Amy E. Foxx-Orenstein, DO, FACG

Approach to Pelvic Floor DysfunctionApproach to Pelvic Floor DysfunctionApproach to Pelvic Floor DysfunctionApproach to Pelvic Floor Dysfunction

Amy Foxx-Orenstein, DO, FACG, FACPAmy Foxx-Orenstein, DO, FACG, FACP

Professor, Mayo Clinic College of Medicine

Division of Gastroenterology and Hepatology

Co-Director of Motility

Director of Constipation and Pelvic Floor Disorder Center

Professor, Mayo Clinic College of Medicine

Division of Gastroenterology and Hepatology

Co-Director of Motility

Director of Constipation and Pelvic Floor Disorder Center

DisclosureDisclosure

• Research grant funding Salix• Research grant funding Salix• Research grant funding Salix

• Advisory Board Ironwood / Forest

• Research grant funding Salix

• Advisory Board Ironwood / Forest

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Amy E. Foxx-Orenstein, DO, FACG

Normal Colonic ActivityNormal Colonic Activity

Colonic Functions• Absorption of water

P l i f t t

Colonic Functions• Absorption of water

P l i f t tTransverse Transverse

• Propulsion of contents

• Storage of feces

• Expulsion of feces

Colonic Motor Activity

• Two main types

• Propulsion of contents

• Storage of feces

• Expulsion of feces

Colonic Motor Activity

• Two main types

coloncolon

Ascendingcolon

Ascendingcolon

Descendingcolon

Descendingcolon

CC• Propagated

• Segmental

• Propagated

• Segmental

Cook IJ et al. Am J Physiol 2000.Ford MJ et al. Gut 1995.Cook IJ et al. Am J Physiol 2000.Ford MJ et al. Gut 1995.

CecumCecum

RectumRectum

Sigmoid colon

Sigmoid colon

With defecationWith defecationAt restAt rest

Role of Pelvic Floor MusclesRole of Pelvic Floor Muscles

Anorectal angle

Anorectal angle

Symphysispubis

Symphysispubis

Anorectal angle

Anorectal angle

CoccyxCoccyx

Descent of pelvic floorDescent of pelvic floor

External anal

sphincter

External anal

sphincter

PuborectalisPuborectalis

RectumRectum

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Amy E. Foxx-Orenstein, DO, FACG

3 Primary Causes of Constipation3 Primary Causes of Constipation

Pelvic FloorDysfunctionPelvic FloorDysfunction

Slow TransitConstipationSlow TransitConstipation

Functional Functional

13%-28%13%-28% 11%-13%11%-13%

Constipation(CC and IBS-C)

Constipation(CC and IBS-C)

Schiller, Aliment Pharmacol Ther 2001;Mertz, et al. Am J Gastroenterol 1999.Schiller, Aliment Pharmacol Ther 2001;Mertz, et al. Am J Gastroenterol 1999.

59%-71%59%-71%

Secondary Causes of ConstipationSecondary Causes of Constipation• Lifestyle

• Low intake, dehydration, low fiber• Lifestyle

• Low intake, dehydration, low fiber

• Iatrogenic• Medications (calcium, narcotics, anticholinergics)• History of surgery

• Organic Disorders• Metabolic disorders (hypothyroidism)• Myopathies (amyloidosis)

• Iatrogenic• Medications (calcium, narcotics, anticholinergics)• History of surgery

• Organic Disorders• Metabolic disorders (hypothyroidism)• Myopathies (amyloidosis)• Neurologic disorders (Parkinson’s)

• Psychogenic • Eating disorders• Axis disorders

• Neurologic disorders (Parkinson’s)

• Psychogenic • Eating disorders• Axis disorders

• Anatomic • Stricture• Rectal prolapse• Cancer

• Anatomic • Stricture• Rectal prolapse• Cancer

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Amy E. Foxx-Orenstein, DO, FACG

Initial Evaluation of ConstipationInitial Evaluation of Constipation• History and Physical

• MOST important tool in diagnosis

• History and Physical • MOST important tool in

diagnosis

• Alarm Symptoms • Unexplained weight loss• Anorexia

Bl di

• Alarm Symptoms • Unexplained weight loss• Anorexia

Bl di• rectal examination

• Early workup recommended if• Alarm symptoms

• Risk factors for secondary constipation

• rectal examination

• Early workup recommended if• Alarm symptoms

• Risk factors for secondary constipation

• Bleeding• Family history of colon cancer• Family or personal history of IBD• Lack of improvement with therapy• Unexplained change in bowel pattern

• Risk factors for secondary constipation• Co-morbidities• Age >50

• Bleeding• Family history of colon cancer• Family or personal history of IBD• Lack of improvement with therapy• Unexplained change in bowel pattern

• Risk factors for secondary constipation• Co-morbidities• Age >50g• Medications• Gender• Abuse• Pelvic surgeries

g• Medications• Gender• Abuse• Pelvic surgeries

Bristol Stool Form ScaleBristol Stool Form Scale

Separate hard lumpsSeparate hard lumps

Sausage-like but lumpySausage-like but lumpy

Type 1Type 1

Type 2Type 2 Sausage like but lumpySausage like but lumpy

Sausage-like but with cracks in the surfaceSausage-like but with cracks in the surface

Smooth and softSmooth and soft

Soft blobs with clear-cut edgesSoft blobs with clear-cut edges

Type 2Type 2

Type 3Type 3

Type 4Type 4

Type 5Type 5

Fluffy pieces with ragged edges, a mushy stoolFluffy pieces with ragged edges, a mushy stool

Watery, no solid piecesWatery, no solid pieces

Type 6Type 6

Type 7Type 7

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Amy E. Foxx-Orenstein, DO, FACG

Focused HistoryFocused History

• Assess stool (Bristol Stool Form Scale)

• # Pregnancy surgical history

• Assess stool (Bristol Stool Form Scale)

• # Pregnancy surgical history• # Pregnancy, surgical history

• Ask About• duration of symptoms• number of stools daily/weekly• time on commode

• straining

• # Pregnancy, surgical history

• Ask About• duration of symptoms• number of stools daily/weekly• time on commode

• straining

• fecal soiling

• incontinence

• effect of laxatives

• pencil thin stools

• fecal soiling

• incontinence

• effect of laxatives

• pencil thin stoolsg

• urge

• complete evacuation

• Pain with movements

g

• urge

• complete evacuation

• Pain with movements

pencil thin stools

• manual maneuvers

• use of enemas

pencil thin stools

• manual maneuvers

• use of enemas

Anorectal ExamAnorectal ExamInspection• Integrity, moisture

h h id

Inspection• Integrity, moisture

h h id• hemorrhoids • anal fistula, fissure• perineal descent

Digital examination• anal spasm• anal tone at rest, with squeeze• knife-like pain vs. discomfort

• hemorrhoids • anal fistula, fissure• perineal descent

Digital examination• anal spasm• anal tone at rest, with squeeze• knife-like pain vs. discomfort

• descent/ability to expel finger• puborectalis muscle spasm posteriorly?• assess anteriorly and posteriorly for rectocele

• descent/ability to expel finger• puborectalis muscle spasm posteriorly?• assess anteriorly and posteriorly for rectocele

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Amy E. Foxx-Orenstein, DO, FACG

Utility of Diagnostic Tests in ConstipationUtility of Diagnostic Tests in ConstipationClinical Utility

Tests Strengths Weaknesses Evidence Grade

Blood testsThyroid function, R/O systemic or Not cost-effective None Cserum calcium, metabolic disorderglucose, electrolytes

Tests Strengths Weaknesses Evidence Grade

Blood testsThyroid function, R/O systemic or Not cost-effective None Cserum calcium, metabolic disorderglucose, electrolytesglucose, electrolytes

Imaging testsPlain abdominal Widely available Controlled studies Poor CX-ray lacking

Barium enema Anatomy Radiation exposure Poor C

Defecography Anatomy Radiation exposure, Good B

Hirschsprung’s interobserver bias

Anorectal Visualizes internal anal Interobserver bias Poor C

glucose, electrolytes

Imaging testsPlain abdominal Widely available Controlled studies Poor CX-ray lacking

Barium enema Anatomy Radiation exposure Poor C

Defecography Anatomy Radiation exposure, Good B

Hirschsprung’s interobserver bias

Anorectal Visualizes internal anal Interobserver bias Poor Cultrasound sphincter and pubo-

rectalis muscles

EndoscopyFlexible Visualizes colon to Invasive, related risks Poor Csigmoidoscopy exclude mucosal and colonoscopy lesions

ultrasound sphincter and pubo-

rectalis muscles

EndoscopyFlexible Visualizes colon to Invasive, related risks Poor Csigmoidoscopy exclude mucosal and colonoscopy lesions

Rao SS et al. Am J Gastro 2005.Rao SS et al. Am J Gastro 2005.

Clinical Utility

Utility of Diagnostic Tests in Constipation (con‘t.)Utility of Diagnostic Tests in Constipation (con‘t.)

Tests Strengths Weaknesses Evidence Grade

Dynamic magnetic Anatomy; Expensive, interpre- Good B1resonance imaging Dynamic motility tation not standardized

not really available

Tests Strengths Weaknesses Evidence Grade

Dynamic magnetic Anatomy; Expensive, interpre- Good B1resonance imaging Dynamic motility tation not standardized

not really available

Physiologicalcolon transit study Evaluates transit; Inconsistent methodology Good B1with radiopaque inexpensive; and validity have beenmarkers widely available questioned

Colonic transit Provides evaluation Not readily available; Good B1study with of whole gut transit Interpretation notscintigraphy standardized

Anorectal manometry Dyssynergic Interpretation not Good B1ith b ll d f ti t l t d di d

Physiologicalcolon transit study Evaluates transit; Inconsistent methodology Good B1with radiopaque inexpensive; and validity have beenmarkers widely available questioned

Colonic transit Provides evaluation Not readily available; Good B1study with of whole gut transit Interpretation notscintigraphy standardized

Anorectal manometry Dyssynergic Interpretation not Good B1ith b ll d f ti t l t d di d

Attaluri A et al. The Gastroenterology Report 2007.Attaluri A et al. The Gastroenterology Report 2007.

with balloon defecation; rectal standardizedexplusion sensitivity; compliance;

Hirschsprung’s

Smart pill Colon and whole 3-5 day test Fair B2gut transit measurement

with balloon defecation; rectal standardizedexplusion sensitivity; compliance;

Hirschsprung’s

Smart pill Colon and whole 3-5 day test Fair B2gut transit measurement

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Amy E. Foxx-Orenstein, DO, FACG

2 Primary Types of Pelvic Floor Dysfunction*

2 Primary Types of Pelvic Floor Dysfunction*

FunctionalFunctional MechanicalMechanicalFunctional

• Dyssynergy

• Inadequate descent

• Weak propulsive f

Functional

• Dyssynergy

• Inadequate descent

• Weak propulsive f

Mechanical

• Anal fissure

• Mass

• Intussusception

• Rectal prolapse

Mechanical

• Anal fissure

• Mass

• Intussusception

• Rectal prolapse

*AKA Defecatory Disorder, Outlet Obstruction, Evacuation Disorder*AKA Defecatory Disorder, Outlet Obstruction, Evacuation Disorder

forcesforces • Pelvic floor laxity

• Large rectocele

• Pelvic floor laxity

• Large rectocele

EpidemiologyEpidemiology

Prevalence of functional PFD is unclearPrevalence of functional PFD is unclear

• 25% of women age 40-59 show signs

• Females >> Males

• Increases with age in females, not males

Predisposing Factors: chronic constipation excessive

• 25% of women age 40-59 show signs

• Females >> Males

• Increases with age in females, not males

Predisposing Factors: chronic constipation excessivePredisposing Factors: chronic constipation, excessive straining, child bearing, multiparous, psychological disorders, sexual/physical/psychological abuse

Predisposing Factors: chronic constipation, excessive straining, child bearing, multiparous, psychological disorders, sexual/physical/psychological abuse

Nygaard I et al. JAMA 2008; Van Geluwe B et al. Nygaard I et al. JAMA 2008; Van Geluwe B et al. Acta Chir Belg 2013; Koc O et al. Curr Opin Obstet Acta Chir Belg 2013; Koc O et al. Curr Opin Obstet Gynecol 2012. Gynecol 2012.

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Amy E. Foxx-Orenstein, DO, FACG

Defecation Disorders: Rome IIIDefecation Disorders: Rome III

During repeated attempts to defecate the patient must have at least two of the following:• Evidence of impaired evacuation, based on balloon

During repeated attempts to defecate the patient must have at least two of the following:• Evidence of impaired evacuation, based on balloonEvidence of impaired evacuation, based on balloon

expulsion test or imaging

• Inappropriate contraction of the pelvic floor muscles (i.e., anal sphincter or puborectalis) or less than 20% relaxation of the basal resting sphincter pressure by manometry, imaging

• Inadequate propulsive forces assessed by manometry or

Evidence of impaired evacuation, based on balloon expulsion test or imaging

• Inappropriate contraction of the pelvic floor muscles (i.e., anal sphincter or puborectalis) or less than 20% relaxation of the basal resting sphincter pressure by manometry, imaging

• Inadequate propulsive forces assessed by manometry or• Inadequate propulsive forces assessed by manometry or imaging

• Inadequate propulsive forces assessed by manometry or imaging

Longstreth GF, et al. Gastroenterology 2006.Longstreth GF, et al. Gastroenterology 2006.

Inadequate reflex relaxation or paradoxical contraction of pelvic floor muscles withInadequate reflex relaxation or paradoxical contraction of pelvic floor muscles with

Pelvic Floor DyssynergiaPelvic Floor Dyssynergia

contraction of pelvic floor muscles with defecation contraction of pelvic floor muscles with defecation

DyssynergiaType I

DyssynergiaType I

DyssynergiaType II

DyssynergiaType II

Inadequate expulsion

Inadequate expulsion

RectalRectal

NormalNormal

Remes-Troche JM et al. Curr Gastroenterol Rep 2006;Surrenti E et al. Am J Gastroenterol 1995Remes-Troche JM et al. Curr Gastroenterol Rep 2006;Surrenti E et al. Am J Gastroenterol 1995

00

5050mmHgmmHg

AnalAnal

00

5050mmHgmmHg

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Amy E. Foxx-Orenstein, DO, FACG

Dyssynergy: MR Dynamic ImageDyssynergy: MR Dynamic Image

At restAt rest SqueezeSqueeze

Anterior Rectocele and Excessive Descent

Anterior Rectocele and Excessive Descent

rectocele

perineal descent 4-5 cm

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Amy E. Foxx-Orenstein, DO, FACG

Intussusception and SRUIntussusception and SRU

Solitary rectal ulcerAnorectal intussusception

1 in 100,000Median age 48 years, range 14-76Men and women affected equallyPredisposing factors : constipation, straining

Organ/ Rectal ProlapseOrgan/ Rectal Prolapse

A Internal prolapse – intussusception

B Mucosal prolapse

C Full thickness prolapse

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Amy E. Foxx-Orenstein, DO, FACG

Summary: Common diagnostic findings in evacuation disorders

Summary: Common diagnostic findings in evacuation disorders

Anorectal manometry with balloon expulsion• High average resting anal sphincter tone

Anorectal manometry with balloon expulsion• High average resting anal sphincter tone

• High anal sphincter pressure during valsalva

• Failure to expel balloon

Defecography• Too little or excessive descent• Incomplete rectal emptying

L t l

• High anal sphincter pressure during valsalva

• Failure to expel balloon

Defecography• Too little or excessive descent• Incomplete rectal emptying

L t l• Large rectocele

• Intussusception or mucosal/rectal prolapse

• Large rectocele

• Intussusception or mucosal/rectal prolapse

Bharucha AE, et al. Gastroenterol 2006Bharucha AE, et al. Gastroenterol 2006

Bowel Management Techniquesin Constipation

Bowel Management Techniquesin Constipation

Basics:

I h i l i i

Treatment

Increase physical activity

Avoid constipating drugs

Hydrate

Increase fiber to 25-30 gms daily

High fiber may worsen constipation symptoms in PFD and slow transit.Add slowly, reevaluate.

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Amy E. Foxx-Orenstein, DO, FACG

Bowel Management TechniquesBowel Management Techniques

1. Improve stool consistency

2. Maximize AM colonic stimuli - HAPC’s are triggered by waking, eating, caffeine, stimulant laxatives (qhs)

3. Respond to the urge

4 Sit up straight elevate feet4. Sit up straight, elevate feet • 10 minute maximum

5. Slow, deep breathing

Mayo Bowel Management Patient Education

HAPC = high amplitude peristaltic contractions

Treatment of Pelvic Floor DisordersTreatment of Pelvic Floor Disorders

Biofeedback / pelvic floor retraining

• Education and Instrument-based behavioral training

Biofeedback / pelvic floor retraining

• Education and Instrument-based behavioral training• Education and Instrument-based behavioral training program

• 50%-91% success with symptomatic improvement

• Trainer/patient relationship

• Benefits can be sustained

• Education and Instrument-based behavioral training program

• 50%-91% success with symptomatic improvement

• Trainer/patient relationship

• Benefits can be sustained

Physical therapy to treat pelvic floor spasm, inadequate descent

Consult surgery for refractory disorders

Physical therapy to treat pelvic floor spasm, inadequate descent

Consult surgery for refractory disorders

Rao SS, et al. Clin Gastroenterol Hepatol 2007;Chiarioni G, et al. Gastroenterol 2006.Rao SS, et al. Clin Gastroenterol Hepatol 2007;Chiarioni G, et al. Gastroenterol 2006.

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Amy E. Foxx-Orenstein, DO, FACG

Biofeedback in Dyssynergy and IBSBiofeedback in Dyssynergy and IBS

• Prospective study in patients with dyssynergic defecation (N=50) plus IBS C

• Prospective study in patients with dyssynergic defecation (N=50) plus IBS Cdyssynergic defecation (N=50) plus IBS-C (n=29)• Similar responses to biofeedback in

dyssynergic and IBS-C groups (55% vs 67%, P >0.05)

• IBS-C symptoms disappeared in 41% patients who had pre treatment IBS C symptoms

dyssynergic defecation (N=50) plus IBS-C (n=29)• Similar responses to biofeedback in

dyssynergic and IBS-C groups (55% vs 67%, P >0.05)

• IBS-C symptoms disappeared in 41% patients who had pre treatment IBS C symptomswho had pre-treatment IBS-C symptoms

• Assessment of pelvic floor function may be useful in select patients with IBS-C

who had pre-treatment IBS-C symptoms

• Assessment of pelvic floor function may be useful in select patients with IBS-C

Patcharatrakul T et al. J Clin Gastroenterol. 2011

Treatment SummaryTreatment Summary

• Range of non-pharmacologic prescription and• Range of non-pharmacologic prescription and• Range of non-pharmacologic, prescription and nonprescription treatments for constipation

• High degree of inter-patient variability

• Treatment is tailored to subtype and to the individual patient

• Range of non-pharmacologic, prescription and nonprescription treatments for constipation

• High degree of inter-patient variability

• Treatment is tailored to subtype and to the individual patientp

• Biofeedback/PT are treatment of choice for dyssynergy and other forms of PFD

p

• Biofeedback/PT are treatment of choice for dyssynergy and other forms of PFD

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Amy E. Foxx-Orenstein, DO, FACG

PFD SummaryPFD Summary

• A focused history and anorectal examination • A focused history and anorectal examination yis key to the diagnosis

• Limit diagnostic testing

yis key to the diagnosis

• Limit diagnostic testing

• Biofeedback and bowel management techniques can reduce symptoms in most patients

• Biofeedback and bowel management techniques can reduce symptoms in most patients

Thank You!Thank You!

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Amy E. Foxx-Orenstein, DO, FACG

Symbiotic for Functional Constipation

Symbiotic for Functional Constipation

•14-day crossover trial •14-day crossover trial P<.01

yof each:

• Symbiotic: yogurt with 10(8) UFC/g of B animalis and fructoligosaccharide

• Control: lacteous dessert without probiotics

S bi ti i ifi tl

yof each:

• Symbiotic: yogurt with 10(8) UFC/g of B animalis and fructoligosaccharide

• Control: lacteous dessert without probiotics

S bi ti i ifi tl•Symbiotic significantly improved stool frequency, stool consistency, straining, and pain with defecation

•Symbiotic significantly improved stool frequency, stool consistency, straining, and pain with defecation

DePaula JA et al. Acta Gastroenterol Latinoam. 2008

Effect of Fiber on Constipation Subtypes

Effect of Fiber on Constipation Subtypes

)) P<.001

100100

No effectNo effect

ImprovedImproved

Symptom-freeSymptom-freePat

ien

ts (

%)

Pat

ien

ts (

%)

2020

4040

6060

8080

Patients were given 15-30mg/d of Plantago ovata seeds in 3 divided dosesPatients were given 15-30mg/d of Plantago ovata seeds in 3 divided doses

Voderholzer WA et al. Am J Gastroenterol; 1997Voderholzer WA et al. Am J Gastroenterol; 1997

00

Disordered defecationDisordered defecation

Slow transitSlow transit BothBoth Drug-induced

Drug-induced

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Amy E. Foxx-Orenstein, DO, FACG

Therapies for Chronic Constipation: Level A Recommendations

Therapies for Chronic Constipation: Level A Recommendations

Treatment Evidence

Bisacodyl 1 double-blind RCT with 1 open-label controlled trial

Lactulose 2 systematic reviews of RCTs showing benefits vs placebo

Lubiprostone ≥3 well-designed RCTs showing benefits vs placebo

PEG ≥3 RCTs showing benefits vs placebo

Psyllium ≥3 well-designed RCTs showing benefits vs placebo

Senna ≥3 well-designed RCTs showing benefits vs placebo

Leung L et al. J Am Board Fam Med. 2011.

Therapies for Chronic Constipation: Level B and C Recommendations

Therapies for Chronic Constipation: Level B and C Recommendations

Treatment Comments

LEVEL B

Bran 2 controlled trials showed efficacy in reducing laxative use

Docusate sodium 1 double-blind RCT vs psyllium

Methylcellulose 1 controlled trial of medium quality

Polycarbophil 1 case series of medium quality

Sorbitol 1 double-blind RCT showing similar efficacy vs lactuloseSorbitol 1 double-blind RCT showing similar efficacy vs lactulose

LEVEL C

Milk of magnesia No evidence of benefits from any studies;1 adverse report of overuse

Leung L et al. J Am Board Fam Med. 2011.

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Amy E. Foxx-Orenstein, DO, FACG

PEG for Chronic ConstipationPEG for Chronic Constipation• US multicenter RDBPC trial of PEG (17 g) vs placebo for 6 months• US multicenter RDBPC trial of PEG (17 g) vs placebo for 6 months

DiPalma JA et al. Am J Gastroenterol. 2007.

AEs between PEG and placebo were not different except for GI complaints (P=.015)

Lubiprostone for IBS-C: Data from Two Phase 3 Trials

Lubiprostone for IBS-C: Data from Two Phase 3 Trials

•12-wk treatment period•12-wk treatment period

•Overall responder= monthly responder ≥2-3 mo

•Monthly responder = at least moderate relief for 2-4 wk or significant

•Overall responder= monthly responder ≥2-3 mo

•Monthly responder = at least moderate relief for 2-4 wk or significant grelief >2-4 wk

grelief >2-4 wk

Drossman DA et al. Aliment Pharmacol Ther. 2009.

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Amy E. Foxx-Orenstein, DO, FACG

Linaclotide for Chronic Constipation: Results from Two Phase 3 Clinical Trials

Linaclotide for Chronic Constipation: Results from Two Phase 3 Clinical Trials

‡P≤.01†P≤.001

Lembo AJ, et al. N Engl J Med. 2011.

Responder: >3 CSBM/wk and > 1 CSBM/wk for 9 out of 12 wks• Diarrhea most common AE: 15.0% vs 5.0%

Treatment SummaryTreatment Summary

• Range of non-pharmacologic prescription and• Range of non-pharmacologic prescription and• Range of non-pharmacologic, prescription and nonprescription treatments for constipation

• High degree of inter-patient variability

• Evaluation and treatment is tailored to subtype and to the individual patient

• Range of non-pharmacologic, prescription and nonprescription treatments for constipation

• High degree of inter-patient variability

• Evaluation and treatment is tailored to subtype and to the individual patientp

• Biofeedback is treatment of choice for dyssynergy

p

• Biofeedback is treatment of choice for dyssynergy

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Amy E. Foxx-Orenstein, DO, FACG

PFD SummaryPFD Summary

• A focused history and anorectal examination • A focused history and anorectal examination yis key to the diagnosis

• Limit diagnostic testing

yis key to the diagnosis

• Limit diagnostic testing

• Biofeedback and bowel management techniques can reduce symptoms in most patients

• Biofeedback and bowel management techniques can reduce symptoms in most patients

Thank You!Thank You!

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