Int J Colorectal Dis DOI 10.1007/s00384-014-2044-2
LETTER TO THE EDITOR
Physical therapy at anal incontinence secondary to sexual abuse Aline Moreira Ribeiro & Mariana Nicoletti Ferreira & Juliana dos Santos Ribeiro & Heliana Pandochi & Luiz Gustavo Oliveira Brito
Accepted: 21 October 2014 # Springer-Verlag Berlin Heidelberg 2014
Dear Editor, Anal incontinence (AI) brings negative consequences that affect daily life activities, health, and quality of life of patients. We also know that approximately 25 % of patients with pelvic floor disorders reported previous sexual abuse and that 12 % of patients with AI have had sexual abuse [1], especially when occurred during childhood. Treatment of this cause of AI is difficult; thus, we aimed to report the physical therapy of a young woman who presented AI secondary to sexual abuse. Patient and her legal responsible gave oral consent to this report. A 35-year-old nulliparous woman initiated her follow-up at our institution when she was with less than 1 year due to the lack of weight gain reported by her caregiver. Four years later, she returned to the service with a battered syndrome, fever, and urinary infection and stayed at the hospital for 3 months. By the reports of the father and brother, the patient was assaulted several times by her stepmother. In addition to the beatings, she forced her to perform household services with 3– 4 years and forced her to eat her own feces and swallowing vomiting arising from this act. Even at this age, according to the reports of his brother, the stepmother sexually abused her by inserting objects into her vagina and anus with significant injuries, as pieces of the objects remained in it. Thus, between 4 and 5 years, the patient underwent surgical repair of perineal injuries through sphincteroplasty of internal and external anal sphincters. Between 5 and 7 years of age, the patient was forced by her uncle to anal sex, almost daily, while she remained at her A. M. Ribeiro : M. N. Ferreira : J. dos Santos Ribeiro : H. Pandochi : L. G. O. Brito (*) Hospital das Clinicas da FMRP-USP, Ribeirao Preto Medical School, University of Sao Paulo, Avenida Bandeirantes, 3900 – 8th floor – Monte Alegre, Ribeirao Preto, SP 14049-900, Brazil e-mail: [email protected]
grandmother’s stepmother for work. In addition to the abuse, the patient was threatened that the situation was not exposed to others. Since then, the patient reports of early abuse of minor fecal losses, realized on the exchange of underwear. At 8 years of age, after moving from her stepmother’s house, the patient had the courage to expose the fact denouncing the abuses; however, despite the family tried to report it formally, the competent authorities did not believe to her confession, according to her interview. When she was 15 years of age, the patient underwent surgery for correction of a rectovaginal fistula, but after 5 years, the same uncle, at a unique episode, abused her again. Thirteen years later, she underwent a new surgery to correct a previous perianal fistula with anal fistulectomy and colostomy. This last procedure had prolapsed and she performed a new surgery for reconstruction of intestinal transit. After these surgeries, AI progressed, leading to the use of continuous protection against fecal losses that were daily and in large quantities. At age 29, she fell from height with evolving cerebral seizure and transient global amnesia, mild mental retardation, dissociative disorder, and post-traumatic syndrome, remaining in a coma for a month and a half. In March 2013, during follow-up with the Outpatient Proctology Clinic from the same hospital, the patient underwent anorectal manometry, which diagnosed decreased sensitivity and rectal capacity and lack of functional anal canal. After that, the patient was referred for physiotherapy assessment for rehabilitation of the pelvic floor muscles (PFMs). During physical therapy evaluation, the patient reported frequent insensitive loss of stools after bowel movements and feeling of incomplete rectal emptying. On physical exam, two scars were found in the anal region, one in the vaginal region, and another in the abdominal region. The patient had preserved cutaneous sensitivity, absent anocutaneous reflex, and preserved clitoral reflexes. The anal palpation was painful with a deficit at PFM strength (grade 2, modified Oxford Scale)
Int J Colorectal Dis
and asymmetric at contraction of PFM due to the presence of local fibrous tissue. In order to complement the functional evaluation of the PFM, we performed surface electromyography (EMG) of these muscles using an anal probe. Moreover, we standardized the collection of electromyographic signals using the following protocol: an initial rest period of 60 s followed by five sustained contractions for 2 s and five sustained contractions for 10 to 10 s of rest between contractions. Thereafter, a final sustained contraction for 60 s was performed, preceded and followed by standing for 10 s followed by a final resting period of 60 s. For data normalization, we used the maximal voluntary contraction (MVC) performed before protocol. There were collected three MVC sustained for 2 s each, taking the greatest value for normalization. Another treatment consisted of supervised exercise, whose protocol ranged from isolated contractions of PFM in different postures and exercises to strengthen the accessory muscles (gluteus, adductors, and rectus abdominis). The patient was encouraged to perform an exercise protocol for PFM at home daily. This protocol consisted in ten sustained contractions of 6 s with 12 s of rest between each contraction and five quick contractions, performed in four different postures: supine, quadruped, sitting and standing. Electromyographic biofeedback sessions with anal probe were held once a week, with a duration of 45 min. It was stimulated isolated contractions of PFM with fast and slow twitch fibers at protocols of gain strength, power, and endurance, as well as progressive work load according to MVC percentages. The following questionnaires (FIQL—Fecal Incontinence Quality of Life, Continence Grading Score and FISI—Fecal Incontinence Severity Index) were applied before and after 4 months of physical therapy. All of them showed an improvement of their values. With regard to the functional assessment of PFM through anal palpation, the patient had a gain of two points in the Modified Oxford Scale and PFM strength from grade 2 to grade 4 at the end of 4 months of rehabilitation. Fast, slow, and unique contractions of PFM were also improved by surface electromyography. During the patient’s clinical evaluation, fecal losses (that were daily and in large quantities) improved significantly in frequency ranging from once a week or less, with decreased volume of stool. The patient still makes use of loss protectors; however, she changed for a thinner absorbent used, using only by precaution when she goes for some place outside home, and it is always clean when she removes it, most of the time. The patient is still undergoing treatment at the Physical
Therapy Service in quarterly returns for monitoring the evolution of the problem and evaluation of adherence to home exercise program. The relationship between sexual abuse and symptoms of the lower urinary tract, gastrointestinal symptoms, and sexual dysfunction is described in many studies; Beck et al. [2], in their study, found that women with pelvic floor disorders had high prevalence of sexual abuse episodes and found that these women had a greater tendency to hypertonia of PFM, as a defense mechanism. The largest report from AI secondary to sexual abuse comes from Muleta et al. [3], referring a treatment of 91 Ethiopian women. Most of the girls (n=78) were abused under the cover of marriage, and nine were kidnapped with the intention of marriage, raped, and then discarded by their would-be husband. However, there are no data in the literature that showed an improvement by physical therapy of this type of AI. Biofeedback is an important therapeutic tool for the treatment of mild to moderate AI, based on the PFM training using visual and/or auditory stimulus in order to obtain a better response in active contraction and relaxation exercises. However, there are few studies at this treatment with objective reports by validated instruments, such as questionnaires and scales, either immediately after surgery or after long-term physiotherapy [4]. Thus, many studies using biofeedback bring results empirically, because most studies do not show adequate methodology. This case report showed a close association between the severity of symptoms reported by the patient and the treatment outcome. Biofeedback should be considered as an alternative or adjuvant to standard therapies for AI. Further studies with this option demonstrating the improvement or not by objective outcomes should be performed. Conflict of interest None.
References 1. Imhoff LR, Liwanag L, Varma M (2012) Exacerbation of symptom severity of pelvic floor disorders in women who report a history of sexual abuse. Arch Surg 147(12):1123–1129 2. Beck JJ, Elzevier HW, Pelger R, Putter H, Voorham‐van der Zalm PJ (2009) Multiple pelvic floor complaints are correlated with sexual abuse history. J Sex Med 6(1):193–198 3. Muleta M, Williams G (1999) Postcoital injuries treated at the Addis Ababa Fistula Hospital, 1991–97. Lancet 354(9195):2051–2052 4. Leite FR, Lima MJ, Lacerda-Filho A (2013) Early functional results of biofeedback and its impact on quality of life of patients with anal incontinence. Arq Gastroenterol 50(3):163–169
LETTER TO THE EDITOR
Physical therapy at anal incontinence secondary to sexual abuse Aline Moreira Ribeiro & Mariana Nicoletti Ferreira & Juliana dos Santos Ribeiro & Heliana Pandochi & Luiz Gustavo Oliveira Brito
Accepted: 21 October 2014 # Springer-Verlag Berlin Heidelberg 2014
Dear Editor, Anal incontinence (AI) brings negative consequences that affect daily life activities, health, and quality of life of patients. We also know that approximately 25 % of patients with pelvic floor disorders reported previous sexual abuse and that 12 % of patients with AI have had sexual abuse [1], especially when occurred during childhood. Treatment of this cause of AI is difficult; thus, we aimed to report the physical therapy of a young woman who presented AI secondary to sexual abuse. Patient and her legal responsible gave oral consent to this report. A 35-year-old nulliparous woman initiated her follow-up at our institution when she was with less than 1 year due to the lack of weight gain reported by her caregiver. Four years later, she returned to the service with a battered syndrome, fever, and urinary infection and stayed at the hospital for 3 months. By the reports of the father and brother, the patient was assaulted several times by her stepmother. In addition to the beatings, she forced her to perform household services with 3– 4 years and forced her to eat her own feces and swallowing vomiting arising from this act. Even at this age, according to the reports of his brother, the stepmother sexually abused her by inserting objects into her vagina and anus with significant injuries, as pieces of the objects remained in it. Thus, between 4 and 5 years, the patient underwent surgical repair of perineal injuries through sphincteroplasty of internal and external anal sphincters. Between 5 and 7 years of age, the patient was forced by her uncle to anal sex, almost daily, while she remained at her A. M. Ribeiro : M. N. Ferreira : J. dos Santos Ribeiro : H. Pandochi : L. G. O. Brito (*) Hospital das Clinicas da FMRP-USP, Ribeirao Preto Medical School, University of Sao Paulo, Avenida Bandeirantes, 3900 – 8th floor – Monte Alegre, Ribeirao Preto, SP 14049-900, Brazil e-mail: [email protected]
grandmother’s stepmother for work. In addition to the abuse, the patient was threatened that the situation was not exposed to others. Since then, the patient reports of early abuse of minor fecal losses, realized on the exchange of underwear. At 8 years of age, after moving from her stepmother’s house, the patient had the courage to expose the fact denouncing the abuses; however, despite the family tried to report it formally, the competent authorities did not believe to her confession, according to her interview. When she was 15 years of age, the patient underwent surgery for correction of a rectovaginal fistula, but after 5 years, the same uncle, at a unique episode, abused her again. Thirteen years later, she underwent a new surgery to correct a previous perianal fistula with anal fistulectomy and colostomy. This last procedure had prolapsed and she performed a new surgery for reconstruction of intestinal transit. After these surgeries, AI progressed, leading to the use of continuous protection against fecal losses that were daily and in large quantities. At age 29, she fell from height with evolving cerebral seizure and transient global amnesia, mild mental retardation, dissociative disorder, and post-traumatic syndrome, remaining in a coma for a month and a half. In March 2013, during follow-up with the Outpatient Proctology Clinic from the same hospital, the patient underwent anorectal manometry, which diagnosed decreased sensitivity and rectal capacity and lack of functional anal canal. After that, the patient was referred for physiotherapy assessment for rehabilitation of the pelvic floor muscles (PFMs). During physical therapy evaluation, the patient reported frequent insensitive loss of stools after bowel movements and feeling of incomplete rectal emptying. On physical exam, two scars were found in the anal region, one in the vaginal region, and another in the abdominal region. The patient had preserved cutaneous sensitivity, absent anocutaneous reflex, and preserved clitoral reflexes. The anal palpation was painful with a deficit at PFM strength (grade 2, modified Oxford Scale)
Int J Colorectal Dis
and asymmetric at contraction of PFM due to the presence of local fibrous tissue. In order to complement the functional evaluation of the PFM, we performed surface electromyography (EMG) of these muscles using an anal probe. Moreover, we standardized the collection of electromyographic signals using the following protocol: an initial rest period of 60 s followed by five sustained contractions for 2 s and five sustained contractions for 10 to 10 s of rest between contractions. Thereafter, a final sustained contraction for 60 s was performed, preceded and followed by standing for 10 s followed by a final resting period of 60 s. For data normalization, we used the maximal voluntary contraction (MVC) performed before protocol. There were collected three MVC sustained for 2 s each, taking the greatest value for normalization. Another treatment consisted of supervised exercise, whose protocol ranged from isolated contractions of PFM in different postures and exercises to strengthen the accessory muscles (gluteus, adductors, and rectus abdominis). The patient was encouraged to perform an exercise protocol for PFM at home daily. This protocol consisted in ten sustained contractions of 6 s with 12 s of rest between each contraction and five quick contractions, performed in four different postures: supine, quadruped, sitting and standing. Electromyographic biofeedback sessions with anal probe were held once a week, with a duration of 45 min. It was stimulated isolated contractions of PFM with fast and slow twitch fibers at protocols of gain strength, power, and endurance, as well as progressive work load according to MVC percentages. The following questionnaires (FIQL—Fecal Incontinence Quality of Life, Continence Grading Score and FISI—Fecal Incontinence Severity Index) were applied before and after 4 months of physical therapy. All of them showed an improvement of their values. With regard to the functional assessment of PFM through anal palpation, the patient had a gain of two points in the Modified Oxford Scale and PFM strength from grade 2 to grade 4 at the end of 4 months of rehabilitation. Fast, slow, and unique contractions of PFM were also improved by surface electromyography. During the patient’s clinical evaluation, fecal losses (that were daily and in large quantities) improved significantly in frequency ranging from once a week or less, with decreased volume of stool. The patient still makes use of loss protectors; however, she changed for a thinner absorbent used, using only by precaution when she goes for some place outside home, and it is always clean when she removes it, most of the time. The patient is still undergoing treatment at the Physical
Therapy Service in quarterly returns for monitoring the evolution of the problem and evaluation of adherence to home exercise program. The relationship between sexual abuse and symptoms of the lower urinary tract, gastrointestinal symptoms, and sexual dysfunction is described in many studies; Beck et al. [2], in their study, found that women with pelvic floor disorders had high prevalence of sexual abuse episodes and found that these women had a greater tendency to hypertonia of PFM, as a defense mechanism. The largest report from AI secondary to sexual abuse comes from Muleta et al. [3], referring a treatment of 91 Ethiopian women. Most of the girls (n=78) were abused under the cover of marriage, and nine were kidnapped with the intention of marriage, raped, and then discarded by their would-be husband. However, there are no data in the literature that showed an improvement by physical therapy of this type of AI. Biofeedback is an important therapeutic tool for the treatment of mild to moderate AI, based on the PFM training using visual and/or auditory stimulus in order to obtain a better response in active contraction and relaxation exercises. However, there are few studies at this treatment with objective reports by validated instruments, such as questionnaires and scales, either immediately after surgery or after long-term physiotherapy [4]. Thus, many studies using biofeedback bring results empirically, because most studies do not show adequate methodology. This case report showed a close association between the severity of symptoms reported by the patient and the treatment outcome. Biofeedback should be considered as an alternative or adjuvant to standard therapies for AI. Further studies with this option demonstrating the improvement or not by objective outcomes should be performed. Conflict of interest None.
References 1. Imhoff LR, Liwanag L, Varma M (2012) Exacerbation of symptom severity of pelvic floor disorders in women who report a history of sexual abuse. Arch Surg 147(12):1123–1129 2. Beck JJ, Elzevier HW, Pelger R, Putter H, Voorham‐van der Zalm PJ (2009) Multiple pelvic floor complaints are correlated with sexual abuse history. J Sex Med 6(1):193–198 3. Muleta M, Williams G (1999) Postcoital injuries treated at the Addis Ababa Fistula Hospital, 1991–97. Lancet 354(9195):2051–2052 4. Leite FR, Lima MJ, Lacerda-Filho A (2013) Early functional results of biofeedback and its impact on quality of life of patients with anal incontinence. Arq Gastroenterol 50(3):163–169
