Common Tests for the Pelvic Floor
Pelvic floor disorders affect a significant portion of the population and their prevelance increases with age. Colorectal surgeons will undoubtedly be called upon to evaluate and treat this complex patient population. A thorough history and physical exami
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Key Concepts • Pelvic floor disorders affect a significant portion of the population and account for relevant portion of patients seen in colorectal clinics. • Proper history and thorough physical examination is the cornerstone of the evaluation of patients suffering from functional disorders. • Specialized tests to evaluate structure and function augment the evaluation of this complex patient population.
Introduction Disturbances in bowel evacuation and continence are common in North America. In a population based study of nearly 2000 non-pregnant women, Nygaard et al. found 15.7 % of women had at least one pelvic floor disorder. In women aged 80 or older, the prevalence approached 50 % [1]. Although 9 % of women in this study experienced symptoms of fecal incontinence, another recent survey found nearly 20 % of women age 45 or older have experienced accidental bowel leakage at least once per year [2]. Constipation appears to be a more frequent complaint of patients, affecting up to 20 % of North Americans [3–5]. The direct annual costs associated with ambulatory care for pelvic floor disorders were estimated at $412 million dollars in 2006, compared to $262 million in 1997 [6]. As the population ages, health care expenditures in treating pelvic floor disorders are expected to escalate. Given the psychosocial stresses that accompany pelvic floor disorders, the true cost of these disorders to society is probably extremely underestimated. Functional disorders account for approximately a quarter of a typical colorectal practice’s referrals. A traditional approach is to start the evaluation ruling out significant pathology, such as neoplastic or inflammatory bowel disease, with lower endoscopy. This chapter will
focus on the next steps in evaluating patients with fecal incontinence, obstructive defecation, and rectal prolapse. Pelvic floor testing includes anatomic evaluations, functional investigations, and exams that evaluate both anatomy and function of the pelvic floor.
History A detailed history is critical in the management of patients with pelvic floor disorders. Patients will often give limited details, and self-diagnose (“I have hemorrhoids”) to avoid feeling embarrassed about their condition. The patient should be comfortable and clothed during the interview. The onset, duration, and evolution of symptoms should be elicited. Patients should be queried about other possible pelvic floor complaints; rectal prolapse can easily cause constipation or bowel leakage, and symptoms of fecal incontinence may develop after years of obstructed defecation. A high incidence of urinary incontinence and vaginal vault prolapse is prevalent in these patients, and presently there are treatment options that can address multi-compartment complaints in these complex patients. Addressing stool consistency is key, as well as the factors that may have changed it. Diet changes, food intolerances, and allergies should be identified. Changes in medications and supplements can cause disturbances as well. Surgeries such as cholecystectomy and g
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