Pelvic Floor Disorders. Amir Darakhshan MD FRCS (Gen Surg) Consultant Colorectal and General Surgeon

Transcription

1 Pelvic Floor Disorders Amir Darakhshan MD FRCS (Gen Surg) Consultant Colorectal and General Surgeon

2 What is Pelvic Floor Disorder Surgical perspective symptoms of RED, FI or prolapse on the background of PF failure

3 What is Pelvic Floor Disorder Pelvic Floor Failure = Structural Perineal descent Rectocoele, enterocoele, cystocoele, poor bladder neck support Uterine, vaginal vault prolapse Rectal Evacuatory Difficulties (RED) ODS, RI, rectocoele, anismus, poor effort Incontinence FI, UI Dysmotility Constipation, diarrhoea, IBS

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5 Stress MRI

6 What is Pelvic Floor Disorder Pelvic Floor Failure Perineal descent Rectocoele, enterocoele, cystocoele, poor bladder neck support Uterine, vaginal vault prolapse Rectal Evacuatory Difficulties (RED) ODS( descent, RI, rectocoele), anismus, poor effort Incontinence FI, UI Dysmotility Constipation, diarrhoea, IBS

7 What is Pelvic Floor Disorder Pelvic Floor Failure Perineal descent Rectocoele, enterocoele, cystocoele, poor bladder neck support Uterine, vaginal vault prolapse Rectal Evacuatory Difficulties (RED) ODS, RI, rectocoele, anismus, poor effort Incontinence FI (urge, passive), UI Dysmotility Constipation, diarrhoea, IBS

8 What is Pelvic Floor Disorder Pelvic Floor Failure Perineal descent Rectocoele, enterocoele, cystocoele, poor bladder neck support Uterine, vaginal vault prolapse Rectal Evacuatory Difficulties (RED) ODS, RI, rectocoele, anismus, poor effort Incontinence FI (urge, passive), UI Dysmotility Constipation, diarrhoea, IBS

9 Patient Assessment -1 History and examination Are symptoms primarily pan enteric/colonic dysmotility RED Incontinence (+/- urinary) All of above

10 Patient Assessment -2 Bowel habit constipation, abdo distension/pain, nausea straining, perineal support, digitation, prolapse, fragmented defaecation, difficulty wiping Obstetric number, 2 nd stage labour, forceps, tears Urinary symptoms

11 Patient Assessment -3 Investigations U&Es, TFT, Ca 2+ Colonic transit marker study, colonoscopy EAUS, Total Pelvic Floor US Anorectal physiology Video proctography Stress MRI Urodynamic studies (urogynaecology)

12 Transit Marker Study

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14 Anatomy

15 EAUS Transverse perineii External sphincter Internal sphincter

16 Video Proctogram Sacrum Small bowel Rectum Femur

17 Stress MRI - Straining Multi-compartment failure

18 RED Poor propulsive effort Perineal descent Rectocoele Rectal mucosal Intussusception Rectal prolapse Anismus

19 Rectocoele Rectal intussusception Rectocoele

20 FI - Normal Anus Diarrhoea Infection Inflammatory Bowel Small Bowel Resection Tumours Entero-enteric fistula Rectum Reduced Sensation Reduced Capacity Fibrosis Radiotherapy Resection, Proctitis Tumour Poor emptying Faecal impaction ODS Poor technique

21 FI Abnormal Anus Passive Reduced resting tone IAS atrophy Neurologic Dysfunction Urge Trauma Obstetric anal injury Iatrogenic Stretch Fistula Haemorrhoidectomy Impalement Military

22 EAUS External sphincter Internal sphincter

23 Management of RED Diet, fluid intake optimisation Soft, bulky stool Exercise Biofeedback Non-operative Correct toilet technique Perineal/vaginal splinting Pelvic floor exercises, balloon expulsion

24 Management of FI Non operative Diet fluid intake optimisation Medication Loperamide, codeine, colestyramine Suppostories, Enemas Anal plug Biofeedback Rectal irrigation: Peristeen, Qufora

25 Biofeedback Balloon expulsion

26 Biofeedback

27 Anal Plug

28 Rectal Irrigation

29 Management of RED Operative Rectocoele repair Rectopexy Ventral mesh Posterior STARR

30 Rectocoele repair

31 Rectocoele repair

32 Rectocoele repair

33 Rectal Intussusception Lindsey et al

34 Oxford Rectal Prolapse Grade

35 Rectal Prolapse

36 Surgical options Abdominal Effective Low recurrence rates Better improvement in FI Anterior/posterior Open or lap Constipation Perineal Frail/elderly Avoid laparotomy/ga High recurrence Higher FI Low morbidity Lower constipation

37 Rectopexy

38 Results Post Rectopexy Improvement in continence 80-90% Severe post-op constipation 50% denervation inertia Kinking of rectosigmoid Resection? Recurrence <5% at 5 years (c/f perineal procedure 18-30%)

39 Results Ventral Rectopexy Lead point of intussusception = anterior No postero-lat mobilisation Resolution of constipation 80% Avoids worsening of constipation supports denervation inertia refutes kinking Long term function unclear Decreases at 12 months

40 STARR for ODS

41 STARR

42 Management of FI Operative Restore anatomy Anterior sphincter repair +/- perineum repair Correct prolapse/intussusception Rectopexy, intra-anal Delormes, STARR Repair rectocoele Transvaginal, STARR Bulking agents IAS defect, keyhole deformity

43 STARR - Outcome Improvement ODS and structure in >90% of patients European STARR registry 2,224 patients, 12-month follow-up significant improvement obstructive defaecation score (15.8 vs. 5.8, P<0.001) symptom severity score (15.1 vs. 3.6, P<0.001) quality of life Jayne DG et al. Stapled transanal rectal resection for obstructed defecation syndrome: one year results of the European STARR Registry. Dis Colon Rectum 2009 July;52(7):

44 STARR - Complications Overall - 36% Urgency 20% Bleeding 5% Sepsis 4.4% Staple line complications 3.5% Incontinence % Pain <2% rectal necrosis <1% rectovaginal fistula <1%

45 Management of FI Operative Restore anal function Artificial Anal Sphincter, Graciloplasty Neuromodulation SNS, PTNS

46 Anterior Anal Sphincter Repair

47 Anterior Anal Sphincter Repair - 2

48 Sacral Nerve Stimulation SNS Minimally invasive Urinary incontinence FI/Constipation Implantable electrode Electrical stimulation sacral nerve Neuromodulation Sub-threshold stimulation

49 Sacral Nerve Stimulation 2 stage Temporary/trial Bowel diary Improvement 50-75% fully continent >75% pts incontinence episodes halved Improved ability to defer defaecation Increased bowel movements Reduced abdominal pain and bloating

50 SNS Permanent If temporary SNS successful Fully implantable Tined/barbed leads IPG Stimulation parameters Hand-held patient controller

51 Sacral Nerve Stimulation

52 Injectable Bulking Agents For passive soiling/fi Into intersphincteric space/ias Biomaterials PTQ carbon-coated beads (Durasphere(R) dextranomer in stabilised hyaluronic acid (NASHA Dx) The Gatekeeper( ) prosthesis: solid polyacrylonitrile cylinder

53 Injectable Bulking Agents Outcomes Improved continence scores at 6 months <50% maintained improvement at 12 months Better results with >2 sites injected May require repeat treatment SE: Pain mainly, infection

54 Restore anal function