Background

Important statistics on pelvic floor disorders:

• More than 50% of women age 55 and older suffer one or more of the problems caused by pelvic floor dysfunction.
• 1 in every 9 women will undergo surgery for a pelvic floor disorder.
• Women who suffer from pelvic floor disorders underreport their condition due to embarrassment.
• 1 in every 3 women will suffer sphincter muscle damage due to vaginal childbirth. This damage may lead to loss of bowel control.
• 30% of women with overactive bladder or urinary incontinence also suffer from loss of bowel control.
• 20% of patients suffering from vaginal organ prolapse also experience loss of bowel control.
• 60% of nursing home occupants suffer from loss of bowel control and/or urinary incontinence.

Although men can suffer from pelvic floor disorders, the obvious differences in anatomy and function of the pelvic organs and their support that exist between men and women, make this set of disorders much more common in women. Therefore, most of the information below is geared towards women; however we also treat men with similar disorders.

PELVIC FLOOR

The “pelvic floor” refers to the pelvic diaphragm, the sphincter mechanism of the lower urinary tract, the upper and lower vaginal supports, and the internal and external anal sphincters. It is a network of muscles, ligaments and other tissues that hold up the pelvic organs (vagina, rectum, uterus and bladder). When this system is torn or weakens, the organs may shift, bulge and push outward or against each other. As a result, women may suffer from urinary or fecal incontinence or obstruction, vaginal prolapse, vaginal pain, sexual dysfunction, and other problems. Women who vaginally delivered several children and those who experienced tears in the perineum and pelvic floor during childbirth, are at higher risk for pelvic floor disorders.

Additional factors contributing to pelvic floor relaxation include aging, menopause, connective tissue disorders, degenerative neurologic conditions, and prior pelvic surgery. Any of these factors alone or in combination may occur acutely or over time, and result in some of the most common and feared health problems faced by women.

Pelvic floor disorders include:

• involuntary loss of bowel control
• urinary incontinence
• constipation
• rectal pain
• vaginal and/or rectal prolapse
• pelvic pain/trauma
• sexual dysfunction (Dyspareunia, Apareunia)

Obesity is an additional risk factor for pelvic floor disorders. Excessive body weight adds extra strain to the pelvic floor resulting in pelvic organ prolapse, incontinence, and sexual dysfunction. Dr. Kaufman’s special interest in the effects of morbid obesity on the pelvic floor led him to work collaboratively with the USC Bariatric Program. As a member of the Bariatric Surgery team, Dr. Kaufman offers open and laparoscopic surgerical options for morbid obesity.

Traditionally, the pelvic floor has been segmented by specialists treating disorders of the distal urinary tract, genital organs, and anus and rectum as separate entities. Disorders across these anatomic areas that are only separated by millimeters of tissue are common. When a compartmental approach is followed to treat women with a pelvic floor disorder, there is a possibility of inaccurately identifying which segment of the pelvic floor is causing the disorder. This may lead to an inadequate surgical repair, and the original problem can recur or additional problems may be unmasked.

USC Approach

At USC we take a different approach - a multidisciplinary approach to treat these disorders. This means that specialists from colorectal surgery, gynecology, urology, and radiology, meet on a regular basis to discuss patients, plan treatment, and perform surgery together. In addition, specialists share common office space so patients can be seen by members of the team on the same day, in one convenient location. Locations of other team members are within walking distance.

Specialists
Colorectal: Dr. Howard Kaufman
Gynecology: Dr. Claire Templeman
Urology: Dr. David Ginsberg
Radiology: Dr. Suzanne Palmer
Physical Therapy: Julie Guthrie, DPT

DISORDERS

Loss of Bowel Control - Loss of control of bowel movements or gas is known as fecal incontinence. This condition is reasonably common, particularly in women who have had children. Studies have demonstrated that at least 30% of women will sustain damage to the anal sphincter muscles during childbirth. However, symptoms of fecal incontinence may not become clinically evident for decades.

Our physicians and staff understand the traumatic consequences of having to live with loss of bowel control. We empathize with this socially debilitating condition, and we do not want patients to suffer in silence. There are many options for treating and managing this disorder. Our goal is to provide options to allow patients to regain control of bowel function. Patient care is individualized, and your doctor will discuss surgical and nonsurgical treatment options aimed at improving your quality of life.

Our colorectal specialists work with patients to find the cause of incontinence which may include disorders of the colon and rectum, the anus, and/or the pelvic floor. Treatment depends on the cause and severity of fecal incontinence, and may include medication, dietary changes, biofeedback and exercise programs to strengthen anal and pelvic muscles, or surgery.

Secca Procedure - a new treatment procedure that has shown positive results, is the Secca procedure. The procedure may be an option for patients with loss of bowel control who have failed conservative therapies such as fiber supplementation, anti-diarrheal medications, and biofeedback, and are not optimal candidates for surgery due to lack of a discrete sphincter injury. Studies have demonstrated that 60% to 80% of patients experience significant improvement in incontinence symptoms.

Latest Therapies
In addition to evaluation of the muscles and nerves of the anus and rectum, we offer the latest therapies available in for patients who have failed traditional types of therapy. Alternative therapies include:

• Artificial Bowel Sphincter
• Antegrade continence enema procedure

Anorectal Physiology Laboratory
In the USC University Hospital Anorectal Physiology Laboratory, state of the art equipment is available to help identify the causes of loss of bowel control. Your doctor may order some or all of the following tests:

• Pudendal nerve testing - The pudendal nerves have branches that travel to many of the pelvic floor structures including the anal sphincter muscles. The pudendal nerves are often stretched and damaged during childbirth. Such damage may contribute to fecal incontinence. A simple test is performed to measure the best fibers of the pudendal nerves to the anal muscles.
• Anorectal manometry - The pressures generated by the anal muscles are tested at rest and during squeezing. We also measure reflexes that contribute to bowel control and various measures of rectal sensation.
• Anal Ultrasound – Anorectal ultrasound is a very useful tool for imaging the anatomy of the anal sphincters and rectum in patients with a variety of anorectal diseases. It is not an x-ray, therefore there is no radiation exposure. A probe the size of an index finger is inserted into the anal canal and the rectum. Using ‘sound waves’ produced by the probe, an image is captured on the screen. The patient may feel vibration from the probe during the examination, but discomfort is uncommon. The study takes 15 to 30 minutes.

Rectal Prolapse – Rectal prolapse is different than prolapsing hemorrhoids. Rectal prolapse may involve the full lining and muscles of the rectum protruding with attempts at bowel movements. In more advanced cases, the rectum may protrude without straining. More milder forms may only involve the lining of the rectum (mucosal prolapse). Internal rectal prolapse occurs when the rectum telescopes on itself inside the pelvis and does not protrude out of the anus. Depending on the cause and type of prolapse as well as patient factors and desires, surgery may be performed through the abdomen (open, laparoscopic, or robotic) or via a “perineal approach” (through the bottom). Most patients who have loss of bowel control or constipation associated with rectal prolapse will note improvements in theses associated symptoms following surgical correction.

Vaginal Prolapse – Prolapse comes from the Latin word, “to fall.” In medicine, this term indicates that an organ has slipped out of its proper place. Women with pelvic floor disorders may suffer from the rectum protruding through the back wall of the vagina (rectocele), the bladder protruding out through the anterior vaginal wall (cystocele) or the entire vagina (vaginal vault prolapse) or uterus (uterine prolapse) prolapsing through the vaginal opening. The small intestine may even prolapse (enterocele), especially in women who have had a hysterectomy. When an organ prolapses vaginally, it may be indicative of an unusually difficult labor during childbirth, obesity or the effects of constant straining on the female pelvic floor.

Prolapse can also involve the slippage of an organ out of its original location but not necessarily outside the body. Unless an organ protrudes through a genital orifice, a woman may not know that she has a prolapsed organ. Symptoms of urinary incontinence, rectal and/or vaginal heaviness or pain, constipation, and discomfort or pain experienced during sexual activity, may indicate vaginal prolapse.

Sexual Dysfunction - Women suffering from a pelvic floor disorder may experience dyspareunia (pain with intercourse) or apareunia (no sexual intercourse).