Incorporating Pelvic Floor Physical Therapy in the Treatment of Obstructed Defecation Syndrome and Posterior Compartment Pelvic Organ and Rectal Prolapse

Referral Process

1. In patients with ODS, prompt referral to a properly trained PFPT is recommended after exclusion of other pathologies or impediments to active participation in therapy.
PFPTs are clinicians with expertise in the role of the musculoskeletal component on defecatory symptoms. Pelvic floor PT involves examination and manipulation of the rectum and/or vagina by a trained physical therapist. Internal examination is necessary for pelvic floor PT work.

Suspicion of a diagnosis of musculoskeletal involvement is based on the assessment of the clinician and maybe based on a combination of reported symptoms, examination findings, and results of diagnostic testing. [7]There is no specific or unique examination finding or diagnostic test result that determines on its own whether referral to PT is appropriate for patients with symptoms of ODS, with or without posterior compartment prolapse. Referrals should be considered after appropriate screening for contraindications such as undiagnosed malignancy, and physical, psychological, or cognitive barriers to active participation in therapy.

Referral to a PFPT requires a reasonable understanding of the goals of treatment by the patient and the referring provider. Referring clinicians should include a plan for follow-up with the patient to assess progress toward these goals and to determine the need for any additional interventions based on the outcome of the pelvic floor PT program. Referring providers should provide pertinent clinical information to the PFPT, but they should also expect physical therapists to make their own assessment and plans for care based on their expert assessments. The group established that there is no minimum information needed by the PFPT apart from the patient’s complaint and relevant clinical examination findings. However, details of any diagnostic testing (eg, manometry, defecography) may be helpful to the PFPT, especially in the case of re-referrals after a prior pelvic floor PT failure. [7]Referrals requesting “evaluation and treatment” were noted to be more useful and flexible to the physical therapist than referrals specifying treatment modalities (eg, referral for “biofeedback”).

2. Local availability of PFPTs knowledgeable in bowel dysfunction may impact early pelvic floor PT referrals for some clinicians and patients. Advanced training in the treatment of bowel disorders is necessary for PFPTs to appropriately treat patients with ODS, whether posterior compartment prolapse is present or not. There are no uniform requirements across PT graduate school curricula or postgraduate certification for the treatment of bowel disorders, so PFPT expertise in treating defecatory dysfunction can vary widely. This variety can create challenges for referring providers to identify a PFPT with the appropriate skill set to treat these disorders and for patients to access them in a timely manner. Variations in PT training and privileging were noted on the basis of country and continent.

Only 20% to 48% of patients referred for pelvic floor PT in the setting of defecatory dysfunction and/or high tone pelvic floor disorders will initiate therapy and complete their program. [8][9][10] Multiple barriers are reported by patients, with cost being the most frequently cited. However, inconvenience, limited access, and/or travel distance are the next most commonly reported challenges to completing a prescribed pelvic floor PT program. [10],[11][12]

Geographic access to an appropriately trained PFPT may be challenging for patients with bowel dysfunction, even when providers with general training in pelvic health are accessible. Although limited evidence produced since the COVID pandemic suggests that telehealth may have some utility in mitigating these challenges, the majority of patients treated by PFPTs using telehealth still preferred some in-person visits. [13]

There are opportunities to expand or standardize bowel dysfunction training at the postgraduate level or during PFPT training. This would improve access and help referring providers more easily identify local PFPTs with appropriate expertise.

In practice settings where access to PFPTs with bowelspecific training is limited or uncertain, it may be appropriate to await the results of diagnostic testing to prioritize referrals and guide patients to the most appropriate available care. Active discussion between referring providers and PFPTs regarding local expertise and available services may help inform optimal referral practices and timing.

Role of Testing and Imaging in Relationship to Pelvic Floor PT Evaluation and Treatment

3. A formal diagnosis of ODS by rectal testing and imaging is not necessary for a patient to undergo an initial pelvic floor PT evaluation for symptoms of defecatory dysfunction. Early involvement of properly trained PFPTs is beneficial for patients. [14][15][16]Results of testing should not be taken in isolation from the holistic care of the patient and should not delay referral. Most patients undergo several investigations during the diagnostic phase of their evaluation, including anorectal manometry (ARM), rectal sensation test, balloon expulsion testing (BET), and dynamic imaging. Digital rectal examination (DRE) has high diagnostic accuracy when performed by experienced examiners and can be useful in predicting dyssynergic defecation (DD) in the absence of other diagnostic testing. One study of 218 patients meeting Rome IV criteria for functional constipation found that DRE had high sensitivity (71.3%) and specificity (76.1%) for diagnosing DD, which was similar to the diagnostic accuracy of highresolution ARM in their meta-analysis.[17] However, another study evaluating the rates of performance and diagnostic accuracy of DRE by providers at a tertiary care center ordering ARM testing demonstrated only 42.3% of patients had a DRE performed by the ordering provider, and when performed, sensitivity of DRE ranged widely by the experience and training of the examiner (25.0% for non-GI specialists vs 82.6% for gastroenterology faculty). [18]Testing provides supplementary data that may not be able to be gathered on clinical examination. [19],[20]Whether testing results affect specific pelvic floor PT protocols and outcomes across practice settings is unknown and needs to be investigated.

4. Findings of anorectal function tests and dynamic imaging can serve as treatment targets for PFPTs and can optimize referrals to PFPTs in limited-resource settings or when there are long wait times for PFPT evaluation. Overall, there is insufficient evidence to provide consensus on how best to use diagnostic testing to guide a pelvic floor PT management plan or to predict its efficacy in treating ODS or posterior compartment prolapse, especially when it comes to practice outside an academic or research setting. However, some insights can be found in the literature for the most commonly used testing modalities.

Anorectal Manometry

ARM provides information on anal tone and contractility, anorectal coordination, and rectal sensation and helps stratify functional defecatory disorders (eg, obstructive defecation) from slow transit. [21][22][23]ARM helps to stratify the referral population for limited pelvic floor PT resources [24] and can also support indications for other treatments such as anal botulinum therapy. [25]The important parameters on ARM that predict outcomes with pelvic floor PT include anal squeeze pressure, endurance squeeze pressure, rectal pressure change during push, anal pressure change during push, and first sensation volume. [23],[24],[26],[27]The ability and motivation of the patient to participate in ARM predict the ability of the patient to participate in pelvic floor PT, [28] whereas a greater willingness to participate in biofeedback therapy independently predicts an improvement in global bowel satisfaction scores. [29]Although the improvement of anorectal parameters after pelvic floor PT has not been consistent in all trials, [30]in a recent meta-analysis of biofeedback therapies, 4 of 11 studies showed correction of dyssynergia in a total of 72% of patients; biofeedback therapy was superior to non–biofeedback therapy for resolution of dyssynergia (OR 9.43; 95% CI, 0.8–111.2; Z = 1.78; p < 0.00001; I²= 93%).[31]

Defecography

By identifying components of pelvic organ prolapse, fluoro- or MRI defecography may guide the scope of treatment and help define the type of impairment patients have. In addition to imaging components of pelvic organ prolapse, defecography can identify the presence of pelvic floor dyssynergia that may not be diagnosed by other methods of anorectal physiology testing. [32]By differentiating patients with obstructive defecation due to dyssynergia versus pelvic organ prolapse, defecography may identify patients with a poorer response to pelvic floor PT. Adusumilli et al noted that in 64 patients who were offered pelvic floor PT, the Patient Assessment of Constipation Symptoms score improved significantly (24 vs 19; p = 0.01) in patients with obstructed defecation without a highgrade rectal prolapse compared with no significant change (26 vs 25; p = 0.21) in patients with a high-grade rectalprolapse. [33]GI quality-of-life improved only in patients without a high-grade internal rectal prolapse. However, other studies have shown that rectocele size, contrast trapping, and the presence of internal prolapse do not appear to affect the success of biofeedback in treating obstructive defecation. [34][35][36]Components of anismus on defecography may also identify patients with a poorer response to pelvic floor PT. In 80 consecutive patients treated for DD, an increased anorectal angle during squeeze (p = 0.029) was found to be independently associated with a lack of response to biofeedback therapy. [37]

Balloon Expulsion Testing

BET is often performed in conjunction with ARM. It does not define the mechanism of disordered evacuation. [24] Although the inability to expel a balloon was associated with a lower successful response to pelvic floor PT in 2 studies, [37],[38]a prolonged BET has been shown to be able to independently predict success after biofeedback therapy. [29] Future prospective large-scale studies are needed to further assess the impact of BET on biofeedback success.

When access to PFPTs is limited, consider sending patients only after positive dyssynergia testing to reduce the wait times to see a qualified specialist. ARM has high sensitivity, but BET is more relevant as a single screening test for DD, especially in laxative-refractory chronically constipated patients when the availability of PT expertise is limited. [20]Test results before referral also allow for the opportunity for nonlocal qualified specialists to treat patients virtually for PT to expand access to care.

Pelvic Floor PT Treatment for Patients With Defecatory Symptoms

5. Pelvic floor PT treatment goals should be set with patients, tailoring the therapy plan to address underlying pathology, patient values, and ensuring collaboration with open multidisciplinary communication. Treatment plans should be individualized; pelvic floor PT programs are typically targeted to patient goals rather than to a specified duration, number of visits, or a prescribed sequence of modalities. A Cochrane Review of randomized trials using biofeedback for treatment of chronic idiopathic constipation in adults reported that for this PT modality alone, there was considerable variation in the number (5–14), frequency (daily to once every 2 wk), and duration (2 wk–3 mo) of sessions. [39]Our experts did not reach a consensus on a set number of pelvic floor PT visits. There was a general agreement reached that 4 to 6 treatment sessions are needed to see a change in symptoms. Reevaluation and additional diagnostic testing may be performed at the discretion of the treating providers, but this is unlikely to alter management until after at least 8 sessions.

6. Clinicians and PFPTs need to acknowledge the possibility of undisclosed trauma and treat everyone with a trauma-informed examination during their patient assessments.Patients with functional pelvic and GI disorders often have a history of trauma or sexual abuse, which may impact their treatment outcomes and their relationship with treating providers. Multiple studies have estimated the rate of patient-reported sexual or physical trauma in patients with GI functional disorders and/or pelvic dysfunction at 23% to 38%. [40],[41]However, half of patients with a history of sexual trauma have not disclosed this history with another family member, and one-third have not disclosed this history with anyone, [42]so patient-reported data almost certainly underestimates the prevalence. There is a 2-fold increased odds of pelvic floor dysfunction among those with a history of sexual violence versus nontraumatized controls. [40],[41]Sexual trauma is a negative prognostic indicator for outcomes of medical and surgical management of pelvic floor dysfunction. [40],[43]

Traumatic experiences can also occur in a medical setting and may involve illness, injury, pain, and frightening and/or distressing treatment experiences. Obstetric trauma from normal or instrumented vaginal delivery is associated with mechanical trauma of the levator complex in more than 30% of cases, resulting in future morbidity, including pelvic organ prolapse, urinary and fecal incontinence, and sexual dysfunction. [44]An estimated 20% to 33% of women report psychological trauma in the peripartum period, including anxiety about mode of delivery and postpartum complications. [44]The rate of anxiety disorders related to childbirth is reported at 16%, and the rate of posttraumatic stress disorder related to childbirth across multiple studies is 4%. [45],[46]

Clinicians should expand their definition of trauma to include sexual, birth/medical, and emotional trauma. Providers need to acknowledge that patients may not be comfortable sharing a trauma history. Given the intimate nature of pelvic floor examinations, trauma-informed care should be performed for all patients, and providers should emphasize the person’s agency and control over their body throughout the physical examination. Patients should be informed in advance that they can ask to stop the examination or pelvic floor PT session at any time. For patients with known or suspected trauma where testing could also be perceived as traumatic, referral to a PFPT is considered appropriate before ordering additional testing, such as ARM or defecography.

7. Pelvic floor PT bowel specialists use a multifaceted approach, tailored to the needs of the individual patient. Tools and techniques may involve patient education, habit training, instrumented biofeedback, noninstrumented biofeedback, and musculoskeletal therapy (Table 2). [47][48][49][50][51][52][53][54]Individualized pelvic floor PT sessions incorporate both patient education on lifestyle and tools. For example, the squatting stool is low risk, requires minimal instruction on correct use, and can assist with defecation by elevating the legs and improving the anorectal angle. [48],[49]Biofeedback is a best practice in the treatment of ODS, and its efficacy is supported by multiple randomized trials. [7],[39]Biofeedback is defined as a conditioning treatment in which typically unknown information about a bodily process is converted into simple visual, auditory, or tactile cues. Various forms of biofeedback can be used (surface electromyography, DRE, pressure sensors, abdominal or perineal ultrasonography, or simple visual feedback, such as a mirror) to deliver results through neuromuscular reeducation. Biofeedback approaches that use external devices, such as probes, are referred to as “instrumented,” whereas biofeedback delivered without the use of devices is “noninstrumented.” The decision on the type of biofeedback or other modalities to include is best made by the PFPT. There is insufficient evidence in the literature to support any specific biofeedback techniques over others for ODS and posterior compartment prolapse. [7],[39]

8. Patients who show benefit from manual therapy with a trained PFPT may benefit from home devices that simulate treatment. Patients should be provided with high-quality resources to continue practicing their PT exercises at home, and this option can also be offered to patients with limited access to PFPTs. Home devices and therapies can be recommended after evaluation by a knowledgeable clinician and with appropriate patient education on how to use them. An internal examination by an appropriately trained provider is recommended to inform the choice of device that best meets the patient’s needs. Limited data suggest that biofeedback devices and therapies for home use may provide benefit to some patients with ODS, but the devices used in these trials are not currently available for home purchase. [55],[56]Specific units and therapies should be recommended after evaluation by a knowledgeable therapist. If a patient is unable to undergo internal examination or findings are limited, data from appropriate diagnostic testing may also inform this choice.

9. Content that is “good” for patient education will be easy to understand, include graphics, be concise, and be accurate (for anatomy, physiology, procedure, and recommendations). It will also be easy to find and share. Education on lifestyle changes, behavioral modifications, and habit training can also be used to individualize patient care during pelvic floor PT. Characteristics of useful educational materials to augment the patient experience, and how to locate them, were considered. Although no studies on open-source materials specific to patients with defecatory disorders were identified, there are relevant studies in patient populations with other GI disorders, such as rectal prolapse and colorectal cancer. One study evaluating 12 online patient educational resources for colorectal cancer screening found that 83% were written beyond the recommended sixth-grade reading level. [57]A recent review also found that none of the patient-facing educational materials on the ASCRS website were accessible at the sixth- or seventh-grade reading levels recommended by the American Medical Association and the National Institutes of Health, respectively. [58]Patient-reported challenges to accessing helpful open-source materials on rectocele and rectal prolapse included finding appropriate content, navigating complex language, and concerns about source reliability. [59]Various educational resources were reviewed, including opensource videos, handouts, and other open-access websites. No single search criterion can be used to find the “best” open-source educational content due to the extensive variety of platforms and the variability in content that is beneficial for patient education. Patients may face multiple challenges when trying to find and access appropriate educational resources. Clinicians may wish to identify or create accurate, concise, and easily accessible resources relevant to their practices at an appropriate reading level and actively direct their patients to these materials.

10. Videos that contain accurate information and review defecation mechanics, pelvic floor muscle exercises, and general anatomy in a clear and concise manner are most valuable to clinicians treating pelvic floor disorders. There are very limited data on the use of video-based educational materials for the treatment of bowel dysfunction. One randomized trial in pediatric patients with bladder and bowel dysfunction demonstrated noninferiority of an animated training video when compared to standard urotherapy. [60]Another prospective trial evaluated the benefit of adding a video-based educational intervention to the treatment plan of 107 patients with irritable bowel syndrome, and it demonstrated a significant improvement in quality of life and depression scores compared with standard therapy alone. [61]There are no trials comparing video-based educational materials to written materials or other graphical formats with regard to outcomes of treatment for bowel dysfunction. Most studies evaluating video resources in patient care include patient-reported outcomes, with a prominent theme of anxiety reduction. [62]There is evidence to support the use of video-based resources to help prepare patients undergoing diagnostic procedures, although not for those specific to the diagnosis of defecatory dysfunction. A recent meta-analysis of 16 studies of educational videos used before diagnostic procedures demonstrated a reduction in patient anxiety and improved patient satisfaction in the majority of studies. [63] Due to the wide range of video-based resources available through open sources, which are intended for a variety of different audiences, patients may have difficulty locating resources geared to their needs. Clinicians wanting to provide video-based educational materials to patients with pelvic floor disorders may find that resources with these characteristics are most helpful in their practices.

sEMG = surface electromyography; DRE = digital rectal examination.

Pelvic Floor PT in the Setting of Rectocele/Posterior Vaginal Prolapse

11. Patients with posterior vaginal wall prolapse, symptoms of ODS, and increased pelvic floor muscle tone or dyssynergia should be treated with pelvic floor PT to address the high tone and pelvic floor coordination before rectocele surgery. Pelvic floor hypertonicity (PFH) or “non-neurogenic hypertonicity” is defined as increased contractile activity or passive stiffness of the pelvic floor muscles and can coexist with posterior vaginal wall prolapse and dyssynergia. [64]The prevalence ranges from 50% to 90%, and PFH is often associated with urological, gynecological, GI, sexual dysfunction, and chronic pelvic pain. [65]Pelvic floor PT in patients with PFH increases awareness and proprioception, improves muscle relaxation and elasticity, and was shown to be effective for chronic pain and dyspareunia in a systematic review. [66]Furthermore, patients with PFH, dyssynergia, and a posterior prolapse are less likely to benefit from early surgery than those with a weak pelvic floor. [34],[67][68][69][70][71][72]Pelvic floor PT is recommended to treat PFH and dyssynergia before considering rectocele repair.

12. Patients with symptoms of ODS, feelings of a bulge, and need to digitate in the setting of decreased pelvic floor muscle tone can be offered pelvic floor PT to address proper defecation mechanics either before or after rectocele surgery. Pelvic floor PT to address underlying musculoskeletal dysfunction should be considered for any patient with rectocele before considering surgery. [34],[67][68][69][70][71][72]In a Cochrane review update on the conservative management of pelvic organ prolapse, pelvic floor PT increased the chance of improvement in prolapse stage by 17% compared to no pelvic floor PT. [73]In a blinded randomized controlled trial comparing 59 women allocated to pelvic floor PT to 50 controls (no pelvic floor PT), posterior vaginal wall prolapse on Pelvic Organ Prolapse Quantification (POP-Q) System and incontinence to flatus (54% vs 90%; relative risk 0.60; 95% CI, 0.39–0.92) and loose fecal incontinence (36% vs 100%; relative risk 0.38; 95% CI, 0.20–0.76) improved after pelvic floor PT. [74]For women who demonstrate average or diminished pelvic floor tone, pelvic floor PT can be performed either before or after surgical intervention.

Pelvic Floor PT in the Setting of Internal and External Rectal Prolapse

13. Timely surgery is recommended as first-line treatment for external prolapse (procidentia). Pelvic floor PT should be considered postoperatively for patients with persistent symptoms. Preoperative PT can be considered if it does not delay the time to surgery. Patients with external prolapse (procidentia) are likely to benefit from surgical intervention. Surgical intervention for external prolapse improves patients’ quality of life, regardless of the surgical approach used. [75]Appropriate timing and surgical approach are left to the judgment of the provider. Some patients may benefit from pelvic floor PT before surgical intervention, although evidence-based selection criteria have not been elucidated. Without surgical correction, patients with external rectal prolapse are likely to develop worsening fecal incontinence over time. [76] Studies evaluating the efficacy of pre- and postoperative pelvic floor PT for patients undergoing surgery for external rectal prolapse have demonstrated improvement in external anal sphincter function and incontinence symptoms but not internal anal sphincter or resting sphincter tone. [77],[78]

Although surgical correction of external rectal prolapse (procidentia) benefits patients’ quality of life and may prevent or improve incontinence symptoms, surgery does not consistently improve symptoms of constipation or DD. [79],[80]One retrospective review of 19 patients showed reduction of prolapse does not correct dyssynergia on manometry when compared before and after surgery.[81]

In the consensus discussion, patients with significant dyssynergia and preserved sphincter and/or puborectalis tone were thought to have more potential benefit from preoperative pelvic floor PT than those with poor or absent tone. In patients with preserved tone, the time required for a preoperative pelvic floor PT program may not represent a delay to surgery. Postoperatively, persistent abnormal bowel symptoms or examination findings suggestive of ongoing musculoskeletal dysfunction (incontinence, incomplete defecation) should prompt consideration for pelvic floor PT referral.

14. In patients with high-grade intussusception and symptoms of ODS, pelvic floor PT should be offered before considering surgery. If the patient’s symptoms persist after the initial pelvic floor PT program is complete and surgery is performed, pelvic floor PT also should be considered postoperatively ("the sandwich approach"). High-grade internal prolapse is defined as intussusception descending to the level of the anal canal or below (intraanal, grades III–IV per the Oxford Rectal Prolapse Grade radiographic scale), and low-grade prolapse is defined as descending within the rectum proximal to the anal canal (intrarectal, grades I–II per the Oxford scale). [82] Available evidence demonstrates that in the setting of internal rectal prolapse/intussusception, most patients will benefit from pelvic floor PT regardless of grade. [35],[83],[84]One retrospective review of prospectively collected data, including 61 patients with low- and high-grade internal prolapse, demonstrated improvement in fecal incontinence and ODS scores with biofeedback therapy in both groups. [83] However, a similar study of 120 patients failed to demonstrate a significant benefit for pelvic floor training in the subgroup of patients with high-grade internal rectal prolapse. [33]Other studies have demonstrated a potential benefit for surgery in patients with high-grade internal prolapse who have failed to meet treatment goals with pelvic floor PT and medical management. [33],[85]Due to the lower risk of pelvic floor PT interventions and the prospect of benefit with or without surgery, it is recommended that these be offered before considering surgery for high-grade internal rectal prolapse.

15. Patients with low-grade intussusception and patients with solitary rectal ulcer syndrome should be treated with pelvic floor PT with a therapist trained in bowel management. PT may be combined with other medical treatment options. Surgery is strongly discouraged in these patients unless all other therapies have failed. Patients with low-grade internal rectal prolapse benefit from pelvic floor PT. Few studies stratify patients by grade of internal prolapse, but those that do suggest a greater potential for improvement with pelvic floor PT than with surgery in patients with low-grade internal rectal prolapse. One study evaluating prospectively collected outcomes of pelvic floor training demonstrated a statistically significant improvement in Patient Assessment of Constipation Symptoms and GI Quality-of-Life scores in the subgroup of 24 patients with low-grade internal prolapse. [33]Another study that included 22 patients with low-grade internal prolapse demonstrated a statistically significant reduction in the Cleveland Clinic Constipation Score with pelvic floor training in this subgroup. [83]Conversely, patients with low-grade internal rectal prolapse, including those with solitary rectal ulcer syndrome, do not appear to benefit from surgical intervention. [33],[86],[87]If surgery is offered as a last resort after failure of all other options, appropriate expectations should be set with the patient that the potential benefit of surgery is uncertain, and such potential benefits must be weighed against the risks.