Pelvic Floor Dysfunction

History ( Box 150.1 )

The history should include details of presenting symptoms, onset, duration, frequency, severity, and any exacerbating or relieving factors. A complete past medical, obstetric (for women), and surgical history should be obtained. The obstetric history should include current pregnancy status, future pregnancy plans, birth history with child size, traumatic deliveries, and need for episiotomy or repair. The patient's body mass index (BMI) should be documented, as well as any recent weight gain or loss. Current medication regimens should be documented. A social history, including psychiatric illness, sexual and physical abuse must be obtained, because they are associated with defecation difficulties and impact patient perception of symptoms. The pattern of bowel function needs to be documented in detail, including frequency of evacuation, length of time spent for each evacuation, straining at stool, rectal pain, posturing and digitations, and the trend of any problems over time. Stool consistency influences the severity of incontinence and constipation and can be graded using the Bristol Stool Scale ( Fig. 150.1 ). Validated scoring systems add subjective and objective measures to the clinical history and include the Cleveland Clinic Incontinence (Wexner) score, Cleveland Clinic Constipation score, American Society of Colon and Rectal Surgeons (ASCRS) Fecal Incontinence score, ASCRS Fecal Incontinence Quality of Life score, St. Mark's Incontinence score, the PAC-SYM Patient Assessment of Constipation, the Fecal Incontinence Quality of Life Scale, and many others.

One of the most important issues to define while taking a history from this group of patients is to learn exactly why the patient is seeking help and how much their problem is affecting their quality of life. Specific items one must ask about when eliciting a pelvic floor history are seen in Box 150.2 .

Continence is maintained from a complex interaction of stool volume, stool consistency, rectal sensation, rectal capacity, and the resting tone of the anal canal. Any disturbance to these elements can result in fecal incontinence. It is important to understand that fecal incontinence is a sign or a symptom of another disease, not a definitive diagnosis. Fecal incontinence can result from a myriad of different causes, including obstetric injury, postmenopausal changes, anorectal surgery, neurological disorders, constipation, diarrhea, and inflammatory bowel diseases. Urge incontinence results from an inability of the rectum to store stool. This can be from a sudden overwhelming bolus of stool or a rectum that is not compliant and will not hold the stool. Patients can have a combination of both problems, and a careful history is needed to differentiate what is occurring during defecation. The history should elicit a disturbance in any of the elements that maintain continence. Dietary changes, recent changes in weight, medications, and gastrointestinal surgery can impact stool volume and consistency. Low spinal cord injury, trauma, and anorectal surgical procedures can impact rectal sensation. Rectal capacity can be impaired from normal aging, pelvic radiation, low anterior resection, inflammation, and anorectal surgery. Baseline resting pressure can be reduced with vaginal delivery, muscular trauma, and hemorrhoid issues. When investigating incontinence, the physician needs to assure there is no mass or infection is being masked by incontinence symptoms. Most patients with severe fecal incontinence will require an endoanal ultrasound (EUS) to define the sphincter muscle anatomy and physiological testing to define sensation, tone, and function.

Constipation is a common complaint, affecting an estimated 20% of Americans. Physicians define constipation by frequency, with less than three spontaneous bowel movements per week as diagnostic, while patients may define constipation based on stool consistency, feelings of incomplete emptying, straining, or urge for defecation. As constipation is a symptom-based disorder, and its definition is mainly subjective, the history is especially important. It can stem from functional, structural, or metabolic issues with the colon or anorectum. Colonic obstruction from processes such as malignancy or Hirschsprung disease must be ruled out before diagnosing constipation. In patients with constipation, the type should be stratified into slow transit, from irregularities in colonic motility, or outlet obstruction, from dysfunction of the anorectal mechanism for defecation. The Rome criteria were established to standardize the definition of constipation with consensus-derived criteria, with diagnostic questions sensitive and specific for the diagnosis of many functional gastrointestinal disorders. The Rome III criteria for constipation requires having at least two of the following: (1) straining during ≥25% defecation; (2) lumpy or hard stools in ≥25% of defecation; (3) sensation of incomplete evacuation in ≥25% of defecation; (4) sensation of anorectal obstruction/blockage in ≥25% of defecation; (5) need for manual maneuvers to facilitate in ≥25% of defecation; and (6) fewer than three defecations per week ( Box 150.3 ). The Rome IV diagnostic questionnaire was recently validated, and further excludes patients with opioid-induced constipation and irritable bowel syndrome from the diagnosis of functional constipation. Patients presenting with constipation can have a multitude of symptoms; the investigations should be guided by the symptoms described and recent medical/surgical events in formulating a treatment plan. A bowel diary focused on dietary intake, defecation frequency, stool consistency, and any associated symptoms can be helpful to both the patient and the medical provider to formulate a treatment plan. Those with recent change in bowel habits or bleeding per rectum, especially if over age 50, should be considered for a colonoscopy.

Physical Examination ( Box 150.4 )

Following a meticulous history, a physical exam should be performed in a stepwise manner. The general exam should be undertaken to detect any systemic disease that may be contributing to the patient's symptoms, including palpation of the patient's lymph node basins and assessment of the thyroid gland. Blood work, including a complete metabolic panel, calcium, blood glucose, and thyroid hormone levels is recommended.

An abdominal examination including documenting previous surgical scars should be performed. Abdominal distention or the presence of a mass may be noted.

Simple inspection of the perineal area can be informative. Inspect for scarring, excoriation, erythema, soiling, anal sphincter shape, the bulk of the perineal body, any skin tags or signs of inflammatory bowel disease, flattening of the perineum, hemorrhoids, or overt rectal prolapse. Ask the patient to strain and assess for pelvic floor descent and for prolapse. To fully evaluate prolapse, the patient should simulate evacuation on the toilet or commode.

Vaginal examination, both at rest and with strain, should be completed. Prolapse of pelvic organs should be elicited with strain and graded using a validated instrument such as the Pelvic Organ Prolapse Quantification System (POPQ) or the Baden-Walker system.

Examination of the anus includes observation of scars and assessment of tone. Digital assessment should note any obvious anal pathology such as a mass, sphincter tone (at rest and squeeze), and muscle mass and any palpable sphincter defects.

Rectal examination should involve a clinical evaluation of resting tone and the ability to voluntarily contract and relax the anal sphincter. Evaluation for pelvic floor dysfunction such as perineal descent with straining, the presence of a rectocele or cystocele, and the volume and consistency of stool in the rectal vault should be noted. Stool load and consistency should also be documented. Levator ani and puborectalis muscles can also be assessed. It is important to differentiate sphincter contraction from puborectalis movement. Proctoscopy should be performed to help exclude neoplasia or undiagnosed inflammatory conditions and may also identify solitary rectal ulcers, hemorrhoids, and fissures. Anoscopy and sigmoidoscopy are options that can be performed to help confirm a diagnosis based on physical exam findings.

Evaluations

Pregnancy testing is considered for all women of childbearing age before any invasive testing is carried out. Thyroid and calcium levels are evaluated for metabolic etiology of bowel disorders. Colonoscopy and gastrointestinal contrast studies should be considered to rule out functional etiologies, inflammatory bowel disease, and malignancy. Stool microscopy and cultures, colonoscopy, and gastroenterologist referral can be considered for patients with diarrhea.