reviewed a larger series of patients with levator-type pain with biofeedback, 37% of whom also had constipation.
One-third of the patients noted improvement. The presence or absence of constipation did not seem to matter. The poorer results in the larger series may well be a reflection of a dif- ferent patient population. Epidural lidocaine and steroid injections were used in a small number of patients with
chronic intractable rectal pain, but had no long-term effect on these patients who exhibited levator spasm as part of their pain syndrome. It did, however, sort out those patients who had no initial relief of their pain at the time of injection. These patients were considered to have pain from a high central, autonomic, or psychogenic origin.
Other modalities have been used for chronic pelvic pain, although not in the narrowly defined group with levator syn- drome. Static magnetic field therapy33 and pulsed magnetic stimulation34 seem to have some salutary effect. Electrical sacral nerve stimulation, which has been used for voiding dis- orders and fecal incontinence, has also successfully reduced the severity of pain in patients who were broadly character- ized as having chronic pelvic pain.35Investigators using lin- early polarized near-infrared irradiation have also reported some success in participants with intractable anorectal pain.36 Anxiety and depression have been associated with chronic pelvic pain syndrome and these conditions should be consid- ered in the comprehensive approach to the management of these patients with pelvic pain.37
Coccygodynia
Coccygodynia, although may be part and parcel of the whole group of pelvic floor musculoskeletal problems, is distin- guished by the distinct pain evoked with pressure or manipu- lation of the coccyx. Several rare tumors of the sacrum or sacral nerve structures have been demonstrated in patients with coccygodynia.38–40 The condition has also been attrib- uted to trauma, avascular necrosis, or referred pain from a prolapsed lumbar disk.41,42When no obvious explanation was available, it often was attributed to a psychosomatic manifes- tation of hysteria or depression. Although coccygectomy was popular at one time, in recent times, it has generally been regarded as ill conceived by most surgeons. Wray and his group43from Leicester studied a group of 120 patients with coccygodynia. They randomized them between treatment with injections of methylprednisolone and bupivacaine alone or injections and manipulation of the coccyx under general anesthesia. Injections alone were successful in 60% and injec- tions plus manipulation was successful in 85% of the patients in that arm of the study. The 23 patients who failed either of these two treatments came to coccygectomy and 21 of 23 had a good result, suggesting that this operation may not be inap- propriate in those patients who have failed a trial of less inva- sive therapy. This success rate with coccygectomy is similar to that reported in two other retrospective series.44,45
Proctalgia Fugax
Proctalgia fugax, as the name implies, is a fleeting pain in the area of the rectum lasting no more than a minute or two. The pain is too transient to study very well, but, presumably, it is secondary to spasm of the rectum itself or muscular compo- nents of the pelvic floor. In a British survey of a healthy
population, 14% of the patients reported that this phenomenon occurred at least once a year and 5% reported the phenomenon more than six times per year.46Kamm et al.47has described a family with a hereditary internal anal sphincter myopathy in which the proctalgia fugax was a very frequent occurrence.
The role of the physician in these cases is mainly to assure the patient that this is not a symptom of any serious disorder.
The use of perianal nifedipine in the same doses and method as for anal fissure and hypertrophic internal anal sphincter may be of benefit. There are no randomized trials to docu- ment improvement.
Pudendal Neuralgia
Pudendal neuralgia is a symptom complex, which is manifest by chronic pelvic/perineal pain in the distribution of one or both pudendal nerves. It may be manifest as vulvodynia, orchalgia, proctalgia, or prostatodynia. The pain patterns overlap with those of levator syndrome, coccydynia, and ure- thral syndrome. It is attributable to compression or entrap- ment of the pudendal nerve and often is positional in nature.
Some have also attributed disordered defecation to pudendal nerve entrapment and have reported resolution with nerve decompression.48 This diagnosis should be entertained if there is a history of trauma, either a distinct episode or chronic perineal trauma such as seen in cyclists or rowers.49
The pudendal nerve arises from S2, S3, and S4 of the sacral plexus. The nerve leaves the pelvis beneath the piriformis muscle through the greater sciatic foramen. It then passes on to the sacrospinous ligament medial to the ischial spine and reenters the pelvic cavity. While beneath the levator ani mus- cles, it runs ventrally through Alcock’s canal, a thickening of the obturator internus fascia. In the ischiorectal fossa, it gives off an inferior rectal and perineal branch. The two docu- mented sites of pudendal nerve entrapment are between the sacrotuberous and sacrospinous ligament and in the pudendal (Alcock’s) canal. Antolak et al.50 have hypothesized that many patients with chronic pain have induced hypertrophy of the pelvic muscles caused by athletic activities in their youth, which has in turn caused remodeling of the ischial spine and rotation of the sacrospinous ligament and nerve compression.
The diagnosis of pudendal neuralgia is supported by repro- duction of the pain with pressure on the ischial spine although this is not a constant finding. Pudendal nerve latency is often prolonged when it is tested. Nerve block under computed tomography51or ultrasound guidance52has been used to sort out those patients who would likely benefit from neurolysis.
Mauillon et al.53surgically decompressed the pudendal nerve in 12 patients after evaluating them with a nerve block under computed tomography guidance. After 21 months of follow- up, three patients were completely relieved of their pain and one slightly improved. Eight patients remained in pain. In the three patients who were completely relieved of their pain, the nerve block had eliminated their pain for 2 weeks on two separate occasions. Pain relief was obtained with nerve block
in only one of the nine patients in whom nerve decompression was unsuccessful.
Conclusion
Various benign anorectal conditions may cause considerable trouble for patients. A stepwise, scientifically sound approach to the evaluation and treatment of these disorders may offer a prompt diagnosis and treatment. Referral of patients who con- tinue to suffer despite the physician’s best treatment efforts is encouraged.
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