Dyssynergia of the Pelvic floor
The pelvic floor
Weird as the words sound, the pelvic floor simply designates the muscles that are below the pelvic area which assist in the passage of stool through the rectum and out the anus. It is a significant clinical part of the body, because if damaged, it can lead to a variety of medical conditions that have negative impact on quality of life.
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Women who give birth sometimes damage muscles in the pelvic floor. Athletes who engage in particular kinds of sports, such as equestrian sports or biking can also damage the pelvic floor.
The result is some loss of control over the bladder, known as urinary incontinence, or loss of control over defecation, known as fecal incontinence. Therefore, the pelvic floor frequently is a source for the causes of constipation.
Impairment of defecation
Other terms for pelvic floor dyssynergia are anorectal dyssnergia, dyssynergic defecation, and anismus. Because the muscles are damaged, coordinated movement of muslces to expel stool becomes impaired leading to chronic constipation. The feeling that most people get is the inability to empty the rectum fully. Others experience the need to strain very hard, and others find that some manual intervention is absolutely necessary to empty the rectum.
Mechanical diagnosis
To assess this type of condition, and how it is leads to causes of constipation, a physician can employ a balloon expulsion test. First, a balloon is inserted into the rectum and inflated. Then, the patient is told to try to expel the balloon. The pressure exerted by the rectal muscles, and hence the pelvic floor muscles, can be measured by devices attached to the balloon. Problems with pelvic floor dyssnergia can be revealed by abnormally low ability to contract.
Imaging diagnosis
There is a major type of constipation known as prolonged or delayed or slow transit constipation. The causes of constipation in this case may be unclear. This means that stool takes an abnormally long time to go through the gastrointestinal tract. Physicians can measure this at their facility by first giving the patient a small radioactive pill (which is of such low radioactivity that it is safe to ingest). The patient swallows it and returns in a few days, at which time an x-ray device is able to pinpoint the location of the pill in the intestine. This allows the physician to assess whether the stool took a long time to get to its current position. Patients with dyssnergia have been found to exhibit slow transit constipation, although explaining why this is true is not so easy.
Treatments
For such patients, first line constipation treatments are still standard high dose insoluble fiber intake of 25-30 grams. However, one should keep in mind that only about 30% of patients with pelvic floor problems will resopnd to such therapy. Even worse, a study by Voderholzer et al showed in the American Journal of Gastroenterology that intensive fiber therapy can worsen constipation symptoms in patients with particular kinds of pelvic floor dysfunction. In other patients with constipation, fiber therapy can have a success rate as high as 80%. Beyond first line therapy, patients have the option of using laxatives and other constipation medication, but recent research by Chiarioni et al have shown that biofeedback, which is a sort of psychotherapy for strengthening and improving coordination of the pelvic floor muscles, is a statistically superior therapy.
Sources:
Fox-Orenstein et al, Update on constipation: One treatment does not fit all, Cleveland Clinic Journal of Medicine, 2008; 75(11):813-824
Muller-Lissner, The Pathophysiology, Diagnosis, and Treatment of Constipation, Deutsches Arzteblatt International, 2009; 106(25):424-32