Fecal Incontinence & Pelvic Floor Rehabilitation

Dr. Leah R. Tobey, MBA, PT, DPTPhysical Therapist, Certified in Pelvic Floor Rehabilitation

Clinical Coordinator AGEC

Connect with us! www.agec.uams.edu facebook.com/uamsagec@uamsagec

Webinar Objectives

1. Discuss the pelvic floor musculature and understand its functional role with fecal incontinence

2. Describe pelvic floor physical therapy (PFPT) and identify appropriate patients

3. Understand compliancy barriers: PFPT from the patient’s perspective

IntroductionPelvic floor physical therapy (PFPT)

• What is it?• Effective & beneficial treatment

• Why should I know?• Considered 1st-line treatment

conservative management

• Patient empowerment • Crucial for patient quality of

life & confidence beyond our office doors

•Barriers?

Stigmas, Hesitancy, Compliancy, Intimately personal

• 2014 Cochrane Review found high quality evidence to support pelvic floor muscle training as the 1st line treatment for stress & mixed UI in women.

Debunking Myths • Incontinence (urinary or fecal) after childbirth is normal.

• Incontinence (urinary or fecal) is a natural part of aging.

• “Fecal incontinence is a burden I have to carry because I’m older now.”

• “Nothing can be done to change incontinence.”

• “It’s not that bad…”

Barriers on Diagnosis & Treatment

The nature of the conditions of UI, FI or both presents unusual challenges.

Why does FI occur?

• Weak pelvic floor muscles • Weak IAS/EAS (sphincter tone

and strength)• These sphincters hold in feces

until ready to have a BM

• Damaged nerves or muscles • From inflammatory bowel disease-

chronic diarrhea, stroke, childbirth, diabetes, MS, etc.

• H/o chronic constipation: FI can occur as a result of an attempt to prevent constipation.

• OAs (older adults)• Use of laxatives & stool softeners

FI continued

Common symptoms:• Having an accident before

getting to the bathroom • Difficulty staying clean• Not being able to hold in gas• Passing fecal matter while

passing gas• Passing stool during normal

everyday activities

Who is more likely to have FI?• Are older than age 65• Are not physical active• Have other chronic conditions or

health problems• Have had gallbladder removed • Current smoker

How common is FI?NIDDK: National Institute of Diabetes and Digestive and Kidney Diseases

• Reports FI affects approximately 1 in 3 people who seek a primary health care provider

Nursing home residents:

• More greatly impacted due to their population being mostly OAs

• Between 50-70 out of 100 have FI

Hospitalized adults:

• Between 18-33 out of 100 have FI

Non-hospitalized adults:

• Between 7-15 out of 100 have FI

The nature of the conditions of UI, FI or both presents unusual challenges.

Let’s further discuss why…

Barriers on Diagnosis & Treatment

Multi-factorial challenges patients face: • The person with incontinence is faced with a persistent challenge of

overcoming social and cultural taboos. • Psychosocial barriers, Social stigma, Cultural factors

• Shame• Embarrassment• Uncertainty• Unpredictable• Reluctance surrounding discussion of toileting habits

• Internal & External factors • Influence whether or not a person will seek medical treatment for their chronic

condition• + concepts of self-image, self-worth & health expectations

Barriers on Diagnosis & Treatment

• It has been said, “uncertainty is the worst illness.”• FI can lead to:

• Older adult isolation• Leading cause for institutionalization of elderly

• Limited life chances • Leisure, Church, etc.• Less likely to marry

• Workplace lost productivity • Less likely to hold a normal, working job

• Reduced self-esteem

Overcoming the social stigma

• Comments you may hear:• “I feel uncomfortable mentioning

it.” • “It’s embarrassing. I don’t want to

bring it up to my doctor.”• “It’s probably just something I

ate.”

Talking to your doctor is the first step toward freedom from bowel incontinence.

Advocate for treatment

Be an Advocate for patients & loved ones!• Patients will go to considerable lengths

to keep their symptoms secret if they are able.

• Literature review shows 50-70% of incontinent persons do not seek help for their condition.

You can start here…

• Educate• Speak up • Affirm• Reach out

• Patients have been silent about FI issues for far too long.

• Again, 50-70% do not seek treatment for their condition.

• The work of many organizations has helped to break some of the silence.

• The National Association for Continence• National Institute of Diabetes and

Digestive and Kidney Diseases (NIDDKD) • The Simon Foundation for Continence • The International Foundation for

Functional Gastrointestinal Disorders (IFFGD)

• Asked <25% of their patients about incontinence

PCPs

• 70% did notvoluntarily report their continence

Patients • When asked by PCPs, 75% of incontinent patients did report their condition.

Both

Study from Clinical Geriatric Medicine: Psychosocial impact of urinary incontinence in the elderly populationhttps://www.ncbi.nlm.nih.gov/pubmed/15341815

Physicians don’t ask; patients don’t tell

The floor of your pelvis

The pelvic floor is a bowl-shaped or hammock with several layers of muscles that cover the bottom of the pelvic cavity

Functions & Importance

• Pelvic floor is the group of muscles, ligaments, connective tissues & nerves that: (three layers)

• Functions: 1. Support2. Sphincteric3. Sexual4. Sump-Pump

• Pelvic health can be crucial for:• Self-pain management & self-care• Relationships • Quality of life• Confidence

Pelvic floor anatomy reviewUrogenital triangle: Layer 1 & 2 Colorectal triangle: Layer 3

PFPT: Pelvic floor physical therapyMISSION:

• To provide effective, evidence-based physical therapy interventions while promoting lifelong musculoskeletal health.

• Treatment emphasis is placed on patient education, behavioral management, home exercise and symptom management.

• Common goals for PFPT:• Reduction of FI symptoms • Improve patient’s quality of life (QOL)• Restore function and return patients back

to social, home and leisure activities with as little pain and/or deficit as possible

Patient education

FI vs. Dyssynergia

https://monalisatouch.co.nz/menopausal-hormone-therapy-linked-faecal-incontinence/

Patient education

Role of Physical Therapy

• PT can be a very beneficial intervention for most all PF disorders• PT can be a valuable learning experience for patients

• Learning anatomy & how things function • “Uncertainty is the worst illness” Knowledge is power

• PT can help a patient isolate the correct group of muscles• Assessment of pelvic floor musculature for appropriate strength & isolation

• External & Internal examinations (tone, strength, pain, contractibility, etc.)• 1:1 training to ensure activation of pelvic floor muscles

• EMG/Biofeedback, Anal Manometry

The pelvis is a complicated place

Role of PFPT continued

• PT can help beyond “does it fix my problem?”Other benefits:• Increases knowledge of pelvic floor

• How your pelvic floor works?• Increases knowledge of bladder and/or bowel irritants (foods & fluids)• Retrains poor bowel & bladder habits

• Timed voiding to help retrain bladder• Improved PF strength can assist with urge suppression, flatulence, mucous loss, etc.• Proper bowel movement posturing is essential to avoiding straining or Valsalva

maneuver

Avoiding constipation with proper toilet posture

PFPT Treatment Overview

• Wide range of treatments• Focus some of PF muscle strengthening protocols

• Some conditions do not need• Not just about PF strength but, rather the when & how to use the muscles during the

day to communicate with the bladder, bowels and spinal cord • Stretching protocols

• Helpful for pelvic pain conditions and often with constipation• Not all treatments are related to pelvic floor work

• Abdominal wall work• Orthopedic: Hip/Low back assessment• Myofascial release techniques

• Teach different maneuvers to help empty bowel/bladder with little to no strain on PFM

Treatment: Pelvic floor exercises

• Pelvic floor muscle exercises are known as Kegel exercises• “Those kegels…been there-done that. They don’t work for me.”• Not appropriate for all conditions

• Medical research indicates that after brief verbal or written instruction only 49% of women can correctly contract these muscles

• Correct use of pelvic floor exercises can:• Increase strength of contraction• Increase tone of PFM • Improve EAS/IAS tone

• This can lead to better control of sphincter closure & help reduce FI symptoms

Assessment & Treatment

• Biofeedback & Anal Manometry• With electrode directly on the PFM, it records the amount of electrical

activity; Manometry measures how well the rectal sphincters are working via insertion of a catheter and balloon to measure anal sphincter strength

• Helps patients to gain better awareness of their pelvic floor muscles with use of a sensor placed within the rectum

• EMGs are transmitted through the sensor and onto a computer screen, via graph format.

• Evaluates Type 1: Endurance (10-15”) & Type 2: Quick flicks (2-3”)• Evaluates resting state (aka ”resting level” of microvolts) and Coordination during

contractions

Case 1 of Mrs. Fiona

• 68 y/o referred to PT for “Pelvic floor therapy for FI”• C/c is recent, insidious onset of bowel leakage with an average of 2-3

episodes occurring on average twice per day. • Been a runner her entire life. Initially, SUI began in her early 40s while

running. Her symptoms progressed to MUI and fecal smearing; ceased running.

• H/o TVT 8 years ago for grade 3 cystocele & grade 2 rectocele• Initially after TVT = constipation. Now, has 4+ small BMs/day.

• 10 years ago cholecystectomy; 5 years ago L THR; G2P2: V-back with “difficulty healing” x 1; emergency C-section 3 years later.

• Medications: PPI for Gerd, Aleeve, Inhaler for asthma • Also referred, by her PCP, to a dietician

• Treatment duration: 2x/wk for 4 weeks then 1x/wk for 3 weeks.

Fiona’s PFPT Treatment:

Week 1-2• Consultation & Examination including Biofeedback • B&B diary + Diet• Behavioral, bowel and bladder retraining

• Toileting positions • Quick flicks for behavioral retraining • Timed voiding q 1.5 hours

• Increasing fiber in diet naturally for 2 weeks, then added OTC fiber supplement

• Breathing exercises with partial Kegel

Treatment continued

Week 3-5• Progression with EMGS & HEP to endurance training 8-10” 40x/day

(Type 1) & 1” 40x/day quick flicks • Using ”My Kegel” Ap on iPhone to help her stay mentally focused &

consistent with home program• Able to resume walking 2 miles/day with 30-40% symptom reduction

• Orthopedic examination of L hip showing significant gluteus mediusweakness with global atrophic changes of L glutes

• Began several L, then B hip strengthening exercises & SLS balance activities Week 6-7 • Continued progression of behavioral, pelvic floor & L hip exercises &

activities

CMS & Billing

• CMS stance: • ”Biofeedback may be used to improve health, performance, and the

physiological changes which often occur in conjunction with changes to thoughts, emotions, and behavior. Eventually, these changes may be maintained without the use of extra equipment.”

• PTs: when completing documentation keep in mind--• Codes for mm. incoordination, mm. weakness reimburse while FI, UI do not.• Charge carefully for “self-care/home management”• During initial evaluation remember to document 4 weeks of failed pelvic

muscle exercise training (showing the pt has tried Kegels).

Case 2: Mr. Charles “I’m constipated, why am I leaking stool?”• Bowel regimens are important!

• Diet• Laxatives • Water

• H/o IBS-C and OAB • Treatment duration: 1x/wk fo 6 weeks; 2 week and 3 week follow ups. • Became more physically active with a chair exercise program (Ageless Grace);

Eliminated FI symptoms. Managed constipation with increased fluid (water) intake, bladder retraining q 2 hours BM positioning, abdominal bowel massage, Kegel exercise regimen.

*Managing constipation first* can often help reduce accidental bowel leakage

PFPT Treatment Overview

• Patient consultation: • Patient Education

• Examination of orthopedic influences:• Treatment of hip, low back, or pelvis issues

• PF Examination • Biofeedback and/or manometry

• Core retraining • Helps to reintegrate the pelvic floor with the other deep core muscles • Proper lifting techniques

• Proper breath control-breathing exercises• Dietary & nutritional education• Behavioral, bladder & bowel retraining

References• Bocchini, R., Chiarioni, G. et.al. “Pelvic floor rehabilitation for defecation disorders.” Tech Coloproctol. 2019 Feb;23(2):101-115. doi: 10.1007/s10151-

018-1921-z. Epub 2019 Jan 10.

• Bump R, Hurt G, et al. (1991). "Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction." Am J Obstet Gynecology 165: 322-329

• Colorectal Dis. 2017 May;19(5):456-461. doi: 10.1111/codi.13510. Faecal incontinence in patients with a sphincter defect: comparison of sphincteroplasty and sacral nerve stimulation.Rodrigues FG1,2, Chadi SA1, et al.

• Curr Gastroenterol Rep. 2019 Apr 23;21(5):21. doi: 10.1007/s11894-019-0688-3.A Practical Guide to Biofeedback Therapy for Pelvic Floor Disorders.Narayanan SP1, Bharucha AE2.

• Freeman, A., Menees S. Fecal Incontinence and Pelvic Floor Dysfunction in Women: A Review. Gastroenterol Clin North Am. 2016 Jun;45(2):217-37. doi: 10.1016/j.gtc.2016.02.002.

• Harvard Health Publishing: Harvard Medical School. May 2019. https://www.health.harvard.edu/staying-healthy/tips-for-better-bowel-control

• International Foundation for Gastrointestinal Disorders. Incontinence and Aging. October 2017. https://www.aboutincontinence.org/incontinence-and-aging.html

• Michigan Medicine Fecal Incontinence Bowel Program. Nov 2018. www.umwomenshealth.org/pelvicfloor

• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Definitions and Facts of Fecal Incontinence. July 2017.

• Norton, N. International Foundation for Functional Gastrointestinal Disorders. NIH: National Institutes of Health conference on Prevention of Fecal and Urinary Incontinence in Adults, held December 10-12 2007. https://www.aboutincontinence.org/barriers-on-diagnosis-and-treatment.html

• Nygaard, I., Barber, M. et.al. Prevalence of Pelvic Floor Disorders in Women. JAMA. August 2010. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2918416/

• Whitehead WE, Palsson OS, Simren M. Treating fecal incontinence: an unmet need in primary care medicine. North Carolina Medical Journal. 2016;77(3):211–215.

Questions?Thank you for joining AGEC’s webinar today

& a special thanks to Dr. Conan Mustain.

AGEC’s next 2 hr webinar: 5/13 “The Aging Eye”

Leah Tobey, MBA, PT, DPTlrtobey@uams.edu