Pelvic floor clinic

This is an embarrassing and socially restricting disorder. Formed stool, or faeces, cannot be retained until a toilet is reached (grade 3 incontinence). Inadequate control of wind/gas (grade 1) or of liquid/soft stools (grade 2) are milder forms of incontinence. Soiling or stained underwear is often the first sign of incontinence. I investigate and treat incontinence disorders in my pelvic floor clinic.

I see patients of all ages with various forms of constipation. The definition of constipation refers either to the frequency of defaecation (less than twice per week) or to problems emptying stool (strong straining, hard stool consistency, feeling of 'blockage' , incomplete evacuation). Problems emptying stool are accurately referred to as obstructed defaecation.

Chronic pelvic pain syndromes are both common and complex. I am frequently referred patients with such syndromes for a second opinion. The symptoms are often long-lasting, intense and incapacitating. Exacerbation may occur during sitting, cycling, defaecation and sexual intercourse.

There are two main factors determining continence: the function of the sphincter muscles and stool consistency. Even a healthy sphincter muscle has problems controlling liquid stool. Many patients referred for investigation of incontinence actually have a problem with diarrhoea. The most common causes of incontinence are sphincter damage during vaginal delivery of a baby and damage caused by haemorrhoid surgery. I also see rarer birth defects.

We distinguish between two main causes of constipation:

• Problems with the complete emptying of stool, with strong straining and the feeling of 'blockage'
• A seldom urge to emptying (slow transit constipation).
  Bloating and fullness often co-exist. Anal tears (fissures) are examined by proctoscopy.

Chronic pelvic pain often appears after surgery or pelvic trauma.

Exact history-taking and examination are most crucial. I value and appreciate the need for sensitivity and discretion during these investigations. The consultation last about 30 minutes and comprises manual and ultrasound examination and the sphincter pressure measurement (manometry). Sometimes I will need an x-ray or MRI (proctogram). If you have diarrhoea regularly, I will search for the underlying cause and treat it.

Questions relating to the time-course of the constipation and a physical exam are important. If the constipation is new, a colonoscopy may be indicated. In case of a difficulty emptying stool (obstructed defaecation), a functional test of the pelvic floor muscles and an x-ray (proctogram) may be useful. Measurement of colonic transit times by x-ray allows diagnosis of a slow transit colon.

Physical examination and history-taking are the most important diagnostic tools in pelvic pain. Clinical and specialist experience are crucial. Additional information can be obtaind by proctoscopy and a pelvic floor MRI to exclude hidden underlying causes.

This is dependent on the underlying cause, symptom severity and your age. Conservative lifestyle changes, pelvic physiotherapy and/or medication are mainstays of treatment. Surgery or neurostimulation are very useful additional possibilities for specific situations.

Treatment needs to be personalised. I will discuss dietary adaptation, plant-based or pharmaceutical treatment with you. In case of an obstructed defaecation, pelvic floor biofeedback physiotherapy is highly effective and I will organise a referral to experienced therapists. Sometimes there are specific surgical options we can discuss.

Chronic pelvic pain is generally treated with medication and/or specific physiotherapy ((Thiele, trigger point).
It is important not to trivialise these burdensome disorders.