Bowel and ball and Anorectal Dysfunction.pptx

Bowel and bladder dysfunction can manifest in various ways, including:

Bowel Dysfunction:

1. Constipation
2. Diarrhea
3. Abdominal pain
4. Bloating
5. Incontinence
6. Impaction
7. Megacolon (rare)

Bladder Dysfunction:

1. Urinary incontinence
2. Frequency
3. Urgency
4. Nocturia (nighttime urination)
5. Retention
6. Painful urination
7. Incomplete emptying

Causes:

1. Neurological disorders (e.g., multiple sclerosis, Parkinson's disease)
2. Spinal cord injuries
3. Pelvic floor disorders
4. Infections (e.g., UTIs)
5. Medications (e.g., anticholinergics, opioids)
6. Hormonal changes (e.g., menopause)
7. Aging
8. Trauma
9. Surgery

Treatment:

1. Medications (e.g., laxatives, anticholinergics)
2. Behavioral modifications (e.g., bowel training, bladder retraining)
3. Pelvic floor physical therapy
4. Biofeedback therapy
5. Surgery (in severe cases)
6. Management of underlying conditions

If you're experiencing bowel and bladder dysfunction, consult a healthcare professional for proper evaluation and treatment. They will help determine the underlying cause and develop an appropriate treatment plan.Bowel and bladder dysfunction can manifest in various ways, including:

Bowel Dysfunction:

1. Constipation
2. Diarrhea
3. Abdominal pain
4. Bloating
5. Incontinence
6. Impaction
7. Megacolon (rare)

Bladder Dysfunction:

1. Urinary incontinence
2. Frequency
3. Urgency
4. Nocturia (nighttime urination)
5. Retention
6. Painful urination
7. Incomplete emptying

Causes:

1. Neurological disorders (e.g., multiple sclerosis, Parkinson's disease)
2. Spinal cord injuries
3. Pelvic floor disorders
4. Infections (e.g., UTIs)
5. Medications (e.g., anticholinergics, opioids)
6. Hormonal changes (e.g., menopause)
7. Aging
8. Trauma
9. Surgery

Treatment:

1. Medications (e.g., laxatives, anticholinergics)
2. Behavioral modifications (e.g., bowel training, bladder retraining)
3. Pelvic floor physical therapy
4. Biofeedback therapy
5. Surgery (in severe cases)
6. Management of underlying conditions

If you're experiencing bowel and bladder dysfunction, consult a healthcare professional for proper evaluation and treatment. They will help determine the underlying cause and develop an appropriate treatment plan.Bowel and bladder dysfunction can manifest in various ways, including:

Bowel Dysfunction:

1. Constipation
2. Diarrhea
3. Abdominal pain
4. Bloating
5. Incontinence
6. Impaction
7. Megacolon (rare)

Bladder Dysfunction:

1. Urinary incontinence
2. Frequency
3. Urgency
4. Nocturia (nighttime urination)
5. Retention
6. Painful urination
7. Incomplete emptying

Causes:

1. Neurological disorders (e.g., multiple sclerosis, Parkinson's disease)
2. Spinal cord injuries
3. Pelvic floor disorders
4. Infections (e.g., UTIs)
5. Medications (e.g., anticholinergics, opioids)
6. Hormonal changes (e.g., menopause)
7. Aging
8. Trauma
9. Surgery

Treatment:

1. Medications (e.g., laxatives, anticholinergics)
2. Behavioral modifications (e.g., bowel training, bladder retraining)
3.

1. Bowel and Anorectal Function & Dysfunction Dr. Zermeen Zerish; PT

2. Day-to-day living can affect an individual’s normal bowel habit A change in the level of activity A change in location Regular meals, a healthy diet and spicy foods The menstrual cycle The workplace An unhurried environment that enables a person to obey a ‘call to stool’ Availability of a private place to defaecate

3. The side-effects of medication, resulting in bowel dysfunction Some drugs are constipating Anticholinergics Opiates Iron supplements Non-steroidal anti-inflammatory drugs ( NSAIDs) Some medications cause diarrhoea Antibiotics

4. Normal Bowel Function Food propelled through by peristalsis On the way digestion takes place Nutrients are absorbed into the bloodstream chiefly in the small intestines

5. The 7-point scale helps describe your stool shape and consistency

6. Storage The consistency of soup is delivered to the colon Water is absorbed and the remainder formed into faeces The consistency of the final stools depends on how long the faecal material remains in the colon having water removed from it Longer material is in the colon, the dryer and harder is the stool

7. continued The faeces are propelled into the rectum by periodic strong mass gut movements Mass movements are triggered by the gastrocolic reflex, which is itself stimulated by eating and activity The initial sensation of the presence of stool in the rectum can be produced by as little as 11–68mL The maximal sensation at 250–510 mL

8. Storage Factors contribute to the maintenance of anorectal continence: The resting pressure of internal anal sphincter (IAS ) NORMAL: 40 to 60 mmHg The resting closure pressure is contributed by the striated external anal sphincter (EAS ) The anorectal angle The vascular anal cushions An intact nerve supply, both autonomic and somatic, sensory and motor The cohesive contact of the moist rectal walls The consistency of stool

9. Defaecation The act of emptying the rectum is called defaecation or ‘opening the bowels’ The normal frequency of defaecation varies substantially between individuals from three times a day to three times a week If evacuation is inconvenient or impractical, defaecation can be deferred by: Repeated strong voluntary squeezes of the external anal sphincter , which has the effect of reversing peristalsis Return faecal material to the rectum and colon Facilitate a resumption of contraction of the IAS

10. M ay help your rectal muscles into a more neutral position, reducing the straining it takes to get your poop out.

11. Bowel & Anorectal Dysfunction Dysfunctions of the bowel, rectum or anus generally fall into two main groups: Difficulty in evacuating faecal material An inability to store flatus and/or faecal material reliably prior to evacuation at socially acceptable times and places

12. Useful Definitions Anal incontinence The involuntary loss of flatus , liquid or solid per anus Anismus Incoordinate activity of anal sphincters and the levator ani muscles They fail to relax when defecation is attempted Descending perineum syndrome Abnormal descent and bulging of the perineum associated with defecation

13. Useful Definitions Constipation Defecating twice or less a week Functional (non-pathological ) constipation is defined as including two or more of the following symptoms for at least 12 weeks in the last 12 months: Straining in >1/4 defecations Lumpy or hard stools in >1/4 defecations Sensation of incomplete evacuation in >1/4 evacuations Sensation of anorectal obstruction/blockade in >1/4 defaecations Manual manoeuvres to facilitate >1/4 defaecations < 3 defaecations per week

14. Dyschezia Difficulty with rectal evacuation Resulting from a long period of voluntary suppression of the urge to defaecate , and a distended rectum Fecal incontinence The involuntary loss of liquid or solid per anus Mega colon An abnormal massive dilation of the colon May be congenital, toxic or acquired ( Trypanosoma cruzi )

15. Megarectum An abnormal dilation of the rectum Paradoxical puborectalis contraction A problem of the puborectalis muscle failing to relax to allow defaecation Paradoxical anal sphincter contraction A problem of the anal sphincter failing to relax to allow defaecation Passive soiling Losing stool or liquid per anus without feeling the urge to defaecate

16. Proctalgia fugax Sudden severe pain affecting the rectum lasting anything from minutes to hours Pelvic floor dyssynergia Uncoordinated pelvic floor muscle activity

17. Factors Contributing to Difficulties in Defaecation Abnormal defaecation techniques: An uncoordinated defaecation pattern Any inhibition about sitting on toilet seats can contribute Women with a rectocoele ( rectum sags and bulges into the vagina ) often use digital posterior vaginal wall pressure to give support and assist rectal emptying Assist emptying by extracting stool with their fingers per anus

18. Factors Contributing to Difficulties in Defaecation Eating disorders Anorectal abnormalities have been shown in patients with anorexia nervosa complaining of constipation Delayed colonic transit time ( 59 hours ) was probably due to their abnormal eating habits Food and drink Insufficient fluid intake has been suggested as a possible contributory cause to constipation

19. Ignoring the call to stool/workplace constipation Continuously ignore the call to stool and delay defaecation over long periods of time making constipation more likely Irritable bowel syndrome People with IBS can be divided into: Spastic constipation having abdominal pain related to bowel spasm Diarrhoea complaining of stool frequency without abdominal pain

20. Megacolon and megarectum In megacolon the dilated segment shows normal phasic contractility but decreased colonic tone With megarectum , increased rectal compliance with a maximal tolerable volume Menstruation Neurological conditions Alteration to the normal somatic or autonomic control of the colorectal tract is going to have some effect on normal bowel activity

21. Pain associated with anal fissure An anal fissure is a split or tear in the lining of the lowest part of the anal canal May be caused by severe constipation or childbirth The fissure is stretched while opening the bowel provoking acute pain and therefore causing great anxiety each time

22. Pregnancy and postpartum Constipation and a feeling of bloating are common complaints of pregnancy . Decrease colonic peristalsis owing to the effect of progesterone on the smooth muscle of the gut An increase in water absorption due to increased levels of aldosterone and angiotensin Decrease in physical activity can affect colonic activity

23. Prolapse A rectocoele is a herniation of the anterior rectal wall and the posterior vaginal wall into the vagina May be associated with anterior vaginal wall defects or enterocoele , or both Constipation and straining at stool has been thought to be a contributory factor to the formation of a rectocoele

24. Psychiatric disorders Anticholinergic medication to treat the depression can slow the transit time in the gut The elderly Multifactorial Anticholinergic drugs Opiate analgesia Iron supplements Calcium channel antagonists NSAIDs Immobility Parkinson’s disease, diabetes mellitus Low fluid intake Low dietary fibre intake Depression and other psychological problems Hypothyroidism

25. Feeling of incomplete emptying Abdominal cramping Pain Bloating Perineal pain Nausea Headache Skin problems General malaise Haemorrhoids Consequences of Constipation

26. Asbury & White (2001) state that increasing stress can cause many other symptoms: Physical symptoms Muscle tension Palpitations A churning stomach Fatigue Emotional symptoms Irritability Worry and less enthusiasm for life Cognitive symptoms Poor concentration Memory changes Behavioural symptoms Lethargy Poor sleep

27. Factors Contributing to Anal Incontinence Age Resting anal closure pressure and maximum squeeze pressure decline with age. Increase in perineal descent at rest, which would increase the anorectal angle, and a slowed pudendal nerve conduction rate.

28. Factors Contributing to Anal Incontinence Anal Sphincter Dysfunction Damage to the external sphincter tends to present as urgency or urge incontinence Anal sphincter dysfunction may also result from nerve damage or cumulative stretching Childbirth Surgery Accidents Trauma Habitual chronic straining at the stool

29. Factors Contributing to Anal Incontinence Liquid Stool Diarrhoea is the term used to describe very frequent bowel evacuation or the passage of very loose watery, poorly formed stools, or both. Functional Faecal Incontinence Faecal incontinence resulting from failure to reach an appropriate place to defaecate in time

30. Physiotherapy Assessment of Faecal Incontinence & Bowel Dysfunction History: What patients perceive the problem to be? How long they have had the problem? Any predisposing event The symptoms have changed over time Do they ever pass blood or see blood or mucus in their stools? Do they ever have pain before or during opening their bowels? How often do they open their bowels and have there been any recent changes? What is the stool consistency (use the Bristol stool chart)? Have they any symptoms of faecal urgency and for how long are they able to defer? Are they having any faecal loss, is it liquid or solid and are they aware of it happening; how often is it happening and how much is lost? In what circumstances do they experience the loss? Etc.

31. Physiotherapy Assessment of Faecal Incontinence & Bowel Dysfunction Physical Examination Commence with observation of the patient’s gait and posture. Inspection of the lower back may reveal evidence of spina bifida occulta which could be associated with neurological deficit. An abdominal examination should be undertaken with the patient in supine lying to detect any surgical incisions and the presence of any abnormal masses.

32. Physiotherapy Assessment of Faecal Incontinence & Bowel Dysfunction A neurological assessment: S4 dermatome by testing the perianal region S3 dermatome is checked by sensory testing of the upper two-thirds of the inner surface of the thigh S2 by checking of the lateral surface of the buttock, lateral thigh, posterior calf and plantar heel Check the appropriate myotomes : Hip flexors (L2–L3) Adductors (L2–L4) Peronei / Tibialis anterior (L4–L5, S1) Gluteus medius and minimus (L4–L5, S1) Gluteus maximus (L5, S1–S3) Gastrocnemius and soleus (S1–S2) Toe abductors (S3)

33. Anorectal Examination

34. Investigations Anorectal manometry : Anorectal manometry is a noninvasive procedure to evaluate the function of the rectal and anal muscles. Resting anal canal pressure Anal canal squeeze pressure – both peak and duration Anal canal pressure in response to coughs Anal canal pressure in response to attempts to defaecate Simulated defaecation in response to balloon distension Compliance of rectum in response to balloon distension Sensory thresholds in response to balloon distention

35. Investigations Colonic transit studies Carried out by the ingestion of radio-opaque different-shaped and different-sized markers on different days, followed by abdominal X-rays on several days afterwards to track the markers’ progression. Concentric needle EMG Determine the amount of activity in about 20 motor units in the vicinity of its tip in the EAS and puborectalis during an active contraction, at rest and on bearing down

36. Investigations Defaecating proctogram The barium paste is introduced rectally and the evacuation observed during radiography. It can be used to assess: Anorectal angle Descent of the pelvic floor and prolapse Endoanal ultrasonography (EAUS) The 360° rotating ultrasound transducer is placed in the anal canal and is used to gain an image of the subepithelium and both the IAS and EAS. Detect any damage to the sphincters.

37. Investigations Magnetic resonance imaging (MRI) Provides high-resolution images in multiple planes and may be used to evaluate the pelvic floor. Pudendal nerve terminal motor latency (PNTML) Device is placed intra-rectally with its tip directed to the pudendal nerve where it travels around the ischial spine on one side or the other. Two electrodes on the device, one at its tip and one at the level of the anal sphincter. Current is passed through the tip electrode and a measurement taken at the other electrode where it detects activity in the anal sphincter.

38. Investigations Real-time ultrasound Enable to observe: The cranioventral direction of bladder neck movement during PFM contraction The movement of the puborectalis on contraction and bearing down Strength duration curves

39. Treatment for Bowel & Anorectal Dysfunction Diet: Soluble and insoluble fibre should be part of a well-balanced diet. Prebiotics are non-digestible carbohydrates that stimulate the growth of desirable bacteria in the gut. Bananas Asparagus Garlic Wheat Tomatoes Onions etc. Probiotics are supplements of ‘friendly’ bacteria, help the colonic bacteria to maintain normal digestion. Live bacteria added to foods, drinks and yogurts Bio yogurts etc. Recommended that approximately 1.5 litres (3 pints) of fluid a day

40. Treatment for Bowel & Anorectal Dysfunction Bowel Retraining: Retrained by a regular healthy diet and toileting 20–30 minutes after a meal or warm drink, to utilize the gastro colic response. Medication: Some form of medication manipulates the stool consistency that is easier to contain and to expel, also perhaps to stimulate increased peristalsis.

41. Treatment for Bowel & Anorectal Dysfunction Medication for Constipation: Bulking agents: Absorb water and increase the bulk and weight of the stool Include: Ispaghula husk Sterculia Stimulants: Stimulate peristalsis Include: Senna Bisacodyl Docusate sodium Glycerol suppositories Sodium picosulphate

42. Treatment for Bowel & Anorectal Dysfunction Medication for Constipation: Osmotic laxatives: Reduce the absorption of water from the bowel Stool softens, increases its bulk and stimulates peristalsis Include: Lactulose Polyethylene glycol Faecal softeners: Lubricate and soften the stool Include: Arachis oil Docusate sodium

43. Treatment for Bowel & Anorectal Dysfunction Medication for Feacal Incontinence: Antimotility drugs: Reduce peristalsis and gastrointestinal motility by stimulating the opioid receptors in the bowel Include: Loperamide (Imodium) Codeine phosphate Absorbents: Absorb water without increasing stool bulk, making the stool firmer and smaller .

44. Treatment for Bowel & Anorectal Dysfunction Medication for Feacal Incontinence: Antispasmodics: Bowel motility is decreased by a reduction of the peristalsis taking place by blocking acetylcholine from binging to their receptors Topical agents: Application of 10% phenylephrine gel to the anus produces a significant rise in the resting anal pressure in healthy human volunteers ( Carapeti et al 1999) Oestrogen replacement therapy: A possible benefit of oestrogen replacement for this group of women (Donnelly et al 1997)

45. Treatment for Bowel & Anorectal Dysfunction Physiotherapy: Defaecation technique Sitting on a chair Feet supported on a footstool of approximately 15 cm with heels raised Hips flexed to more than 90° The weight of the upper trunk supported on the forearms, resting on the abducted thighs Neutral spinal curves. The action was then described as: Lateral bracing with brief 1–2 second holds and sustained 10–20-seconds holds Anal release facilitated by lower abdominal bulging Practice of the combination of bracing and bulging .

46. Treatment for Bowel & Anorectal Dysfunction Anal sphincter exercise Biofeedback: T herapy used to help children who cannot always have a bowel movement when they need to. Massage Stroking from the stomach to the groin to encourage initial relaxation When relaxation is felt, effleurage along the colon starting in the right iliac fossa and then travelling along the ascending, transverse and descending sections of colon Following the effleurage strokes by circular kneeding along the line of the colon in the same direction as previously More effleurage as previously Side-to-side stroking across the abdominal wall

47. Treatment for Bowel & Anorectal Dysfunction Neuromuscular stimulation Anal cones and plugs

48. Biofeedback