Fig. 16.1
Position used to relax and stretching pelvic floor muscles
6.
Results
At 5 months since the beginning of pelvic floor physical therapy and rehabilitation, the patient reported the resumption of sexual activity that occurs without pain, but without the pleasure present before birth. Over the next 2 months, the patient improves sexual function and reported a satisfactory recovery.
FSFI: 63
7.
Follow–Up
Four months after the end of physical therapy, the patient reported satisfaction with the maintenance of the results.
FSFI: 85
16.4 Case 3: Anna, Rectocele (with the Courtesy of Vittorio Piloni)
1.
Symptoms, complaints reported, history, physical examination
ANNA, 49-year-old, weight 67 kg; height 167 cm, BMI 25.2, multiparous woman (three pregnancies with three vaginal births), currently in surgical menopause. History of vaginal hysterectomy in 2010 due to pelvic organ prolapse; surgery for urethral caruncle in 2014. First-degree ano-vaginal tear at first delivery without episiotomy. Presenting symptoms of difficult defecation, fractionated stools, becoming worse during the last year. Stool frequency: 2–3 times in the day, with frequent sensation of incomplete emptying. She can defecate without digitation. Urinary stress incontinence is complained. Large rectocele is noted at physical examination. Anal tonus is normal, and so are strength, endurance and relaxation. At vaginal inspection, hypotone, decreased contractile activity and endurance are appreciated.
2.
Instrumental diagnosis:
COLONSCOPY: negative
MR DEFECOGRAPHY
See Fig. 16.2a, b
Fig. 16.2
(a) Axial image of the levator hiatus on straining, BFFE pulse sequence: large (>4 cm deep) rectocele projecting beyond the hymen; (b) midsagittal image taken during evacuation of rectal contrast (acoustic jelly) showing large rectocele due to displacement (Type 1) of pelvic organs
3.
Diagnosis
Rectocele
4.
Treatment
Surgery has been proposed to the patient, who accepted.
5.
Results
One year after surgery, the patient reported great improvement during defecation and is satisfied with the result.
16.5 Case 4: Valeria, Obstructed Defecation (with the Courtesy of Vittorio Piloni)
1.
Symptoms, complaints reported, history, physical examination
A 55-year-old multiparous woman (weight, 65 kg; height 165 cm, BMI, 23.9) currently in menopause, with history of third-degree ano-vaginal tear at first delivery, development of utero-vaginal prolapse at 1 year from the fourth childbirth and subsequent surgical repair with combined hysterectomy and vaginoplasty 5 years later. Presenting symptoms include obstructed defecation syndrome since 2 years with recent worsening, sensation maintained but feeling of unsatisfactory evacuation and incomplete emptying, weight sensation and need for manual squeezing of the perineal region to complete the evacuation. Stool frequency: once every 2–3 days. Additional lower urinary tract (LUT) symptoms reported include the following: increased daily and nocturnal frequency, occasional urinary stress incontinence, hesitancy and need for abdominal straining to assist and complete voiding. Other general symptoms include back lumbar pain since 2 years. At physical examination, with no evidence of any wall bulging, a definite vaginal gaping is appreciated together with hypertonic external anal sphincter and puborectalis muscle, weak voluntary contractile activity of the pelvic floor musculature, reduced genital hiatus widening on Valsalva manoeuvre and paradoxical contraction of the levator ani (LA) muscle. More precisely, while a muscular hypotone and decreased contractile activity is appreciated in the right limb of the LA, a hypertone and normal relaxation is observed in the left limb.
2.
Instrumental diagnosis:
MANOMETRY
Conclusions: Increased resting tone, insufficient increase in pressure at voluntary contraction. High-pressure zone length of 2.4 cm. RIRA elicited at 140 ml. Ampullary first sensation increased. Relaxation of the sphincter to distension of the rectum reduced with a paradoxical contraction during straining. Manometric framework compatible with obstructed defecation syndrome.
MR DEFECOGRAPHY
See Fig. 16.3a, b
Fig. 16.3
(a) Axial image of the levator hiatus on straining, BFFE pulse sequence: large (>4 cm deep) rectocele projecting beyond the hymen indistinguishable from that of type I rectocele; (b) midsagittal image taken during evacuation showing protrusion of the anterior rectal wall and an asymmetric “sand glass” appearance of the ano-rectal junction (Type II rectocele) with persistent impression of the puborectalis muscle due to dyssynergic contraction of the levator ani muscle
3.
Diagnosis
Obstructed defecation syndrome linked to a paradoxical contraction of pelvic floor muscles
