Constipation and Clinical Exam

For patients who are diagnosed with constipation, functional anorectal testing is often completed prior to referral for physical therapy. A recent study concluded that clinical examination of pelvic floor muscle function is critical for identifying a rectocele or pelvic muscle overactivity, and that anorectal function tests should be reserved for selected cases. Pelvic rehabilitation therapists are able to perform tests of the pelvic muscles and function during a patient's attempts to contract, relax, and bear down through the pelvic floor. These tests are easy to repeat and a patient can be instructed in corrective muscle techniques to improve the ability to empty the bowels.

Consider the patient who presents to the clinic after experiencing a defecography. In this test, a patient undergoes an imaging study while sitting on an elevated toilet seat. The patient is asked to bear down to evacuate a bolus of material that is placed inside the rectum. It is easy to understand why a patient finds this test to be "embarrassing." Following this test, when a patient is diagnosed with dyssynergia (when the puborectalis muscle contracts rather than lengthening and relaxing during attempt to defecate) he or she is frequently referred to pelvic rehabilitation. A pelvic rehab therapist can observe and palpate the same phenomena in the clinic: when asked to bear down or drop the pelvic floor muscles, if a patient instead contracts or is unable to lengthen the muscles, re-training can be implemented.

I have often wondered why a patient would need to complete this type of testing for constipation-related pelvic muscle dysfunction if the same patient could reverse a dysfunctional muscle pattern with a brief bout of pelvic rehabilitation. The research by Lam and Felt-Bersma (full-free text article linked above) appears to confirm this thought, concluding that anorectal functional testing contributes little to information that can be gained in clinical examination in women who have idiopathic constipation.

The authors studied 100 women who were diagnosed with idiopathic constipation and who fit the Rome III criteria. A prospective evaluation included an extensive questionnaire regarding complaints, abdominal, rectal, and vaginal examination, and anorectal function tests such as anorectal manometry (ARM)and anal endosonograpy (AUS). Exclusion criteria included inflammatory bowel disease, fissures, or fistula, and endocrine disorders orcolonic obstruction were ruled out. Of these 100 women, 25% were found to have hypertonia and dyssynergia of the pelvic floor, and 15% presented with a rectocele. During anorectal manometry, the authors also noted that women had difficulty relaxing during straining. In the group studied, 37 women complained of impaired evacuation, and interestingly, 40% of these women had a rectocele, yet no rectoceles were identified in the women who did not complain of impaired evacuation.

While medical screening for patients who complain of constipation is important, this research identifies a group of patients (those diagnosed with idiopathic constipation) for whom ARM or AUS testing does not contribute significantly to the evaluative process. The study is very valuable reading for pelvic rehabilitation providers as the authors clearly understand the role of rehabilitation and articulate the value ofpelvic floor muscle function in meaningful ways throughout the report. If you are interested in learning how to evaluate and treat patients who have constipation, there are 3 seats remaining in the PF2A continuing education course at the end of this month in Fairfield, California (right next to Napa, in case that interests you!) The PF2A course covers bowel dysfunction such as constipation, fecal incontinence, and other colorectal conditions, and also offers on Day 3 an Introduction to Male Pelvic Floor function and dysfunction related to pelvic pain and urinary dysfunction. Following the West coast PF2A, there are East coast and Midwest dates, click here to find the course information. Sign up early as this course always sells out!