Pelvic Floor Dysfunction

If you have irritable bowel syndrome, chronic constipation, or chronic diarrhea caused by inflammatory bowel disease or an ongoing C. difficile infection, you could have developed a pelvic floor dysfunction. Those who have constipation-predominant symptoms might have pelvic floor muscular incoordination (dyssynergia/anismus) while those who have diarrhea-predominant symptoms might experience bowel urgency and/or incontinence of loose stools. Physiotherapists with specific training in these areas offer treatments that can help.

The pelvic floor consists of muscles that help control defecation. A successful bowel movement requires the coordination of gentle deep abdominal muscle contractions with simultaneous full relaxation of the pelvic floor. The puborectalis muscle acts like a sling that, when relaxed, increases the angle between the rectum and anus and aids in defecation. The external anal sphincter, located just past the anus, helps keep stool safely inside the rectum until a person makes the conscious decision to have a bowel movement. The external anal sphincter relaxes with the puborectalis, allowing defecation.

Pelvic Floor Dyssynergia

If you have chronic constipation, you might inadvertently develop an ineffective habit when moving your bowels, which involves bulging (distending) the abdominal muscles while contracting the pelvic floor – leaving you straining in vain to move stool through a firm muscular wall. Symptoms can include passing only a small amount of stool at one time, typically leading to repeated trips to the toilet within a short period while attempting to evacuate the remaining stool. Residual stool in the rectum might slowly leak out, leading to bowel incontinence.

Ineffective habits typically involve straining/pushing for stool to evacuate while holding your mouth tightly closed (i.e., attempting to exhale against a closed airway), and this can produce or worsen pelvic organ prolapse. A pelvic organ prolapse occurs when the rectal wall, for example, moves from its original position. If the wall between the rectum and the vagina bulges into the vagina, this is called a posterior vaginal wall prolapse (rectocele), or if the wall protrudes from the anus, it’s called a rectal prolapse.

How Physiotherapy Can Help

A physiotherapist with training in pelvic floor rehabilitation can conduct a thorough evaluation of pelvic organ prolapse, and evaluate strategies to evacuate stool. Examination may include a digital vaginal exam (for women), a digital rectal exam, observation and touching (palpation) of the perineum and abdominal wall, and electromyographic (EMG) biofeedback assessment. In EMG biofeedback, the physiotherapist shows you your own physical responses to various stimuli or cueing using computerized instruments.

The goal of treatment is to develop your ability to relax the pelvic floor completely while simultaneously allowing gentle propulsive forces from deep abdominal muscles to evacuate the bowel fully. A physiotherapist will provide education in pelvic floor anatomy and function, pelvic floor dysfunction and dyssynergia, bowel control mechanisms, and physiotherapy treatments. Your physiotherapist will also review healthy bowel habits, including positioning, time spent on the toilet, and facilitating good bowel patterns. Your physiotherapist will help you address diet-related problems contributing to constipation, and might ask you to keep a diary of your physical activity, fibre consumption, and fluid intake. You might find it helpful to discuss any significant dietary modifications with a registered dietitian.

Through your physiotherapist’s feedback and EMG biofeedback, you can retrain motor control and the way your body automatically responds to stimuli related to pelvic floor contraction and relaxation. Your physiotherapist will also suggest management strategies for any prolapse that might be present.

Electromyograph (EMG) Biofeedback

Surface electrodes (internal or external) placed by the physiotherapist detect muscle contraction and relaxation. The information picked up from the biofeedback unit is displayed on a screen for both you and your physiotherapist to view. Internal electrodes are either vaginal or rectal probes. External electrodes may be placed on either side of the anus. An advantage to external electrodes is that you can move or change position (e.g., to sitting or standing) without having to adjust your posture to hold the electrode in place, facilitating a more realistic scenario. EMG biofeedback is a safe treatment with very few contraindications.

Bowel Urgency and/or Incontinence of Loose Stool

Pelvic floor muscles should tighten at the right time to hold stool so that you can reach the toilet to evacuate. The involuntary loss of stool (fecal incontinence) can occur if your pelvic floor muscles lack strength, endurance, and functional control. Physiotherapy for bowel urgency and/or incontinence of loose stool also includes education (e.g., pelvic floor anatomy and function, bowel control mechanisms, physical therapy treatment) as well as pelvic floor proprioceptive and motor control exercises. Your physiotherapist might use EMG biofeedback therapy, and will teach you specific pelvic floor exercises that you can integrate into daily activities, such as coughing, sneezing, lifting, rising from sitting, standing, exercising, and so on.

Finding a Registered Physiotherapist

You can find a physiotherapist through your regional physiotherapy association (see table below). Search for a registered physiotherapist who has incontinence or pelvic floor interest and training. Before making your appointment, ask about the physiotherapist’s experience in treating either pelvic floor dyssynergia or fecal incontinence. In some regions, there are whole clinics that focus on pelvic floor dysfunction. Unless your extended medical plan requires it, you usually do not need a physician’s referral to see a physiotherapist.

Laura Werner, BKin MPT Registered Physiotherapist
Dayan Physiotherapy and Pelvic Floor Clinic

First published in the Inside Tract® newsletter issue 185 – 2013

Image: dolgachov | bigstockphoto.com