INTRODUCTION

A 42-year-old woman (Lucy, pseudonym) presented to a pelvic floor unit with symptoms of tenesmus, a feeling of incomplete evacuation and a sensation of pressure in her vagina. These symptoms have been present since the birth of her second child. She has noticed them becoming more problematic, particularly in the past 2 years.

Lucy lives with her partner and two young children aged 9 and 11 years. She is a primary school teacher and works part-time. On ‘bad’ days she can visit the toilet multiple times, which is especially difficult to manage if she is at work, as she is unable to leave the classroom during lesson time.

ASSESSMENT

Assessment is a fundamental part of the treatment process for a patient and is considered the first step of individualised nursing care. The information that is collated from the assessment is significant to the development of a plan of action that augments health outcomes relevant to the patient.

Lucy’s assessment began with her GP, although she found it embarrassing discussing her bowel symptoms. However, in recent weeks she suffered episodes of post defaecation seepage and experienced leakage during sexual intercourse, which prompted her to visit her GP for advice. This led to a referral to the pelvic floor services at her local hospital who assessed holistically taking into account physical, psychological and social wellbeing.  Her assessment revealed the following:

Bowel symptoms

• 2 bowel movements per week, type 2-3 stool (Bristol stool chart). For as long as she can remember she has been ‘prone to constipation’ and is used to moving her bowel infrequently.
• A feeling of incomplete evacuation. She has read on the internet that she should avoid straining.
• Post defaecation seepage, which is unpredictable and left her feeling unclean, therefore location of toilets is important to know.
• Feels a pressure rectally/vaginally after having a bowel movement.

Medications

• Has tried a variety of laxatives, but experienced abdominal pain and their unpredictability of effect was very difficult to manage. In our clinical practice, it is noted that many patients prefer not to take laxatives for these reasons, despite the impact of symptoms on their quality of life. It is useful to identify constipation which occurs due to evacuation disorders as this does not respond well to laxative therapy¹.
• No other medications taken.

Diet

• 3 meals per day
• Tries to be as healthy as possible, inclusive of 5 portions of soluble fibre each day.
• However, eating more fibre, particularly insoluble fibre, leads to bloating and bowel frequency doesn’t improve. Insoluble fibres can cause increased bloating and may not improve slow transit constipation². On the other hand, it has been demonstrated that diets with soluble fibre can be associated with the improvement of the symptoms in chronic constipation without causing increased bloating³. Although Lucy has not been diagnosed with slow transit, her infrequent bowel movements suggest otherwise.

Digital rectal examination

• No pelvic floor descent, good strength and tone of the pelvic floor muscles, palpation of the anterior rectal wall suggested a rectocele, nil other to note.
• Balloon expulsion was carried out with an Ashley balloon catheter (See figure 1) and demonstrated a slight incoordination of pelvic floor and anal sphincter muscles but no straining.

Figure 1

Investigations

• A defaecating proctogram confirmed a moderate rectocele with trapping of stool. No perineal descent and nil other to note.

Psychological & Social wellbeing

• Faecal leakage has occurred during sexual intercourse, which has left her mortified and avoiding any intimacy with her partner. When a person experiences a traumatic event, their brain may process the event in a way that causes them to feel stuck in a state of hypervigilance or fear, even after the threat has passed. Trauma can also interfere with a person’s ability to form healthy attachments and relationships with others, which can further exacerbate feelings of anxiety and isolation. Lucy has developed a fear of faecal incontinence occurring again, creating anxiety around her relationship with her partner.
• Toilet-centred behaviour, avoids unfamiliar places and finds socialising difficult.

To summarise, Lucy has a moderate sized rectocele and feasibly slow transit constipation, as she is only having 2 bowel movements per week. Her most bothersome symptom is stool trapping in the rectocele, which has led to incontinence.

For further information on rectoceles please visit:

https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/pelvic-organ-prolapse-patient-information-leaflet/

TREATMENT PLAN

Setting goals

• The treatment plan should be one of shared decision making, taking into account patient preferences⁴. This encourages active involvement and commitment to the proposed interventions⁵.

Lucy’s assessment identified her treatment goal using the MYMOP questionnaire (https://www.meaningfulmeasures.co.uk/). This is a problem specific individualised measure. It is quick and simple to use and captures which symptoms are most important to the patient and which activities of daily living they affect. Her goal was to improve rectal evacuation so that the number of toilet visits were reduced, and the risk of incontinence eliminated.

Treatment options for rectocele depend on the severity of symptoms. NICE (2022)⁶ recommend the following strategies:

Lifestyle modifications

• Lifestyle modifications such as weight loss and smoking cessation are frequently recommended as first line management strategies for bowel dysfunction, including rectocele⁶. Obesity and coughing can strain already weakened pelvic floor muscles. However, this is expert opinion since evidence for these is lacking⁴.

Since Lucy neither smokes nor was overweight these were not discussed.

Preventing or treating constipation

• Lucy was advised to slowly increase the amount of soluble fibre in her diet, to prevent bloating. She did not wish to pursue laxatives due to the unpredictable effects.

Oestrogen therapy

• Vaginal oestrogen should be considered for women with pelvic organ prolapse and signs of vaginal atrophy.

Lucy was having regular periods. There were no signs of vaginal atrophy.

Pelvic floor muscle training

• A tailored programme of pelvic floor muscle training has been shown to be effective for relieving symptoms of prolapse by strengthening the muscles and tissues that support the rectum and vagina, alleviating pressure and discomfort⁷.

Lucy had good strength and tone of her pelvic floor and was given a personalised programme to follow.

Rectocele support e.g., vaginal pessaries, splinting, digitation

• Physical support of the rectocele can aid evacuation.

Lucy was taught defaecation dynamics to optimise positioning on the toilet. However, she did not wish to digitate and was embarrassed to continue splinting, stating she wanted ‘a solution for her problems’.

Due to the significant impact on her day-to-day life, a multi-modal approach was applied where Lucy would carry out the tailored pelvic floor exercises and employ rectal irrigation at the same time to enable more complete evacuation, relieving symptoms of post-defaecation seepage, tenesmus and sensation of pressure. Igualada-Martinez et al (2022)⁸ recommends early intervention of rectal irrigation (as an alternative to suppositories), before pelvic floor muscle training, potentially giving symptom relief whilst strengthening these muscles.

RECTAL IRRIGATION

Initiation

Rectal irrigation involves instilling warm tap water into the rectum via a cone or catheter. When this is removed, the water is expelled along with the contents of the rectum and descending colon. The degree of evacuation will depend on several factors including the amount of water that is used.

The wide range of equipment available can be confusing for health care professionals (HCPs). The decision guide is a consensus document based on current evidence and best practice. It guides the HCP through the process of starting a patient on rectal irrigation, including choosing high or low volume irrigation, catheter or cone, aspects to include during teaching and when to follow up.

The decision guide (step 2) recommends low volume irrigation for rectocele and high volume for constipation. In our clinical experience, presentation of bowel conditions as described, the choice of product would lean to high volume, as this will address all symptoms, especially when using the Qufora IrriSedo Flow system, therefore addressing both the constipation with the volume of water and the rectocele with a cone that has a shower effect. Also, bearing in mind that Lucy had good dexterity and no issues with sitting balance therefore a cone system is deemed appropriate.

However, low volume was initiated for several reasons. Lucy’s most bothersome symptom was difficult evacuation (low volume recommended) with symptoms of tenesmus and stool trapping leading to faecal incontinence. She also had a very busy lifestyle so was concerned how irrigation would fit into her routine. For these reasons low volume was chosen i.e. Qufora IrriSedo MiniGo, which looked quick, easy and discreet to use.

Follow up

2-week telephone review

• Procedure took 10 minutes in the morning after breakfast
• Irrigated 10 out of 14 days
• 4 great results, more comfortable and less toilet visits
• 6 days of continued previous symptoms
• Plan – to continue with low volume irrigation, as symptoms may improve

4-week telephone review

• Insufficient relief
• Tenesmus and frequent toilet visits persisted, there had been a few instances of post-defaecation seepage and she was still avoiding intimacy with her partner.
• Since adjusting to a rectal irrigation routine Lucy was aware that high volume would be the next step
• Transitioning to another cone-based product within the same range i.e. Qufora IrriSedo Flow, made teaching high volume straightforward. Lucy was already familiar with attaching the cone (which had the same lubricant, so she knew it was comfortable to insert and remove), the versatile water bag was convenient to use standing on the floor in her bathroom.
• To save another visit to clinic, a starter kit was delivered to her home, and this was taught virtually over a web call.
• Qufora IrriSedo Flow has been evaluated by HCPs as easy to teach, easy to learn and easy to use. This was reflected on the web call.

OUTCOMES

On speaking to Lucy at her 8-week review, it was evident from the tone of her voice that her confidence and self-esteem had improved. She was irrigating most days, using 500-600mls of water, and having very good results, passing dark brown water.  She felt that evacuation was complete, tenesmus and the sensation of pressure in her vagina had both disappeared. Episodes of post-defaecation seepage had stopped. She was happier and had been out shopping and for lunch with friends. She was looking forward to a date night with her partner.

CONCLUSION

This case study demonstrates the importance of identifying goals that matter to the patient. Holistic assessment identified that it was appropriate to start irrigation sooner in the treatment pathway, with a multi-modal approach. Transitioning from low to high volume can be straightforward, leading to successful irrigation and the best possible outcomes for the patient.

REFERENCES

1. Bharucha AE, Pemberton JH, Locke GR 3rd. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013 Jan;144(1):218-38. doi: 10.1053/j.gastro.2012.10.028. PMID: 23261065; PMCID: PMC3531555

• Basilisco G, Coletta M. (2013) Chronic constipation: a critical review. Dig Liver Dis 2013; 45:886–93

• Suares NC, Ford AC. (2011) Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol 2011; 106:1582–91

• Assmann SL, Keszthelyi D, Kleijnen J et al (2022) Guideline for the diagnosis and treatment of Faecal Incontinence-A UEG/ESCP/ESNM/ESPCG collaboration. United European Gastroenterol J. 2022 Apr;10(3):251-286. doi: 10.1002/ueg2.12213. Epub 2022 Mar 18. Erratum in: United European Gastroenterol J. 2022 Jul;10(6):606-607. PMID: 35303758; PMCID: PMC9004250

• Booth J, Bliss D. Consensus statement on bladder training and bowel training.

Neuro-urology and Urodynamics. 2020;1–21.36

• NICE (2022) Urinary incontinence and pelvic organ prolapse in women: management (NG123)

• Hagen S, Stark D, Glazener C et al (2014) Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. The Lancet vol 383,9919 p796-806

• Igualada-Martinez P et al (2022): Physiotherapy Management of Anorectal Dysfunction. Seminars in Colon & Rectal Surgery (2022), doi: https://doi.org/10.1016/j.scrs.2022.100936

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