We're going to keep moving forward and skipping the break for time reasons. Our next speaker is Dr. Megan Barrett-Engler from Roche University Medical Center in Chicago. She's going to be talking to us about pelvic floor dysfunction, associated anorectal complications, and endoscopic management. Megan? Hello, everybody. My name's Megan Barrett-Engler. Again, I'm at Roche University Medical Center. I'm very honored to be able to give you a little TED Talk today. I too thought I'd be walking around the stage for a TED Talk, but we'll see how this goes. I have no disclosures for you today. I want to start off by welcoming you to my clinic. I have a feeling a lot of you probably have similar clinics and hear similar things. I'm not going to be talking about all the fancy new technology and kind of bringing us back to some fundamentals that we may not be talking about or thinking about very much. Things that I hear in my clinic, Dr. Engler, I feel so full. No matter what I'm doing, I just feel full. Or I'm sitting on the toilet and I cannot push it out. I'm sitting there, I'm sitting there, I can't get it out. Or I'm pooping, but there's still something there. Also I hear there's just something blocking it. You have to check. Something is blocking how this poop is leaving me. Other things that you'll hear, the more that you talk to some of your patients is, I have to move like this, I have to press here, and they might point to their perineum or in their suprapubic region. They may talk about having to put their finger within their vagina to push backwards to get that stool out. These are all little things that you can get clues from your patients when you're talking to them. Or your classic, it hurts when I have a bowel movement, it feels like glass whenever I poop. I'm nervous now to have that bowel movement. And so yes, this can be constipation, but an important thing for all of us to think about too is pelvic floor dysfunction. So why am I talking about pelvic floor dysfunction and really what is it? So pelvic floor dysfunction is much more common than I think a lot of us are aware of. 25% of females have some sort of pelvic floor dysfunction. And then as you get older, so 50s, 60s, it's an even higher proportion of that population. And it's not just females, it's males as well. So you have 10% to 19% of males that can struggle with some pelvic floor dysfunction as well. And what it is, it's a broad category of different conditions that can occur when there's an issue with, I describe it as like the bowl of support. And so there's a bowl of support of different connective tissue and muscles that are all keeping up our organs. So the prostate in males, the vagina and the uterus in females, the bladder, the anal-rectal area in the GI tract. And the pelvic floor consists of endopelvic fascia, perineal membranes, lots of different muscles, but most importantly, the levator ani muscles. And just to review, because I think a lot of us may have forgotten what those were, is your pubococcygeus, your iliococcygeus, and most importantly is the puborectalis muscle. What the puborectalis muscle does, it creates that sling that accentuates that anal-rectal angle for the patients. And it's really important in bowel control. And so when there's an issue with the puborectalis muscle or issue with the sphincters, you have a lot of issues with bowel function and can have a lot of issues for our patients. We can think about pelvic floor dysfunctions in the anterior and the posterior compartments, although a lot of times these are all interrelated. So anterior compartments, you think of more the urogynecological issues. So you have difficulty with urination. You have systoceles, vaginal uterine prolapse. But then for us, the posterior is going to be more dysinergic defecation. So this is really important and something my fellows hear me talk about a lot in clinic. But this is uncoordinated muscles when you're pooping. So for whatever reason, the muscles have retrained themselves and we're not effectively getting those bowel movements out, can result in a lot of backup complications from that. You can get rectal prolapse. So again, when there's injury to the pelvic floor or there's this repetitive straining, you get weakness in the fibers that are holding the rectum and eventually can lead to mucosal lapse and then full rectal prolapse can come out of the anal canal. Patients complain about mucus, about blood, about pain. And then if it's big enough, they actually can get like obstructive type symptoms from that. Rectocele, so weakness in the lining of the rectum, the little pockets where stool can get stuck. We actually think more of like three centimeters as being most clinically significant. Fecal incontinence, so this can be pretty troublesome, especially in our older female population. Again, thinking about that puborectalis muscle strength and that sphincter sphinct to helping with that. And then you have pelvic pain as well. So whenever I talk about pelvic floor dysfunction, I love talking about how we defecate. I know it's a really interesting topic when we're eating lunch today. But when we're talking about defecation, most of us don't think about how we do it, right? We go and sit on the toilet and we have a bowel movement. But it's important for us as GI clinicians to understand what are all those processes that have to all come together for it to work well. And I think it's fascinating all the things that can work together to do it. So what happens, again, is you have that stool that gets to the rectum, you have these stretch receptors, sends a signal to the brain, you get those giant migraine encompasses to push that stool down towards the rectum. And then you have the smooth muscle of the internal anal sphincter relaxing. If it's not an appropriate time, ideally, that external anal sphincter is contracting, so preventing that fecal incontinence. So again, if that's too weak, it's not going to hold that stool back. Big issue for our patients. If it is an appropriate time, you relax that anal sphincter. So we're opening that door, is the way I like to describe it, so that stool can come out easier. You want to relax that puborectalis muscle that I talked about. Again, that sling that's making that angle, that anal rectal angle, when that relaxes, it straightens it. So the path of least resistance, again, decreasing that stress, decreasing that strain in the anal rectal angle so that stool can pass easier. And the other thing that needs to happen, you need descent of the pelvic floor and increase intra-abdominal pressure by contracting your abdominal muscles and your diaphragm. So again, several different components that are all helping you have that appropriate aboundment, helping you have decreased pressure in the anal rectal angle. Now when you have uncoordinated muscles, so specifically dysenergic defecation, you get really hard to treat constipation, increased pressure in this area, risk of increased injury as well to the anal rectal area. About a third of your constipation patients can struggle with dysenergic defecation. So again, a lot of your patients, so important to be thinking about these steps for these patients to help treat them appropriately. So what are some anal rectal complications of pelvic floor dysfunction? Now there's several different things, and I know these things that are listed are common, even patients without pelvic floor dysfunction. But these are things that you'll see in these patients particularly. When I think about the endoscopic approach to them, I always tell my fellows and anyone who works with me, before you even put the scope in, the most important part is that physical exam, actually. So getting a good physical exam with the lights on, looking at the anal rectum, looking for those fissures, the health of the skin, those hemorrhoids, how the tone of the sphincters are as well are all really important. So even before that scope goes in, doing that good physical exam is important for this type of patient. So the first one to talk about, solitary rectal ulcer syndrome. So this is not very common. So it's a one in 100,000 is one of the estimates. One of the reasons why is it may be underrecognized. It has a wide range of presentations. Endoscopically, you can see it from just redness within the rectum. You can see polypoid lesions, and then you can see ulcers as well. The ulcers a lot of times can be that firm base with the white heaped up edges. Usually these changes are going to be more on the anterior wall of the rectum, and then about 3 to 10 centimeters proximal from the anal verge. There's several theories as to why patients get this. Some of the thoughts are direct trauma to the area, others are local ischemia. And particularly studies show that patients with pelvic floor dysfunction are at higher risk of this local ischemia. Uncoordinated muscles, inappropriate contraction of various muscles can all lead to ischemia to that anterior wall. The other thing that you can see is with the rectal prolapse, a repeated mucosal injury, you get venous congestion and edema, and then again ischemia, again, that can all cause injury to the rectum, especially that anterior rectal wall. So the ways that we treat this, actually the number one thing is behavioral modifications. With anything with pelvic floor, it's behavioral modifications. Pelvic floor physical therapy with biofeedback has been shown to have the greatest success in long-term treatment of the solitary rectal ulcer syndrome. And so you want them to be pooping the right way, retraining those muscles, keeping those knees elevated actually makes that angle where that puborectalis muscle was, again, straightens it so it passes easier, again, reducing that stress and straining down in the anal rectal area, loosening that stool. Topical therapies, there's lots of different topical therapies, so topical sulcrophates, salicylates, glucocorticoids, 5-SAs are all possible treatments of this. Yeah, it usually takes weeks to months to treat. And then if those are still resistant, a lot of times these patients have to go to surgery, but some studies show that you could consider APC for these ulcers, the resistant ulcers. The thought process is that it causes squamous regeneration and re-epithelialization to try to help. So again, if there's anything that you can try to try to help prevent surgery, I think it's worth in some of these patients. Next, anal fissures. So again, very common, a lot of us see these in our clinics, right? So it's not just pelvic floor patients that have this, but pelvic floor patients particularly are at risk of the recurrent fissures and those chronic fissures. The reason why, again, when we go back to the beginning of this talk, talking about how are they defecating, how is the poop coming out? If we're not retraining those muscles so we're not inappropriately contracting, inappropriately having that pressure down in our bottom, you're increasing that risk of injury to the anal rectal area. And so what those anal fissures are, again, it's that linear tear in the dermal lining, just distal to the dentate line. And some of these chronic fissures, you can see the hypertrophied anal papillae or those sentinel skin tags as well as just as signals as to the chronicity of it and where those are. Most are going to be located in the posterior midline, although 25% of females can have an anterior midline. If you start seeing those lateral, obviously you want to think about other conditions as well. Treatments for this, again, behavior modification is actually number one, two, and three, just like with everything with pelvic floor. So pelvic floor physical therapy, retraining how you poop, keeping those knees elevated, a soft stool can all help, sitz baths can help as well with anal fissures. And then helping with the spasms, so aiming to help prevent spasms, helps improve the bub flow to the area so that it can heal better. So topical calcium channabifos, topical nitrates are all your classic medical therapies that you can use. This usually takes several weeks as well to heal. And if that's still resistant, we can consider botulinum toxin as endoscopist. Usually an endoscopy can help us better actually see these fissures. What you can do is you palpate that internal anal sphincter using about 20 to 25 units of botulinum toxin, injecting on either side of that fissure. What that's going to do, again, it paralyzes that muscle, decreasing the spasm, improving that blood flow to that area to allow that to heal. Again though, remember you want to make sure these patients are still modifying how they're having a bowel movement because there is a good recurrence even with botulinum toxin. And then if that fails, surgery. The last one just to talk about hemorrhoids. Very common in our population, right, I think 75% of people in the U.S. I think I saw suffer from some sort of hemorrhoids in their life. So lots of people have hemorrhoids, but especially these pelvic floor patients. Why? Again, increasing that pressure down in the anal rectal area increases your risk of hemorrhoids. So if we're not addressing that for these patients, you're at risk of recurring of these hemorrhoids. Hemorrhoids are those anal vascular cushions lining the anal canal. These are natural. But what I explain to patients with severe constipation pelvic floor is if we're not addressing that, we're putting all that pressure from these vasculature almost blowing up these hemorrhoids like balloons. So if you're not helping with that pressure and you keep blowing up these balloons, you're going to continue to have these hemorrhoids. And so treatment for hemorrhoids is going to aim to, one, help with the behavioral modifications, reducing that pressure, helping those bowel movements pass easier, topical steroids. This is an ASGA course. So when we talk about endoscopic treatment, you can talk about banding. So treatment ultimately aims at reducing the vascularity and redundancy. It increases that fixation of the anal cushions to the underlying muscle. So essentially, you're trying to cause scarring to help prevent those hemorrhoids from occurring and shrinking them. Endoscopic, how you can do that is with a flexible sigmoidoscopy or an upper endoscope. You can put that fan ligator on the top of it. And when you're assessing these internal hemorrhoids, make sure that it's not fully inflating the rectum. So when it's a little bit deflated, you can actually see that redundant tissue easier. And you can see where those internal hemorrhoid bands are and then where you want to focus that bander. Make sure you're at least two centimeters proximal to the dentate line just to make sure you're not including the dentate line and not causing pain for these patients. You suction up that rectum into the bander. And you put the band on. You can do one to two bands. People say you can do three. The more bands you do, the higher risk you are for complications, which is why you usually focus on a few less bands at a time. If you are doing this in the endoscopy lab, make sure that you do evaluate the patient post-op. Make sure that they're not having pain. You can also always assess the area with your finger with a quick rectal exam and post-op massaging on either side of where those bands were. Making sure, again, that you don't have too much tissue in there because, again, it can cause pain and more complications for those patients. So again, pelvic floor dysfunction, it affects a lot of our patients in clinic. It can result in painful anal-rectal complications. What I hope you got out of today is that pelvic floor dysfunction is common. It's actually something that is still pretty stigmatized. People don't like to talk about how they poop. They don't like to talk about things coming out of their rectum. Let your patients know they're not alone. There's a lot of people out there who struggle with this, and we can help them. And so I hope this makes you all think about pelvic floor dysfunctions so that we can better treat our patients. Utilizing that physical exam, utilizing that endoscopic exam to better assess and treat your patient's symptoms can very much benefit your patients long term. So hopefully you enjoyed my Tide Talk today. I'm very grateful for being able to do this today. Enjoy the rest of the ASGE course. Thank you.

pelvic floor dysfunction

anorectal complications

endoscopic management

physical therapy

patient education