Following low anterior resection (LAR), around 90% of patients generate anorectal dysfunction. Particularly fecal incontinence significantly affects the patient's physical, psychological, social, and emotional functioning. Unfortunately, there is no standardized treatment for this. Typical treatment recently concentrated on symptom relief, consisting of lifestyle advice and pharmacotherapy with bulking agents or antidiarrheal medication.
Other options include pelvic floor rehabilitation; it is a better treatment option for fecal incontinence with a success rate. But there is no proof of the usage of PFR after low anterior resection. The pelvis is the bony structure between the legs and spine. The pelvic floor is the set of muscles that create the base of the pelvis. A ligament is a powerful band of tissue that keeps joints together or the place where two bones join.
The pelvic floor muscles:
What Is Pelvic Floor Rehabilitation?
There are four modalities of pelvic floor rehabilitation.
Pelvic Floor Muscle Training:
This includes raising the highest strength of contraction of the muscle and enhancing the coordination of contraction of the pelvic floor muscle. Patients will start the intervention trajectory within three months after lower anterior resection or after six weeks of the closure of the stoma. For three months, the patient will undergo 12 treatment sessions every week. 45 minutes in the first session and 30-35 minutes in the following session. In every therapy, the physiotherapist will finish a case report.
This case form collects all reports involving pelvic floor muscle training, biofeedback, electrostimulation, peri-anal examination, and digital rectal examination. Digital rectal examination of pelvic floor functionality will be utilized to evaluate the capacity to intentionally contract the pelvic floor muscles and quantify the strength of the contraction. Medication use according to the standard treatment will also be reported in the case report form. A physiotherapist about pelvic floor exercises instructs all patients. In addition, they were instructed on how to do the exercise. The patients will be considered to develop voluntary contractions of the puborectal muscle and the external anal sphincter and how to relax these muscles to avoid co-contractions of other muscles.
The pelvic floor has to meet all the necessities of maximal strength, advancement of the time of the strength, and progression in timing and coordination of the contraction. Also, patients are trained to do certain pelvic floor exercises at home at a fixed time, that is, three times a day. A better outcome of pelvic floor rehabilitation depends on patients' motivation, willingness, and self-motivation toward home exercises.
Biofeedback: It is a behavioristic therapy that permits the patient to become mindful of the contraction and relaxation of the pelvic floor muscles and utilizes an anal electromyography probe. It is a cognitive behavioral intervention therapeutically. It is done during pelvic floor rehabilitation, which supports the patient in monitoring the functioning of the pelvic floor.
Biofeedback provides an understanding of the action of the pelvic floor and shows immediate patient feedback during exercises. Biofeedback, if obtainable at the local PFR clinic, be executed by anal electromyography (EMG) probe, with twenty-four sensory points located at six different heights and four different directions along the probe.
The MAPLe system is validated for its purpose, and the assigned physiotherapists are professional users. If this MAPLe system is not available in the participating PFR clinic, the Anuprobe anal probe is permitted to achieve the intervention. Biofeedback will be conducted during all pelvic floor rehabilitation sessions.
Electrostimulation: It can enhance the effectiveness of the contraction power of the pelvic floor muscles and utilizes the exact anal electromyography probe as utilized for biofeedback. It is used to obtain the strength and effectiveness of contractions on the pelvic floor. This is done when contractions cannot be observed or palpable; electrostimulation is used to train pelvic floor muscles and donate to adequate power of contraction. Electrostimulation is performed during all pelvic floor rehabilitation sessions, and biofeedback using the same anal probe.
Training With a Rectal Balloon: It is a process that mimics the urgency to defecate and allows the patients to prepare to retain stool and retain a bigger stool in the rectum. Rectal balloon training is done to stimulate the defecation need. During training, a rectal balloon, usually Ashley's rectal balloon, is inserted into the neorectum, the remaining part of the rectum, and the distal colon.
After this, the balloon is slowly inflated using a syringe that is connected to the balloon. Patients are asked to pay attention to their filling sensation at the rectus. Once a strong sensation of defecation is obtained, an adequate contraction of the sphincter and puborectalis muscle must be delivered to keep the balloon.
Patients should be conscious that their neorectum can adapt to fecal content; thus, after a period of pelvic contraction or active sphincter contraction, the urge for defecation will reduce and will strengthen their confidence in fecal continence. Training in a rectal balloon helps to control the fear of fecal incontinence and allows patients to tolerate a greater volume of stool in the neorectum.
Rectal balloon training is only when patients' maximum pelvic floor function is recovered. During the last session, pelvic floor rehabilitation is combined with biofeedback. Pelvic floor physiotherapists do these interventions. Both hospital-based and private clinic-based doctors are selected accordingly.
What Are the Co-Interventions or Additional Treatments Done in Pelvic Floor Rehabilitation?
In cases of severe fecal incontinence, colon irrigation or permanent colostomy is done. These procedures are done when the standard treatment for fecal incontinence is not found to be effective or does not reduce the severity of fecal incontinence or diarrhea. Diarrhea inhibitors- loperamide derivatives are prescribed if diarrhea is present after low anterior resection or if it causes the severity of fecal incontinence.
There are not many benefits of pelvic floor rehabilitation in all patients, but certain subgroups of patients are benefitted from pelvic floor rehabilitation in various studies. They include patients with urgency or moderate incontinence or no near-complete incontinence. A selective referral policy is recommended to enhance postoperative functional results for patients after low anterior resection for rectal cancer.