Pelvic Floor Dyssnergia
|Mrs. Devlin is a highly active and vibrant 68-year-old woman referred to a gastroenterologist for her chronic constipation. She reports a 40-year history of difficult defecation that seemed to get worse with every pregnancy and delivery. She has had 4 children, all delivered vaginally, several of which were accompanied by what she describes as rather extensive episiotomies. She does not have any records of her perinatal care. Her main complaint is severe straining and a sensation of obstruction. She has a bowel movement approximately every 3 days and describes the stools as pebble-like and occasionally hard and lumpy. Over the last 5-10 years she often has had to resort to pushing up on her perineal area or inserting a finger into her vagina to facilitate bowel movements. She does occasionally pass a normal or even soft stool but states that that is very uncommon. She has embarked on multiple lifestyle regimens including drinking at least 1-2 liters of water per day, increasing her exercise regimen to 5 days per week (treadmill walking at least 2 miles and water aerobics) and eating a high fiber diet. None of these activities has resulted in any change in her bowel symptoms. She has tried a wide variety of over-the-counter and prescription medications and "just about every laxative that is available," also without much success. Most recently, her primary care doctor placed her on both senna and PEG 3350. She reports that she has not seen any change in her straining or sense of obstruction, but has noticed that her stool is softer and easier to pass. She is concerned about the long-term effects of laxatives and estimates that she is only 10% better with the current regimen. Besides the 4 pregnancies, her medical history is only notable for mild degenerative joint disease and osteopenia. Mrs. Devlin takes the following medications:
-Alendronate 70 mg every week
-Acetaminophen 625 mg q 6hrs PRN, for joint pain
-TUMS (for calcium) 2 tabs per day
-ASA 81 mg per day
-Senna 2 tabs per day
-PEG 3350 17 grams per day
Findings from Mrs. Devlin's examination and evaluation include the following:
Physical examination: Normal
Rectal examination: Lack of perineal descent as well as probable rectocele on digital rectal examination; normal sensation and resting tone, no external lesions
Lab results: Normal CBC, complete metabolic panel, thyroid function tests
Colonoscopy: Few small diverticuli in the sigmoid colon and small internal hemorrhoids. The mucosa of the colon does demonstrate melanosis coli.
Colonic marker study: Evacuation delay at day 5 with preponderance of markers accumulating in the rectosigmoid region.
Anorectal manometry: Decreased propulsive efforts, paradoxical increase in external anal sphincter with simulated defecation
Defecography: 2 cm rectocele without preferential accumulation of contrast in the rectocele, delayed colonic evacuation, shortening of anorectal angle with defecation effort
Mrs. Devlin is suffering from defecatory dysfunction, likely due to pelvic floor dyssnergia (PFD). The origins of PFD are varied but in Mrs. Devlin it is likely that her PFD is linked to her obstetrical history. Defecatory dysfunction, or obstructed defecation, is one of the 3 primary types of chronic constipation. It is marked by an inability to coordinate the skeletal muscles of the pelvic floor to facilitate rectal evacuation. There are several historical features suggestive of PFD in this case, most notably severe straining, a lack of response to lifestyle changes and/or medical laxative therapy, and digital manipulation to facilitate defecation. Mrs. Devlin also has a small rectocele that could be responsible for some of her symptoms. Surgical therapy of a rectocele is most likely to result in improvement when frequent digital manipulation and reduction of the rectocele is required and when there is preferential filling of the rectocele on defecography. In Mrs. Devlin's case neither of these features is present, so surgical therapy for the rectocele should be deferred in lieu of the treatment of her PFD with biofeedback therapy.
The use of biofeedback therapy to train patients how to coordinate the pelvic floor is the preferred treatment for PFD, which is characterized by abnormal contraction or failure to relax the pelvic floor muscles during attempts to defecate.[1-2] Several studies have shown that biofeedback therapy, delivered in 5 weekly counseling sessions, was not effective in patients with slow transit constipation, but did result in symptom improvement in patients with PFD. Compared to laxative therapy, the use of biofeedback therapy was found to be more effective than continuous use of polyethylene glycol (PEG), with benefits lasting up to 2 years. One recent systematic review of biofeedback studies in patients with pelvic floor dysfunction found an overall success rate of 67%. An important caveat to consider in older patients is that biofeedback requires good interaction between the therapist and the patient. Therefore, altered mental status or other barriers to communication could reduce the efficacy of this intervention. Biofeedback therapy has not been specifically studied in an elderly population in long-term care.
Mrs. Devlin was treated with biofeedback therapy and did show a marked improvement in her constipation symptoms. She discontinued the PEG 3350 and senna without worsening of her symptoms. Her treatment required 6 sessions and she remains without complaint 6 months after the completion of the biofeedback therapy.
Case contributed by:
Brooks D. Cash, MD, FACP, FACG, CDR, MC, USN
CDR, Medical Corps, US Navy
National Naval Medical Center
Division of Gastroenterology
(1) Chiaroni G, Salandini L, Whitehead WE. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology. 2005;129:86-97.
(2) Chiaroni G, Whitehead WE, Pezza V, Morelli A, Bassotti G. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology. 2006;130:657-664.
(3) Hsieh C. Treatment of constipation in older adults. Am Fam Physician. 2005;72:2277-2284.