Assessment and treatment of anorectal & bowel dysfunction

Bowel & anorectal dysfunctions include:

 Constipation  Fluteal incontinence  Fecal incontinence  Incomplete empty feeling  Post evacuation leakage

Subjective (taking history):

1) Specific symptoms that bring patient to therapy: determine the priorities: constipation, IBS, flatus and feces incontinence, fecal urgency, post evacuation leakage. 2) symptoms of pain: nature, location, duration, severity, irritability, aggravating & relieving factors. 3) Review medical & surgical history:

*respiratory illness

* GI & bowel dysfunctions

* neurological issues

* Urological issues: UTI & IC

* psychological issues

4) Fluid & food charts to note the relationship of eating/ drinking to bowel movements. 5) Allergies & sensitivity related to food, gluten & wheat. 6) Quality & quantity of stool, Bristol stool scale. 7) )ADLs & lifestyle:

* do you exercises routinely? If not, what is the obstacles?

* Habits related to toileting & impact on lifestyle.

* Muscloskeletal problems that may impact patient's ability to take off clothes or reach bathroom on time.

Objective (physical examination):

1) orthopedic screening: *posture/ body, pelvis, sacral, illium & pubic symphsis alignment

* joint mobility & muscle performance around hip & pelvis (adductors, psoas, hamstring, quadrates lumborum, gluts, piriformis, coccygeus & obturator internus)

* observe breathing pattern, coordination between pelvic & thoracic diaphragm

2) Abdomen/ viscera:

*Rebound tenderness by compress slowly & release abruptly if it cause stabbing sudden pain, it’s peritoneal pain.

* Carnett’s test: ask the patient to raise her head while you press to tender areas. If it’s painful, +ve abdominal muscles tenderness and if it’s less pain it means intra-peritoneal

*soft tissue, fascia & scars mobility

* mobility & motility of viscera

3) PFM examination:

* pain & spasm PFM

* PFM strength & endurance.

* external anal sphincter, sensation, tone, tension and relaxation.

* Coordination TrAs & PFM

Treatment plan:

1) Education:

*Process of defecation: peristalsis, letting go, importance of not ignoring the urge to defecate, sensory retraining PFM after bowel movement.

*Defecation mechanics: semi-squatting, bear down with exhaling out & bulge your lower abdomen so that's relaxed

* Fluid & fiber intake:

 For constipated patients: eat breakfast with warm liquids, gradually add the fiber rich foods to your diet 27-40 grams per day & maintain diary.  For IBS patients: Avoid insoluble fibers in ( whole grain, cabbage, broccoli, onion, tomato, carrots, dark leafy vegetables, raisins & grapes) and add soluble fibers food in (oatmeal, apple, orange, pears, strawberries, blueberries, beans & cucumber)  For fecal incontinence patients: fiber increase is essential to restore normal size & texture of stool.

* Explain different types of laxatives: bulk forming (oat meal, Metamucil & konsyl), stimulants (caffeine, aloe, castor oil & correctol), stool softeners to hydrate the intestine ( surfak & colace), osmotic (milk magnesium, ,sorbitol in saline & gum), lubricants (mineral oil, fleet & zymenol).

2) general exercises program & orthopedic intervention to use both inner core stabilizers & outer core mobilizers:

*posture & pelvis re-alignment.

* core training to improve abdominal tone which contributes to appropriate intra- abdominal pressure.

*cardio: walking, swimming, jogging & gentle aerobics

*swiss ball ex's to pelvic mobility, lumbo-pelvic diassociation & core stabilization.

*supervised yoga & general mobility ex's: downward dog, cobra, inversion. Also bridging, bridge & twist, and hooklying spinal twist.

3) pelvic floor treatment:

*rectal and/ or vaginal massage in case of overactive EAS and/ or PFM

*restore contract/ relax efficiency of EAS & PFM

* use manual biofeedback to coordinate EAS, PFM & TrA

*Mobilize sacrococcygeal joint

4) Visceral intervention:

*mobilize liver, ileocecal valve, sigmoid, cecum, mesenteric root, & rectum.

Women's health physical therapist

Alanoud Alduwish