Gastroenterologist, colorectal surgeons and primary care physicians address patient complaints and symptoms of chronic constipation or fecal incontinence. These bowel complaints and presentations of symptoms place patients on two opposite ends of the spectrum. Interestingly, patients who suffer from entirely opposite symptoms can be suggested to try similar over-the-counter products, for example, FiberCon to bulk the stool for incontinence patients as well as for those who are chronically constipated to increase their fiber intake. Physicians only have available less than a handful of prescription medications that are on the market for patient symptoms, that may or may not work for their list of complaints, which leaves patients left to wander the aisles of a $725 million dollar industry of over-the-counter products in attempts to lessen or alleviate their symptoms. 1 The roles of pelvic floor physical therapists are increasing in assisting these two distinct types of patient populations with great success. Physical therapists are able to assess and help correct for a diastasis recti that creates improved bowel movement push out strength, assess abdominal strength along with psoas mobility, visceral motility and mobility, assess internal vaginal and rectal pelvic floor muscle strength and the muscles ability to lengthen for normal evacuation.
Women more than men, and those over the age of 65 seem to suffer from chronic constipation which totals about 27% of all Americans, whereas 7% of the population, both men and women over the age of 50, suffer from lack of control over defecation, leading to involuntary loss of bowel contents: flatus, liquid stool elements, mucus or solid feces. 2 There are many risk factors that include postpartum childbirth, menopause, abdominal surgeries, bowel surgeries, neurological diseases, severe cognitive decline and poor mobility that creates difficulty getting to the bathroom and pelvic floor muscle dysfunction.
As stated there are many reasons for chronic constipation or fecal incontinence that the medical community addresses, however, some of these symptoms can also be due to pelvic floor muscle under-activity, over-activity or paradoxical muscle function status. Patients who have abnormal muscle overactivity in their rectal pelvic floor can lose the normal bowel movement urges, have incomplete bowel emptying (tenesmus), bowel frequency due to their incomplete emptying along with abdominal pain, difficulty passing gas, or excessive gas and abdominal bloating. 4, 5 All of these can be layered and make for a complicated patient history. The most interesting aspect of the evaluation and subsequent first few physical therapy visits are to determine if the fecal incontinent patient is truly chronically constipated. As patients present to the office with complaints of fecal leakage, the main task at hand is to determine if they are fully emptying their bowels. The leakage can be a by-product of liquid that by-passes compacted stool. Physical therapists are able to determine if the patient has paradoxical rectal pelvic floor function through digital palpation that can be confirmed through biofeedback.
This paper can serve to describe relative effectiveness of different interventions as well as the role of physical therapy in the patient population of those who suffer from chronic constipation and fecal incontinence.
REFERENCES:
1. Andrews CN, Storr M. The pathophysiology of chronic constipation. Can J Gastroenterol. 2011;25(suppl B):16B-21B.
2. Bassoti G, Chistolini F, Sietchiping-Nzepa F, et al. Biofeedback for pelvic floor dysfunction in constipation. BMJ. 2004;328:393-6.
3. Pourmomeny AA, Emami MH, Amooshahi M, et al. Comparing the efficacy of biofeedback and balloon-assisted training in the treatment of dyssynergic defecation. Can J Gastroenterol. 2011;25(2):89-92.
4. Prather H, Spitznagle TM, Dugan SA. Recognizing and treating pelvic pain and pelvic floor dysfunction. Phys Med Rehabil Clin N Am. 2007;18:477-496.
5. Sinclair M. The use of abdominal massage to treat chronic constipation. J Bodyw Mov Ther. 2011;15(4):436-45.