Digestive Trac • Fall 2013, Issue 8

DigestiveTrac DIGESTIVE DISEASES • FALL 2013 Issue 8

INSIDE THIS ISSUE: PELVIC FLOOR DISEASE A Team Approach to Pelvic Floor and Rectal Dysfunction Evaluation of Pelvic Floor Dysfunction and Specialized Diagnostic Tools Treatment Ranges From Medication to Physical Therapy to Surgery Medical and Surgical Management of Anorectal Disorders Rectal Prolapse

Multidisciplinary Team Includes the Following Areas of Specialty:

Dear Colleagues, The symptoms of pelvic floor dysfunction can result in not only pain and discomfort, but also embarrassment and reduced quality of life.

While varied pelvic and anorectal disorders can affect people of both genders, pelvic floor dysfunction is most often seen in women who are past childbearing age, and incidence increases with age.

Colorectal Surgery: Scott L. Baker, MD, FACS, FASCRS

These conditions are often highly complicated, involving multiple systems. The specialists of Avera Digestive Disease Institute collaborate across medical disciplines to arrive at an accurate diagnosis and the most effective treatment plan.

Gastroenterology and Hepatology: Steven Condron, MD, MHES, FACP Cristina Hill Jensen, MD Christopher Hurley, MD Dany Shamoun, MD

Primary care physicians are often the first to hear about or discover symptoms of pelvic floor dysfunction. Avera Digestive Disease Institute specialists hope to collaborate with referring physicians in offering patients an effective, seamless approach to care. Therefore, we are dedicating this issue of Digestive Trac to the diagnosis and treatment options associated with pelvic floor dysfunction and anorectal disorders, in order to raise awareness of this entire range of conditions.

General Surgery: Scott L. Baker, MD, FACS, FASCRS Michael Bauer, MD, FACS Wade E. Dosch, MD, FACS David Flanagan, MD Thomas E. Fullerton, MD Michael Person, MD, FACS David A. Strand, MD, FACS Bradley C. Thaemert, MD, FACS Donald J. Wingert, MD, FACS

The Digestive Disease Institute has a full arsenal of diagnostic tools, from colonoscopy to MRI defecography to anorectal manometry and more.

After malignancy is ruled out and the correct diagnosis is made, treatment may include dietary and lifestyle changes, physical therapy, medication and/or surgery.

Genetics: Kayla York, CGC, MS

When surgery is required, DDI offers the latest minimally invasive options, such as laparoscopic rectopexy to treat rectal prolapse, and pelvic reconstructive surgery and sacral neuromodulation to treat urinary incontinence. There are also a full range of surgical procedures to treat anorectal disorders, including hemorrhoids, fissures, abscesses and fistulas.

Hepatology: Hesham Elgouhari, MD, FACP Mumtaz Niazi, MD Medical Oncology: David Elson, MD Mark R. Huber, MD Michael McHale, MD Heidi McKean, MD Benjamin Solomon, MD Addison R. Tolentino, MD

We at the Avera Digestive Disease Institute want to partner with primary care physicians to help patients recover their health and quality of life.

As always, it is our privilege to work closely with primary care physicians for our patients’ best interest and continuity of care. Please feel free to contact us at 605-322-7797 with questions or for more information.

Pathology: Steven P. Olson, MD Bruce R. Prouse, MD Raed A. Sulaiman, MD

Sincerely,

Scott L. Baker, MD, FACS, FASCRS Colorectal Surgery Surgical Institute of South Dakota

Surgical Director of Avera Digestive Disease Institute

Radiation Oncology: Barbara Schlager, MD Kathleen L. Schneekloth, MD James Simon, MD Radiology: Sabina Choudhry, MD Brad A. Paulson, MD Research (Cancer clinical trials)

Steven Condron, MD, MHES, FACP Gastroenterology and Hepatology Avera Medical Group Gastroenterology Medical Director of Avera Digestive Disease Institute

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Transplant Surgery: Christopher Auvenshine, DO Jeffery Steers, MD Urogynecology: Matthew A. Barker, MD, FACOG

A Team Approach to Pelvic Floor and

Rectal Dysfunction

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ecause body systems are intricately interrelated, pelvic floor and rectal dysfunction is a disease category that often requires a multidisciplinary approach, including gastroenterologists, urogynecologists, radiologists, surgeons, dietitians and physical therapists.

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Pelvic floor dysfunction represents a group of differential diagnoses that are quite vast, from dietary problems to anatomical injuries after childbirth or surgery to problems with muscle control. A broader spectrum of expertise is needed to assess and properly address these issues, whether through medication, physical therapy, lifestyle changes or surgery.

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Dr. Matthew A. Barker, board-certified Urogynecologist

Matthew A. Barker MD, FACOG Pelvic floor and rectal dysfunction refers to a wide range of issues that occur when pelvic floor muscles are injured, weakened or tense, or there is an impairment of the sacroiliac joint, lower back, coccyx or hip joints.

Tissues surrounding the pelvic organs may have increased or decreased sensitivity or irritation resulting in pelvic pain.

The pelvic floor refers to a group of muscles which attach to the front, back and sides of the pelvic bone and sacrum, and serve as a sling to support pelvic organs, including the bladder, uterus (in women), prostate (in men) and the rectum. In women, these muscles also wrap around the urethra and vagina.

Bowel movements and bladder functions are controlled by the contracting and relaxing of these muscles. When these muscles are weakened or impaired, impaired function manifests in chronic constipation, difficult defecation, fecal incontinence and leakage of liquid stool, urinary incontinence, painful intercourse and chronic pelvic pain. continued on page 10

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Evaluation of

Pelvic Floor Dysfunction and Specialized Diagnostic Tools

An accurate diagnosis begins with a thorough family history, assessment of symptoms and physical exam in order to determine what further testing needs to take place.

When pelvic floor dysfunction results in urinary and stress incontinence, accurate diagnosis can be made based on a description of symptoms and physical exam.

When fecal incontinence, rectal pain and/or bleeding, straining and chronic constipation or diarrhea are the symptoms, diagnosis often requires further investigation.

A first diagnostic step is often colonoscopy, through which

MRI is most often used as the imaging tool for capturing images of the pelvis.

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MRI provides soft-tissue contrast, allowing us to see virtually every anatomic structure in the pelvis, including fissures or fistulas.

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gastroenterologists can visualize any abnormalities inside the entire colon, including polyps or cancer.

Colorectal cancer should first be ruled out, as well as disorders such as inflammatory bowel disease and irritable bowel syndrome.

Sigmoidoscopy, examination of the rectum and lower colon, is also an option.

Dr. Sabina Choudhry, board-certified Radiologist Magnetic resonance is used for both static and dynamic imaging of the pelvis. MR allows simultaneous assessment of all pelvic structures in one examination, and does not

Cristina Hill Jensen, MD

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expose the patient to radiation in the pelvic area.

MRI defecography is a dynamic test that simulates the act of defecation.

Exam jelly is used to fill the rectum and then rapid images are taken while the material is voided.

Issues may manifest in the dynamic test that appear to be normal in static imaging.

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atients with pelvic organ prolapse and pelvic floor dysfunction may present in various settings, whether they mention their symptoms to their family practitioner, seek out the services of a specialist, or present in the emergency room with acute pain.

This is a very evolving area and highly specialized.

Dr. Choudhry

To fulfill this diagnostic need at Avera, Drs. Choudhry and Matthew Barker reviewed the literature and found the procedure presented in a journal article by the Departments of Radiology and Urology at the University of California Los Angeles.

Anorectal manometry is a procedure using a high-resolution probe inserted into the anus and

These specialized tests provide a “complete arsenal of diagnostic tools

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in the evaluation of pelvic floor and bowel dysfunction.

Dr. Cristina Hill Jensen, board-certified Gastroenterologist

rectum to measure anal sphincter pressure response to bearing down or squeezing. The test is used to diagnose conditions including fecal incontinence, chronic constipation, chronic diarrhea, irritable bowel syndrome, anal and rectal pain, and bowel dysfunction. The probe is equipped with multiple pressure readers which measure the entire radius of the anus. It measures symmetry of muscle function using a computer program.

The procedure, performed at Avera Medical Group Gastroenterology, requires two enemas for preparation, although some patients may have it performed before a colonoscopy to save additional prep. No sedation or anesthesia is needed. The procedure typically lasts a total of 30 to 45 minutes. It is performed by April Schnieder, Nurse Practitioner, and studies are read and interpreted by Dr. Cristina Hill Jensen.

Specialized diagnostic tools • C olonoscopy and sigmoidoscopy provide an inside real-time view of the entire colon and lower colon, respectively; colonoscopy provides the opportunity to remove polyps during the same examination.

Rectal and anal ultrasound can be used to evaluate any abnormalities, including polyps or masses, and inflammatory or infectious conditions. The office procedure requires an enema just before the examination. The ultrasound transducer is inserted into the anal canal and rectum to capture ultrasound images.

• M agnetic resonance is used for both static and dynamic imaging of the pelvis without exposure to radiation in the pelvic area.

A marker study, or colorectal transit study, involves swallowing a capsule containing markers that appear on X-rays taken over several days. This helps physicians evaluate how well food moves through the colon in the case of constipation. n

• A norectal manometry is a procedure using a high-resolution probe to measure anal sphincter pressure response to muscular contractions.

diagnosis helps us arrive “Accurate at the best possible treatment plan.

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Dr. Hill Jensen

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• M RI defecography is a dynamic test that simulates the act of defecation while capturing images

• R ectal and anal ultrasound can identify masses or abnormalities, as well as inflammation or infection.

• C olorectal transit study involves swallowing a capsule containing markers that appear on X-rays taken over several days.

Treatment Ranges From Medication to Physical Therapy to Surgery

vera’s multidisciplinary specialists provide varied treatment approaches to treat pelvic floor dysfunction, depending on the specific diagnosis.

The causes of chronic constipation, diarrhea and fecal incontinence vary greatly.

After the correct diagnosis is determined, treatment approaches may include medication, dietary changes, physical therapy or surgery.

When the pelvic floor dysfunction involves urinary incontinence and stress incontinence, an effective surgical approach is to create an incision through the vagina, and tie connective tissue together to foster the formation of scar tissue, rebuilding structure to hold pelvic organs in place. In this procedure, no mesh is used, and thus risk of harmful side effects is minimized.

Non-surgical treatment options include medications, pelvic exercises, physical therapy and biofeedback.

Sacral neuromodulation is an implantable system in the lower back that sends mild electrical pulses to the sacral nerves that control the bladder. A programmable stimulator is implanted subcutaneously which delivers low amplitude electrical stimulation via a lead to the sacral nerve.

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These treatments are all about helping women to live to their full potential. We at Avera have been vigilant to ensure that the procedures and treatments we offer are effective and safe without high risk of serious complication.

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Dr. Matthew A. Barker, Urogynecologist

Sacral neuromodulation is an implantable system in the lower back that sends mild electrical pulses to the sacral nerves that control the bladder.

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Physical therapy approaches may include pelvic floor and hip girdle exercises, core strengthening, manual therapy to the lower abdomen or pelvic floor, positioning, relaxation exercises, biofeedback, and electrical stimulation or ultrasound modalities.

Staci Wietfeld, DPT, OCS, Avera McKennan physical therapist

Dietary and lifestyle changes should not be overlooked. For chronic diarrhea and constipation that are not related to anatomical issues, the solution is similar, and that is adequate fiber intake. For chronic diarrhea, fiber bulks up the stool, and for constipation, fiber softens the stool.

For diarrhea, a BRAT diet may be recommended, including foods that are exceptionally plain and non-spicy, including bananas, rice, apples and toast. Patients may be advised to cut back on certain foods, such as dairy products, to see if that results in a positive change. If not, patients can resume eating that food and assume it is not the cause. For constipation, eating enough fiber through intake of whole grains, fruits and vegetables along with enough fluids is the recommendation.

Recommendations call for 25 to 35 grams of fiber a day, and most people get less than half that amount.

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Pelvic reconstructive surgery is a procedure involving an incision through the vagina, and tying connective tissue together to foster the formation of scar tissue and rebuild structure to hold pelvic organs in place. In this procedure, no mesh is used, and thus risk of harmful side effects is minimized.

Physical therapy can be an effective, non-surgical treatment for stress or urge urinary incontinence, post-partum pelvic pain, painful intercourse, chronic constipation, fecal incontinence or pelvic pain.

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After the correct diagnosis is made through specialized testing, if needed, treatment approaches may include medication, dietary changes, physical therapy or surgery.

Laparoscopic rectopexy is a minimally invasive surgical procedure used to secure the rectum in proper position in the case of rectal prolapse.

Treatment Ranges From Medication to Physical Therapy to Surgery (cont.)

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Treatment strategies for pelvic floor disease

Dawn Johnson, RD, LN

Specific foods, such as prunes or prune juice can be helpful, but they aren’t necessary. Patients are advised to increase their fiber over a period of time to prevent bloating, gas or diarrhea.

For urinary incontinence, patients can lessen symptoms by avoiding spicy, acidic foods that can irritate the bladder, as well as caffeinated or alcoholic beverages. n

If you have any questions or would like to make a referral to the Avera Digestive Disease Institute, call 605-322-7797.

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Medical and Surgical Management of Anorectal Disorders

emorrhoids, fissures and abscesses with fistulas are common anorectal disorders that can be treated with a range of approaches, depending upon the severity and extent of the condition.

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When patients experience symptoms such as bleeding or protrusion, they often either attribute their symptoms to hemorrhoids, or they assume the worst and fear it is cancer.

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Dr. Scott Baker, board-certified Colorectal Surgeon Certainly malignancy must be ruled out, but it is rare. In actuality, the symptoms could result from a range of conditions.

Most patients with these types of complaints should undergo some form of proctosigmoidoscopy during their evaluation and treatment.

Hemorrhoids are vascular cushions which aid defecation, involving blood vessels, connective tissue and smooth muscles. The function of hemorrhoids is to aid in continence as a plug, and protect the tissue of the sphincters and anus from the trauma of defecation. Everyone has these structures – when they become inflamed they cause pain and bleeding.

Approximately 4.4 percent of the U.S. population has been seen by a physician for symptomatic hemorrhoids.

The symptom of painless bleeding often points to internal hemorrhoids.

An increase of fluid intake and fiber in the diet as well as stool softeners may be enough to cause the inflammation to heal. Over-the-counter creams or suppositories are for the most part ineffective. If symptoms persist, office-based procedures may include rubber band ligation, injection sclerotherapy or infrared coagulation. More severe cases may require surgical approaches such as excisional hemorrhoidectomy.

External hemorrhoids are often painful due to the nerve endings that are present. There may be a protrusion or lump, and seeping/soiling.

Symptomatic relief includes sitz baths, stool softeners or pain medication.

Surgical solutions include excision or thrombectomy.

An anal fissure – a tear in the lining of the anus – is marked by sharp or burning pain during bowel movements, and a show of bright red blood.

The majority of fissures heal with home treatment, however, surgery may be necessary for fissures that do not heal. Anal fissures can affect people

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To relax muscle tension, first-line treatment is topical nitroglycerin, which is about 60 percent effective.

Botulinum toxin (Botox) injection has a success rate of about 70 percent.

Lateral internal sphincterotomy is the “gold standard” surgical approach if less invasive methods fail. Success rates are higher, with less recurrence than medications; however, there is a risk of incontinence in 4-6 percent of cases. Finally, anoplasty is surgical repair of the anus, reserved for extreme cases.

A perianal abscess is a boil-like swelling near the anus. Surgical incision and drainage is the most common treatment for all types of anal abscesses. After an abscess has been drained, however, 30 to 70 percent of patients develop a fistula – an abnormal connection between the rectum and the skin.

A fistula is marked by continual draining of the abscess site.

Surgery is necessary to treat the fistula, often through two procedures – to open the fistula, allowing it to heal from the inside out, and then close the opening.

The approach depends upon where the fistula exists, how much sphincter muscle is affected, risk of incontinence, and the condition of the patient. Options include fistulotomy, seton stitch, mucosal advancement flap, and LIFT – ligation of intersphincteric fistula tract. n

Anorectal symptom assessment The type of pain and bleeding associated with anorectal disorders is important in evaluating what type of condition the patient is suffering from. Is the pain sharp, dull or burning? Is it associated with bowel movements or activity? Is it constant or intermittent? Is bleeding bright or dark red? Gathering an accurate report of symptoms from the patient during assessment often helps to differentiate between common disorders:

Internal hemorrhoids painless bright red bleeding

External hemorrhoids intermittent pain with bleeding, protrusion, seeping/soiling

Anal fissure sharp, burning pain with bright red bleeding associated with a bowel movement

Anal abscess constant, increasing anal pain

disorders can be extremely “Anorectal painful, embarrassing and frustrating for patients. When surgical intervention is necessary for curative treatment, we employ the latest techniques in order to ensure patients receive effective treatment with a low risk of resulting incontinence.

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of any age, and are equally common in women and men. Causes can include a large bowel movement that stretches the anal canal, constipation or repeated diarrhea. Tension or spasm of the underlying muscle is what prevents healing.

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Dr. Scott Baker

Rectal Prolapse

Scott L. Baker, MD, FACS, FASCRS

Rectal prolapse, a condition marked by the full thickness of the rectum protruding out of the anus, is often quite alarming for patients, who seek immediate treatment. Although the condition is not life-threatening, it causes discomfort and unwanted symptoms such as fecal incontinence.

Rectal prolapse most often occurs in older women. “Several conditions come into play for it to develop.

There must be a weak pelvic floor with weak attachments, as well as redundant sigmoid colon causing ‘extra slack’ in the system,” said Dr. Scott Baker, a board-certified colorectal surgeon with Surgical Institute.

Physicians can identify this condition upon physical examination, noted by concentric rings on the protruding tissue, as opposed to hemorrhoids, which appear columnar. The prolapsed rectum may move back inside upon sitting or changing position, but it will continue to slide in and out of the sphincter complex and cause symptoms. Once it reaches this point, it must be corrected surgically.

The most common and effective surgical approach is laparoscopic rectopexy, a minimally invasive surgical procedure used to secure the rectum in proper position. The surgery involves a small incision near the navel, through which a laparoscope is inserted. Several additional small incisions are made to place other surgical instruments.

The prolapsed rectum is freed from surrounding structures and lifted into its proper position inside the pelvis. The rectum is then sutured to the periosteum of the sacrum.

Redundant sigmoid colon is also removed. This procedure is the most successful, with a 3-5 percent recurrence rate.

If patients are not able to tolerate an abdominal procedure, a perineal rectosigmoidectomy is an optional procedure which can be performed using regional anesthesia to the

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perineum. The surgeon removes a portion of the rectum and attaches the remaining rectum to the sigmoid colon. This procedure, also known as the Altemeier procedure, has a 12-15 percent recurrence rate. The third option, the Thiersch procedure, is rarely performed due to its relatively high recurrence rate of 25-30 percent.

In this procedure, a wire or circular band is placed under the skin of the anus to narrow the anal opening and prevent protrusion of the rectum. It is reserved for patients who are not good candidates for more invasive surgery.

Avera Digestive Disease specialists work collaboratively to assess these conditions and determine the correct treatment approach, based on the diagnosis and the physiological and clinical status of the patient. n

A Team Approach to Pelvic Floor and Rectal Dysfunction continued...

When referral is needed Patients presenting with the following symptoms may be suffering from pelvic floor dysfunction.

Because these symptoms can be associated with other conditions, accurate assessment and diagnosis is vital for best possible outcomes.

continued from page 2

Pelvic organ prolapse, common in women, occurs when a pelvic organ such as the bladder, uterus or rectum drops from its normal position and pushes against the walls of the vagina.

Pelvic floor dysfunction can affect both men and women, however the conditions are much more common in women. It is estimated that onefourth to one-third of women are affected by pelvic floor disorders over the course of their lifetimes. A study by the National Institutes of Health found that pelvic floor disorders affect about 10 percent of women ages 20 to 39, 27 percent of women ages 40 to 59, 37 percent of women ages 60 to 79 and nearly half of women age 80 or older. Risk factors include childbirth, with risk increasing in accordance with a greater number of births; obesity; a history of pelvic surgery or radiation treatments; advancing age; heavy lifting; and family history or genetics.

Side effects of medications may contribute to symptoms.

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Chronic constipation

• Difficult defecation

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Fecal incontinence

• Urinary incontinence

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Painful intercourse

• Chronic pelvic pain

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Pelvic organ prolapse (bladder, uterus or rectum)

Avera specialists take a multidisciplinary approach to arrive at the best possible treatment plan, which may include medical treatment, physical therapy, lifestyle changes and/or surgery.

Meet our team

Due to embarrassment or assumption that these conditions are part of the normal aging process, many people simply live with symptoms and accept a lower quality of life. However, with reduced stigma in recent years, more patients are more willing to seek the help they need in order to experience a normal lifestyle. n

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hese conditions are often highly T complicated, involving multiple systems. We work collaboratively to accurately diagnose what in fact is going on with the patient, and find the best way to treat the condition.

Scott L. Baker, MD, FACS, FASCRS board-certified Colorectal Surgeon

Matthew A. Barker, MD, FACOG board-certified Urogynecologist

Sabina Choudhry, MD, board-certified Radiologist

Cristina Hill Jensen, MD, board-certified Gastroenterologist

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Dawn Johnson, RD, LN, Dietitian

Dr. Cristina Hill Jensen, Gastroenterologist

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1325 S. Cliff Ave. Sioux Falls, SD 57105

Avera Makes the Grade!

Avera McKennan Hospital & University Health Center Achieves Top Rankings in Gastrointestinal and General Surgical Care Healthgrades has ranked Avera McKennan the No. 1 Hospital in South Dakota for GI Services and GI Medical Treatment in 2013.

Healthgrades Awards for GI care:

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Top 5% in the Nation for Overall GI Services

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Top 5% in the Nation for GI Medical Treatment

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Top 5% in the Nation for General Surgery

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R anked No. 1 in S.D. for General Surgery

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R anked No. 1 in S.D. for GI Services and GI Medical Treatment

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F ive-Star Recipient for GI Procedures and Surgeries, Treatment of GI Bleed, and Treatment of Bowel Obstruction

Hours: 8 a.m. - 5 p.m. • 605-322-7797 To learn more, visit our website at AveraDigestiveDisease.org ADDI-41849-JL3113