Pelvic floor

Constipation can be due to primary and secondary causes (Table 18-1). Primary or idiopathic constipation is typified by normal-transit constipation, slow-transit constipation, and dyssynergic defecation. In the normal-transit type, colonic motility is unchanged and patients tend to experience hard stools despite normal movements. In the slow-transit type, motility is decreased leading to infrequent harder, drier stools. In dyssynergic defecation (also known as pelvic floor dysfunction), patients have lost the ability to relax the anal sphincter while coordinating muscle contractions of the pelvic floor. Some causes of secondary constipation are listed in Table 18-1. 

Defecatory or rectal evacuation disorders (e.g., Hirschsprung s disease, pelvic floor dyssynergia)... 

Pelvic floor disease prior gynecologic surgery, hormonal status (pre- vs. postmenopausal) Constipation, diarrhea, fecal incontinence,... 

Dyssynergic defecation A lack of coordination between the pelvic floor muscles and the anal sphincter. 

Kegel exercises Specific exercises that strengthen the pelvic floor muscles and help to prevent and treat stress incontinence. 

Nonpharmacologic treatment (e.g., lifestyle modifications, toilet scheduling regimens, pelvic floor muscle rehabilitation) is the chief form of UI management at the primary care level. 

The rate of invasive ER-positive breast cancer, a secondary objective in the MORE trial, showed an 84% reduction after 4 years of followup (Cauley et al. 2001) moreover, during the subsequent 4 years of followup in the so-called CORE trial (Continuous Outcomes Relevant to Evista), invasive ER-positive breast cancer, the primary objective of the study, was reduced by 66%. Over the 8 years of both trials, the incidences of invasive breast cancer and ER-positive invasive breast cancer were reduced by 66% and 76%, respectively, in the raloxifene group compared with the placebo group (Martino et al. 2004). These effects have not been associated with harmful effects on the endometrium (Cohen et al. 2000) or the pelvic floor (Goldstein et al. 2001). 

As a result of these findings, a scheduled standard pelvic exploration is now an obligatory procedure in clinical trials with new SERMs. It is important to note that this adverse effect has not been associated with tamoxifen or toremifene therapy (Maenpaa et al. 1997 Fisher et al. 1998), and in the case of raloxifene, a post hoc metaanalysis of 6926 nonhysterectomized postmenopausal women participating in clinical trials for 3 years or more showed a significant 50% reduction in the incidence of surgery for repairing pelvic floor relaxation, reported as an adverse event, compared with placebo (Goldstein et al. 2001). 

Goldstein SR, Neven P, Zhou L, Taylot YL, Ciaccia AV, Plouffle L (2001) Raloxifene effect on frequency of surgery for pelvic floor relaxation. Obstet Gynecol 98 91-96... 

Exercises to strengthen the pelvic floor muscles Behavioural therapy Anticholinergic drugs Desmopressin... 

Constipation may be caused by slow intestinal transition, pelvic floor dysfunction, bowel dysfunction like irritable Bowel syndrome and tumours, but can also be secondary to other diseases and life conditions. Many medicines cause constipation, for example opiates, calcium channel blockers and drugs with anticholinergic effects, e.g. antidepressants. 

McKenna, P.H., Herndon, C.D., Connery, S., and Ferrer, F.A. (1999) Pelvic floor muscle retraining for pediatric voiding dysfunction using interactive computer games. / Urol 162 1056—1062 discussion 1062—1063. 

Rufford J, Hextall A, Cardozo L, Khullar V. A doubleblind placebo-controlled trial on the effects of 25 mg estradiol implants on the urge syndrome in postmenopausal women. Int Urogynecol J Pelvic Floor Dysfunct 2003 14 78-83. 

Seminal emission and ejaculation are under control of the sympathetic nervous system. Emission results from a-adrenergic-mediated contraction of the epididymis, vas deferens, seminal vesicles, and prostate, which causes seminal fluid to enter the prostatic urethra. Concomitant closure of the bladder neck prevents retrograde flow of semen into the bladder, and antegrade ejaculation results from contraction of the muscles of the pelvic floor including the bulbocavemosus and ischiocavernosus muscles. 

PELVIC TONING EXERCISES Exercises that focus on tightening the muscles of the pelvic floor to relieve urinary stress incontinence. Also known as Kegel or PC muscle exercises. 

Doly S, Fischer J, Brisorgueil M-J, Verge D, Conrath M. 5-HT5A receptor localization in the rat spinal cord suggests a role in nociception and control of pelvic floor musculature. J Comp Neurol 2004 476 316-329. 

The therapeutic indications for BoNTs are numerous. They are used in the treatment of ophthahnological disorders (strabismus, Duane s syndrome, esotropia/exotropia), movement disorders (focal dystonias, blepharospasm), spasticity, neiuomuscular disorders, pain (headache, myo-facial pain), disorders of the pelvic floor (anal fissures), ear/ nose/throat disorders, cosmetic applications (wrinkles), and hyperhidrosis. The recent explosion in new indications for BoNTs in the treatment of a wide range of medical conditions also brings the possibihty for medical errors in BoNT dosing. Systemic botulism may result from injection of excessive doses of the potent neurotoxin. The most infamous case of systemic botulism involved the paralysis of four Florida patients, including the doctor, treated with BoNTs for wrinkles. The physician used non-FDA approved formulations of type A from Toxin Research International,... 

Barbolt TA. Biology of polypropylene/polygalactin 910 grafts. Int Urolgynecol. J. Pelvic Floor Dysfnnct. 2006 17 S26-S30. 

Echols KT, Chesson RR, Breaux EF, Shobeiri SA. Persistence of delayed hypersensitivity following transurethral collagen injection for recurrent urinary stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2002 13(l) 52-4. 

Drutz HP, Appell RA, Gleason D, Klimberg I, Radomski S. Clinical efficacy and safety of tolterodine compared to oxybutynin and placebo in patients with overactive bladder. Int Urogynecol J Pelvic Floor Dysfunct 1999 10(5) 283-9. 

---