Pelvic Floor Dysfunction  Definition of Pelvic floor dysfunction (PFD)  Describe why PFD occurs  Discuss appropriate diagnostic testing  Describe treatment options **Perineal descent of 1-3.5 cm normal during defecation Hirschsprungs Pelvic floor dysfunction Pelvic organ prolapse (anismus, pelvic outlet obstruction, pelvic dyssynergia) Symptoms -Constipation -Digital maneuvers -Pelvic pain -Lower back pain -Fecal incontinence Associated conditions -Interstitial cystitis -Vulvar vestibulitis - Parcopresis -PTSD -Pelvic surgery Why do people develop Pelvic floor dysfunction? Diagnostic testing for pelvic floor dysfunction Rectal exam Assess Pelvic floor -descent -relaxation -spasm -rectocele Anorectal manometry with balloon expulsion test -Can diagnose Hirschsprungs disease. -Pressure measurement can diagnose pelvic outlet obstruction Sitzmarker Can help decipher between the three types of constipation Defecography Can diagnose rectocele, enterocele, intussuseption Pelvic floor dysfunction Pelvic floor dysfunction with spasm  Surgical treatment  Partial dissection of the puborectalis  Anal myomectomy  Pelvic floor rehabilitation  Pelvic floor physical therapy  Biofeedback  Valium suppositories  Botox injections to the pelvic floor BIOFEEDBACK  Teaches patients to relax their pelvic floor  Use of EMG or pressor sensors to deliver feedback  Studies nonstandard PELVIC FLOOR PHYSICAL THERAPY Assess your pelvic floor strength  Help you to isolate your pelvic floor muscles  Utilize biofeedback or muscle stimulation  release muscle tension in your pelvic floor muscles  suggest behavioral changes   Positive prognostic factors      Hard stool consistency Greater willingness to participate Prolonged balloon expulsion time Shorter duration of laxatives Negative prognostic factors  Anal spasm/high anal tone  History of sexual abuse Shim L et al.2011. Alim Pharm Therap Leroi AM et al.1996. Int Jo of Colorectal Disease Park UC et al.1996. Dis Colon & Rectum 100 90 ** 80 70 60 PEG Biofeedback 50 40 30 20 10 0 Worse No change Fair Major ** Significant difference at 6 months which was sustained for 2 years Chiarioni et al. Gastroenterol: 2006. 130(3):657-64  Very few trials and each uses different doses of botox (15 -100 IU) into the puborectalis  Prospective randomized trials for PFD:  Significant 1 month improvement over biofeedback  1 year trend to improvement over biofeedback  Significantly less effective than partial dissection of the puborectalis muscle (short and long term) Farid M et al. 2010:Jo Gastro Surgery Farid M et al. 2009: Intern Jo of Colorectal surgery  Only 1 randomized prospective trial: Biofeedback vs valium po vs placebo  Showed BFB superior to valium or placebo  Diazepam suppositories qhs may be useful  anal spasm, high anal tone, combined Interstitial cystitis and failed BFB  Start 5mg qhs and alternate rectal and vaginally. Can titrate Heymen S et al. 2007.Dis of Colon and Rectum Pelvic floor dysfunction improved Lifestyle adjustments Continue medical management Medical Management Biofeedback prior to surgical correction No improvement Focused evaluation Colonic transit study (Sitz-marker) PFD Pelvic floor physical therapy Anal manometry with balloon expulsion Anatomic defect + high tone pelvic floor Defecography PFD with spasm Pelvic floor physical therapy botulinum injections Valium suppositories Anatomic defect otherwise normal pelvic floor Surgical correction