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 .