Pelvic Floor Physical Therapy Research Articles

A randomized trial comparing perioperative pelvic floor physical therapy to current standard of care in transgender women undergoing vaginoplasty for gender affirmation: the flower trial

A randomized trial comparing perioperative pelvic floor physical therapy to current standard of care in transgender women undergoing vaginoplasty for gender affirmation: the flower trial

Effects of Physical Therapy on Pelvic Floor Dysfunction Among Women; A Randomized Controlled Trial

Background: Pelvic floor dysfunction is the inability to relax and integrate the pelvic muscles appropriately. Constipation, bladder/bowel incontinence, and frequent bladder urges are the common symptoms. Objective: To determine the effects of physical therapy on pelvic floor dysfunction among women. Methods: It was a randomized controlled trial conducted between February to December 2021. About 72 patients were included using convenient sampling and they were equally divided into an experimental group receiving pelvic floor physical therapy and a control group receiving routine care. The woman aged between 18 to 60 years having pelvic floor dysfunction were included in the trial. Patients with pelvic organ prolapse more than stage II, urinary or vaginal tract infections and inability to understand or follow instructions were excluded. The assessment was made at baseline and after 4th week of intervention. Variables like age, body mass index and parity were presented as mean and standard deviation. The normality of the data was assessed using the Shapiro-Wilk test. The difference between pre and post-treatment readings was calculated using paired sample t-test for this parametric data. Statistical significance was set at p≤0.05. Results: The demographics including age, body mass index and parity were found to be 49.31 (12.43%), 25.71(4.56%) and 2.6(0.81%) in the pelvic floor physical therapy group and 51.23 (9.37%), 26.33(5.32%) and 2.2(93%) in the control group respectively, without any significant difference (p-value>0.05). After treatment at the 4th-week assessment, peak perineometer values (cmH2O) were found to be 6.4(5.8) in the experimental group versus 10.3(6.7) in the control group, pelvic floor distress inventory short form 27.43(17.6) versus 42.8(31.8) and short form of pelvic floor impact questionnaire 9.86(4.39) versus 16.87(6.78), with a significant difference in favor of physical therapy group (p-value>0.05). Conclusion: The study concluded that pelvic floor physical therapy is significantly better as compared to the control group for relieving pelvic floor dysfunction including its control, coordination and distress.

Association between 2D trans-perineal ultrasound and physical examination in evaluation of ani function.

To compare the correlation between 2D transperineal ultrasonography and physical examination (intravaginal palpation) for assessing pelvic floor and levator ani function. Due to symptoms of pelvic floor disorder, 40 women between the ages of 29 and 75 were enrolled in this study as candidates for urodynamic and structural evaluation of the pelvic floor. A pelvic floor gynaecologist and radiologist assessed the levator ani function via physical examination (graded based on the Oxford Grading System) and transperineal 2D ultrasound, respectively. The ultrasound parameters for calculating the Levator Ani Index (LAI) demonstrate a difference between the anteroposterior dimension of the levator hiatus (r = 0.691, p < 0.001) and the cranial shift of muscle (r = 0.499, p < 0.001) at rest and during a squeezing manoeuvre in the mid-sagittal plane. Reduced anteroposterior diameter of the hiatus and increased cranial shift were associated with a higher Oxford Physical Examination Score (OPES). The association between LAI and OPES was independent of baseline variables such as age, BMI, number of births, and the presence of incontinence symptoms. Measures such as the LAI can be used to quantify the function of the levator ani muscle, which may be useful for evaluating the efficacy of pelvic floor physiotherapy and exercise.

Sacral Neuromodulation Therapy for Urinary and Fecal Incontinence in Patients With Multiple Sclerosis: Report of 6 Cases and Literature Review.

Urinary incontinence (UI) and fecal incontinence (FI) are challenging manifestations of multiple sclerosis (MS) that have historically been treated with limited success. Sacral neuromodulation (SNM) has provided successful resolution of UI and FI in the general population and in patients with neurologic conditions, including MS. We report on 6 patients with MS-related incontinence treated successfully with SNM and review the literature. Medical records were reviewed retrospectively to identify patients with MS seeking treatment for incontinence. Six patients were identified, and each is presented with follow-up assessment of the severity of UI or FI. All 6 individuals with MS had severe incontinence that had been refractory to therapies that included medications and pelvic floor physical therapy. Five patients reported severe UI and 2 patients reported severe FI. Each patient was successfully treated with SNM, with large reductions of incontinence scores and improved quality of life. In this case series, SNM was effective as a treatment for UI and FI among patients with MS. These findings confirm other published series that have reported the success of SNM in patients with MS with incontinence. Sacral neuromodulation should be considered as a potential treatment option for patients with MS and UI and/or FI.

Motivations, psychosocial burdens, and decision-making modes of post-partum women with stress urinary incontinence engaging in pelvic floor physical therapy: a qualitative research.

This qualitative research explores the motivations, psychosocial burdens, and decision-making modes of post-partum women with stress urinary incontinence (SUI) engaging in pelvic floor physical therapy (PFPT). This study was conducted face-to-face in a treatment room using qualitative semi-structured interviews with post-partum women who received PFPT for SUI between May and October 2022. Participant interviews were transcribed verbatim and thematically analyzed using NVivo software, which is most commonly used for qualitative data analysis. Themes that impacted participants' decisions to receive PFPT included avoiding deterioration of SUI symptoms, believing that the sooner it is treated the better, being unable to adhere to home exercise programs, and dissatisfaction with quality of life. Some participants experienced psychosocial burdens when receiving PFPT, including impact on daily activities, worries about the baby, financial burdens, and uncertainty about the effect. There were two modes of decision making, which brought different experiences. Some participants preferred participant-provider shared decision making and reported effective doctor-patient communication, and striving for autonomous decisions. Other participants preferred their clinicians to decide on PFPT protocols in view of their trust in their midwives, institutional reputation, and lacking knowledge of PFPT. We discovered that participants had both motivations and psychosocial burdens when receiving therapy. Some participants preferred participant-provider shared decision making, whereas others preferred their midwives to make decisions. Further more standardized studies with more robust samples are needed.

The Impact of Pelvic Floor Physical Therapy on Bladder and Bowel Function After Obstetric Anal Sphincter Injury.

Women with obstetric anal sphincter injury (OASI) are at increased risk of pelvic floor disorders. No standard of care exists for management of pelvic floor dysfunction after OASI. The aims of this study were to evaluate the impact of pelvic floor physical therapy (PFPT) on bladder and bowel function after OASI and to describe adherence to PFPT. A retrospective cohort study of women with OASI presenting at a postpartum care clinic from 2017 to 2021 was conducted. Women were grouped according to PFPT attendance. Urinary Distress Inventory 6 (UDI-6) and Fecal Incontinence Severity Index (FISI) were administered at baseline and 6 months. A total of 430 women with OASI presented to a postpartum care clinic, of which 137 (31.9%) attended PFPT, and 293 (68.1%) did not attend. Baseline and 6-month questionnaires were completed by 169 women: 52 (30.8%) in the PFPT group and 117 (69.2%) in the non-PFPT group. Baseline UDI-6 and FISI scores were higher in the PFPT group. Improvement in UDI-6 was not different between groups (-5.8 ± 14.9 vs -3.7 ± 10.8, P = 0.36). The non-PFPT group had greater worsening of FISI compared with PFPT group (9.8 ± 15.2 vs 1.1 ± 11.5, P < 0.001). Sixty-six percent (n = 136) of women referred to PFFT attended at least 1 session, of which 32.4% (n = 44) completed all sessions. Completely adherent women were referred to PFPT earlier (18.5 vs 28.5 days postpartum, P = 0.027). Women in both the PFPT and non-PFPT groups reported improvement in bladder leakage 6 months after OASI. Women who did not attend PFPT had significant worsening of bowel leakage. Early referral to PFPT in women with pelvic floor dysfunction following OASI should be considered.

Patient Receptivity to Integration of Telehealth in Pelvic Floor Physical Therapy Regimens.

Limited research has focused on patient perceptions and barriers to integration of virtual care in the pelvic health arena. The purpose of this study was to determine the willingness of patients to consider telehealth as a means to seek pelvic floor physical therapy (PFPT) care and the promoters and deterrents for deployment in this treatment modality. This is a cross-sectional study of patients (≥18 years of age) at a multidisciplinary pelvic health service in an academic medical center in Northwest Ohio. The data collection occurred over 6 months in the latter half of 2021 using a novel 21-question survey based on focus group perceived patient requests, needs, and concerns that were aligned and cross-referenced with published literature. The survey was completed by 210 patients, with up to 40% (n = 83) being new PFPT patients. Of those interested in telehealth being a component of their PFPT therapeutic regimen (n = 142 [68%]), interest was driven by convenience (78%). Privacy (n = 52 [76%]) was the main barrier impeding interest in this modality. Up to 80% (n = 169) preferred to establish care through in-person visits before initiating PFPT regimens remotely, with 44% (n = 93) suggesting that incorporation of telehealth would positively affect their adherence with care regimens. Offering patients in-person visits or hybrid alternatives may be optimal for improving adherence to therapeutic regimens especially when considering access to care.

To what extent are anorectal function tests comparable? A study comparing digital rectal examination, anal electromyography, 3-dimensional high-resolution anal manometry, and transperineal ultrasound

BackgroundAnorectal function tests are helpful for objective investigation of anorectal (dys)function. A variety of tests are available, but there is no recommendation when to perform which test. Furthermore, which test is the most accurate is controversial and the correlation between these tests is not very clear. The aim of our study was to examine the correlation of anal pressures and the possibility to diagnose pelvic floor dyssynergia between digital rectal examination (DRE) and several anorectal function tests.MethodsBetween January 2020 and April 2022, all men and women aged 18 to 80 years, treated at the Proctos Clinic, who were referred for pelvic floor physical therapy (PFPT) by the surgeon and underwent anorectal function tests, were included. DRE was performed to establish the anal pressure at rest and during squeeze and straining. Anorectal function tests included 3D high-resolution anal manometry (3D-HRAM), balloon expulsion test (BET), transperineal ultrasound (TPUS), and surface electromyography (s-EMG).ResultsA total of 50 patients, 37 (74%) females, were included. Median age was 51 years. Twenty-three (62%) females had a history of two or more vaginal deliveries. The most frequent reason for referral for PFPT was fecal incontinence in 27 (54%) patients. The assessed pressures and pelvic floor function measured with DRE by the surgeon and the pelvic floor physical therapist during rest, squeeze, and straining correlated in 78%, 78%, and 84%, respectively. Correlation between DRE and 3D-HRAM or s-EMG was better for squeeze pressures than resting pressures. The correlation between s-EMG and 3D-HRAM was better during squeeze than at rest with an agreement of 59% and 37%, respectively.ConclusionDRE by an experienced investigator is of sufficient value for daily clinical practice to detect dyssynergia and to measure sphincter tone. Commonly performed anorectal function tests correlate poorly with DRE and with other anorectal function tests. When conservative treatment fails, further investigation is warranted; however, these results should be interpreted with caution.What does this paper add to the literature?Anorectal function tests such as the 3D high-resolution anorectal manometry, balloon expulsion test, surface electromyography, and transperineal ultrasound are all frequently performed in the diagnostic workup in patients with defecation disorders. No previous study has compared these tests regarding their outcomes, nor has the interrater agreement been measured regarding the digital rectal examination by two experienced observers. Furthermore, transperineal ultrasound is in all probability not frequently used and therefore underexposed in the diagnostic workup of patients with dyssynergic defecation.

A Comprehensive Treatment Protocol for Endometriosis Patients Decreases Pain and Improves Function.

The purpose of this paper is to evaluate the efficacy of a multimodal, outpatient neuromuscular protocol in treating remaining sensitization and myofascial pain in endometriosis patients post-surgical excision. A retrospective longitudinal study was conducted for women aged 22 to 78 with a history of surgically excised endometriosis. 60 women with an average duration of pain of 8.63 ± 7.65 years underwent a treatment protocol consisting of ultrasound guided trigger point injections, peripheral nerve blocks, and pelvic floor physical therapy for 6 weeks. Concomitant cognitive behavioral therapy once weekly for a total of 12 weeks was also undertaken. Pain intensity and pelvic functionality were assessed at new patient consults and 3-month follow ups using Visual Analogue Scale (VAS) and Functional Pelvic Pain Scale (FPPS). At new patient consults, average VAS and FPPS were 7.45 ± 2.11 (CI 6.92-7.98) and 14.35 ± 6.62 (CI 12.68 -16.02), respectively. At 3-month follow ups, average VAS and FPPS decreased to 4.12 ± 2.44 (CI 3.50-4.73; p < 0.001) and 10.3 ± 6.55 (CI 8.64-11.96; p < 0.001), respectively. Among FPPS categories, sleeping, intercourse, and working showed the highest statistical significance. Data suggests the multimodal protocol was effective in treating the remaining underlying sensitization and myofascial pain seen in Endometriosis patients post-surgical excision, particularly in decreasing pain and improving function during work and intercourse.

Persistent genital arousal disorder - the present knowledge.

Persistent genital arousal disorder (PGAD) is a relatively recently described sexual disorder, characterized by symptoms of spontaneous genital arousal which persist in the absence of sexual desire and may affect women and men. Epidemiological studies conducted so far indicate that the prevalence of PGAD in the population may reach 1-4%. The etiology of PGAD remains unclear and complex, hypothesized causes include vascular, neurological, hormonal, psychological, pharmacologic, dietary, mechanical factors or a combination of these factors. Proposed methods of treatment include pharmacotherapy, psychotherapy, electroconvulsive therapy, hypnotherapy, injection of botulinum toxin, pelvic floor physical therapy, application of anesthetizing agents, reduction of identifiable factors exacerbating the symptoms, and transcutaneous electrical nerve stimulation. There is no standardized treatment algorithm for PGAD due to lack of clinical trials (evidence-based medicine). The classification of PGAD is under discussion: it could be classified as a separate sexual disorder, a subtype of vulvodynia or a disorder with pathogenesis similar to overactive bladder (OAB) and restless legs syndrome (RLS). Due to specificity of symptoms, patients may feel shame and discomfort during the examination or even delay reporting symptoms to the specialist. Thus, it is crucial to spread knowledge about this disorder, which would allow doctors to diagnose and help PGAD patients sooner.

Pelvic floor physical therapy in the treatment of chronic anal fissure (PAF trial): quality of life outcome.

Chronic anal fissure is one of the most common anorectal diseases and is associated with reduced quality of life. The aim of this study was to investigate the effects of pelvic floor physical therapy on quality of life in patients with chronic anal fissure using the Short-Form 36 Health Survey (RAND-36). Adult patients, with chronic anal fissure and concomitant pelvic floor dysfunction, such as dyssynergia and increased pelvic floor muscle tone, were recruited at the Proctos Clinic in the Netherlands, between December 2018 and July 2021 and randomly assigned to an intervention group, receiving 8weeks of pelvic floor physical therapy or assigned to a control group receiving postponed pelvic floor physical therapy (PAF trial). Quality of life and pain ratings were outcomes of the study and were measured at 8- and 20-week follow-up. One hundred patients (50 women and 50 men, median age 44.6years [range 19-68years]), completed the RAND-36 questionnaire and visual analog (VAS) pain scale score at admission. A significant improvement was found at 20-week follow-up in all domains of the RAND-36; physical functioning, pain, health change (p < 0.001); physical role, vitality, general health, social functioning, emotional role, mental health (p < 0.05). VAS pain was significantly reduced at 8weeks (mean estimated difference 1.98; 95% CI 1.55-2.42, p < 0.001) and remained significant at 20-week follow-up (p < 0.001). The difference between the groups as regards change in the mean pain intensity scores at 8weeks was 2.48 (95% CI -3.20 to -1.75; p < 0.001). Compared to the reference values of the general Dutch population, the patients in our study with a chronic anal fissure and pelvic floor dysfunction reported an impaired quality of life in 8 of 9 domains of the RAND-36. After treatment, significant lower scores were found in 2 out of 9 domains. The results of this study provide evidence that treatment by pelvic floor physical therapy improves quality of life and reduces pain, making it an important tool in management of chronic anal fissure and concomitant pelvic floor dysfunction.

Development of a patient-centered text message-based platform for the self-management of interstitial cystitis/bladder pain syndrome symptoms.

To develop a patient-centered text message-based platform that promotes self-management of symptoms of interstitial cystitis/bladder pain syndrome (IC/BPS). Adult women with IC/BPS interested in initiating a first- or second-line treatments per American Urological Association guidelines (recategorized as "behavioral/non-pharmacologic treatments" and "oral medicines" in the 2022 version) participated in rapid cycle innovation consisting of iterative cycles of contextual inquiry, prototype design and development. We delivered treatment modules and supportive messages using an algorithm-driven interactive messaging prototype through a HIPAA-compliant texting platform. Patients provided feedback through narrative text messages and an exit interview. Feedback was analyzed qualitatively and used to iteratively revise the platform until engagement ≥ 85% and accuracy ≥ 80% were achieved. The final version consisted of four treatment module categories (patient education and behavioral modification, cognitive behavioral therapy, pelvic floor physical therapy, and guided mindfulness practices) and supportive messages delivered through an automated algorithm over 6 weeks. Thirty IC/BPS patients with moderate symptom bother (median IC Problem Index score 9, range 6-12) participated in five cycles of contextual inquiry. Qualitative analysis identified three overarching concepts that informed the development of the platform: preference for patient centered terms, desire to gain self-efficacy in managing symptoms, and need for provider support. Patients preferred the term "interstitial cystitis" to "bladder pain syndrome" which carried the stigma of chronic pain. Patients reported greater self-efficacy in managing symptoms through improved access to mind-body and behavioral treatment modules that helped them to gain insight into their motivations and behaviors. The concept of provider support was informed by shared decision making (patients could choose preferred treatment modules) and reduced sense of isolation (weekly check in messages to check on symptom bother). A patient centered text message-based platform may be clinically useful in the self-management of IC/BPS symptoms.

Trigger point injections followed by immediate myofascial release in the treatment of pelvic floor tension myalgia.

Pelvic floor physical therapy (PFPT) is first-line therapy for treatment of pelvic floor tension myalgia (PFTM). Pelvic floor trigger point injections (PFTPI) are added if symptoms are refractive to conservative therapy or if patients experience a flare. The primary objective was to determine if a session of physical therapy with myofascial release immediately following PFTPI provides improved pain relief compared to trigger point injection alone. This was a retrospective cohort analysis of 87 female patients with PFTM who underwent PFTPI alone or PFTPI immediately followed by PFPT. Visual analog scale (VAS) pain scores were recorded pre-treatment and 2weeks post-treatment. The primary outcome was the change in VAS between patients who received PFTPI alone and those who received PFTPI followed by myofascial release. Of the 87 patients in this study, 22 received PFTPI alone and 65 patients received PFTPI followed by PFPT. The median pre-treatment VAS score was 8 for both groups. The median post-treatment score was 6 for the PFTPI only group and 4 for the PFTPI followed by PFPT group, showing a median change in VAS score of 2 and 4, respectively (p = 0.042). Seventy-seven percent of patients in the PFTPI followed by PFPT group had a VAS score improvement of 3 or more, while 45% of patients in the PFTPI only group had a VAS score improvement greater than 3 (p = 0.008). PFTPI immediately followed by PFPT offered more improvement in pain for patients with PFTM. This may be due to greater tolerance of myofascial release immediately following injections.

Management of Rectocele with and without Obstructed Defecation

Rectoceles are a common finding in female patients; they can be asymptomatic, or they can contribute to the sensation of pelvic pain, pressure, and difficulty with evacuation. Rectoceles coexist with anterior and mid compartment pelvic prolapse in up to 50% of patients. Defecatory dysfunction can be secondary to anismus, anatomic abnormalities such as rectocele or intussusception, and often are due to a complex interplay of both structural and functional abnormalities. Hence patients presenting with these symptoms are best evaluated with anorectal physiology testing and dynamic imaging. Nonoperative approaches include pelvic floor physical therapy, biofeedback therapy, and vaginal pessaries. Various operative approaches exist, each with different targets and measurements of successful repair.

Sexual Dysfunction in Female Patients with Inflammatory Bowel Disease: An Overview.

Sexual dysfunction is common among females with inflammatory bowel disease and may result in issues involving intimacy, sexual activity, and satisfaction, as well both the formation and preservation of personal relationships. Risk factors for sexual dysfunction include select surgical interventions, medications, mental illnesses, and IBD-related intestinal and extraintestinal comorbidities. In addition, certain demographic factors such as age, disease type and activity may influence the severity of sexual dysfunction. Evaluation of sexual dysfunction may include the use of validated sexual functioning questionnaires, a brief mental health assessment, initial inquiry into vulvovaginal or perineal symptoms, and a gynecologic and GI-focused physical exam. An interdisciplinary care team involving IBD specialists, obstetrician-gynecologists, pelvic floor physical therapists, and primary care physicians may be best suited to provide optimal care and treatment recommendations for patients with sexual dysfunction. Options for management often include pelvic floor physical therapy, biofeedback, and mental health support. Further research is necessary to delineate the impact of IBD activity on sexual dysfunction, to determine if health outcome differences exist depending on surgical approaches utilized during J-pouch operations, and finally to evaluate the care and perceptions of patients with IBD who identify as sexual and gender minorities.

Pelvic pain in transmasculine adolescents receiving testosterone therapy

Background: Pelvic pain is a common complaint among individuals assigned female at birth. However, few studies have explored pelvic pain among transmasculine patients on gender-affirming testosterone treatment, and most of these were performed in adult populations. Aims: The aim of our study was to investigate the prevalence, risk factors, nature and treatment of pelvic pain among trans adolescents on testosterone. Methods: A retrospective cohort study was performed on all trans adolescents started on gender-affirming testosterone treatment at our institution between 2007 and 2020. Results: Among 158 trans adolescents who were started on testosterone therapy and followed-up for at least six months, 37 (23.4%) reported pelvic pain, with a median interval between testosterone initiation and reported onset of pain of 1.6 months (range 0.3-6.4). The prevalence of pelvic pain was higher in patients who were receiving menstrual suppression (n = 36, 26.3%) compared to those who were not (n = 1, 4.8%), giving a risk difference of 21.5% (95% CI 9.8% to 33.2%, p = 0.028). The most common descriptive terms were “cramps” (n = 17, 45.9%) and “similar to previous period pain” (n = 8, 21.6%). A range of different pharmacological strategies were employed, including paracetamol, NSAIDs, danazol, norethisterone, medroxyprogesterone, etonogestrel implant, intra-uterine device, goserelin and pelvic floor physiotherapy, with variable outcomes. Conclusion: In conclusion, we report here – in what is to our knowledge the first time – the prevalence rate of pelvic pain in trans adolescents on gender-affirming testosterone treatment, and observe that a quarter of them described pelvic pain. Limitations of our study include its retrospective nature, which is likely to be associated with under-reporting of pelvic pain, and the limited documentation of the nature and likely causes of this pain within the medical records. Prospective longitudinal studies to better understand the nature, etiology and optimal management of testosterone-associated pelvic pain are therefore warranted.

Sexual Perception in Spanish Female Breast Cancer Survivors. Cross-Sectional Survey

The aim was to assess sexual perception in female breast cancer survivors and establish if women presenting with sexual dysfunctions symptoms receive pelvic floor physiotherapy or request information on treatment. Cross-sectional survey carried out between January and March 2021. An online survey designed by the authors was structured in 3 dimensions: demographic and anthropometric data, medical data and sexual perception data. An open format survey with 23 questions available to any website visitor. The survey followed the CHERRIES guidelines. The study included 130 women who fulfilled the inclusion criteria. The presence of pain during sexual activity was reported in 56.92% of cases. Specifically, 40.8% reported superficial dyspareunia, which is most commonly expressed by women as a "stinging pain." Surprisingly, only 4.6% of the women had received any type of pelvic floor physiotherapy treatment or had sought information. Women breast cancer survivors have a negative perception of their sexuality. In addition, there is a lack of knowledge about the role of physiotherapy in sexual dysfunction, and only a small percentage of women received pelvic floor treatment or information to address their sexual dysfunction.

Complete vaginal eversion, uterine prolapse, and stress urinary incontinence: A rare case report

Introduction: Pelvic organ prolapse is a multifactorial gynecological condition, caused by a disruption of muscles of the pelvic organs. Case Report: A 63-year-old female presented with a history of stress urinary incontinence, dyschezia, and sexual dysfunction. A complete clinical and urogynecological evaluation was performed and diagnoses of uterine and vaginal prolapse and urinary incontinence were made. The patient underwent a vaginal hysterectomy with uterosacral ligament suspension and a vaginal wall repair. The patient’s symptoms resolved following pelvic floor physical therapy. Conclusion: The patient benefited from a vaginal hysterectomy with uterosacral ligament suspension and a vaginal wall repair with subsequent pelvic floor physical therapy treatments.

Clinical History Does Not Reliably Predict Clinical Outcomes With Pelvic Floor Physical Therapy to Treat Chronic Constipation

Chronic constipation affects 10%-20% of the population and impacts quality-of-life similarly to rheumatoid arthritis or congestive heart failure.1 We recently showed in a prospective clinical trial that up-front, community-based pelvic floor physical therapy is effective to treat chronic constipation for patients seeking general gastroenterology care after failing a brief trial of osmotic laxative or soluble fiber supplementation2 and can be guided by anorectal function testing.3,4 In this post hoc analysis, we aimed to evaluate whether factors on clinical history including specific symptoms, work-productivity impairment, health-related quality-of-life impairment, and psychological factors are useful to inform patient selection on the expected likelihood of clinical response without using anorectal function tests.

S2030 Fecal Incontinence Due to Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy (CADASIL)

Introduction: Fecal incontinence, or the accidental passing of solid or liquid stool, is a common condition that occurs in up to 15% of the Western population and significantly impairs quality of life. Common causes of fecal incontinence include structural damage to the anal sphincter, fecal impaction, rectal prolapse, and neurologic impairment (e.g. diabetes, stroke). In the following report, we describe a case of fecal incontinence caused by Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL), a rare hereditary neurological disorder of the cerebral vessels that causes recurrent ischemic strokes and progressive loss of cognitive function. Case Description/Methods: A 66-year-old White male with a 15-year history of CADASIL presented to clinic for evaluation of fecal incontinence. He reported that his symptoms began approximately 18 months earlier and improved over time, but then recurred with urinary incontinence and persistent worsening 6 months prior to presentation. He denied having any abdominal pain, unintentional weight loss, rectal bleeding, or history of rectal trauma. He was up to date on screening colonoscopy. On digital rectal exam, the patient was noted to have normal resting tone and diminished sphincter squeeze; there was no evidence of mass, rectal prolapse, or hemorrhoids. Upon review of his prior imaging, it was noted that he had severe small vessel ischemic changes in his brain with multiple infarcts, but no spinal cord compression. He declined anorectal manometry. Given the clinical picture, it was concluded that the patient’s incontinence was due to recurrent strokes secondary to CADASIL. Discussion: Fecal incontinence occurs in up to 40% of patients immediately after stroke. Treatment strategies focus on hygiene and skin protection, regulation of stool consistency, and pelvic floor physical therapy. CADASIL is characterized by multiple, recurrent strokes. Fecal incontinence in these patients is predictive of mortality, with one study showing 72% of patients experiencing fecal incontinence at time of death. Multiple cortical regions of the brain have been shown to be important in controlling the anal sphincter suggesting redundancy of function, which may explain why the presence of persistent fecal incontinence can be a marker of late-stage CADASIL. Our case report highlights the importance of clinical recognition of a rare disease as a potential cause of a common symptom.