Ruth (the doctor)
Ruth came to me after being seen at another clinic for pelvic rehabilitation. She had suffered from fecal incontinence after undergoing anal sphincter repair surgery. Her surgery was complicated by an infection of the surgical site and scar tissue.
I evaluated her and noted that her pelvic floor strength deep layer (III) was weak on the left side > right and she had trace (barely there) contraction of the anal sphincter. Layer II was also weak but she had a contraction present. She had been performing internal electrical stimulation with her daily pelvic floor muscles exercises (Kegels) and sEMG biofeedback.
Ruth was a determined patient and wanted to leave no stone unturned in trying to regain her fecal continence. During the evaluation, I noted that Ruth had a stronger contraction using her pelvic floor muscles when she focused on contracting the “vaginal” aspect of the muscles. (The pelvic floor muscles surround and support both the vagina and the rectum.) So, we began to have her focus on and perform her electrical stimulation intravaginally, in addition to intrarectally.
This caused a mild improvement in her pelvic floor muscle strength and she began noticing a decrease in her incontinent episodes over the next 2 months. Because she only had trace strength in her anal sphincter, it would take a long time to build up or hypertrophy this area and the surgery had caused her to possibly lose nerve function. So, I was not sure just how much return of function she would get and neither was she.
But we were both determined! Oh, and did I mention that Ruth was a neurologist (a nerve doctor).
Ruth performed her home exercise program which included sEMG biofeedback, electrical stimulation, and specific “overflow exercises”. These are pelvic and hip exercises that encourage and recruit the pelvic floor muscles to contract harder. Ruth would come in for follow up appointments to monitor progress and I would then upgrade the difficulty of the exercises as she improved.
Well, after a few months and some mild improvements I thought that perhaps Ruth had reached a plateau and that I could no longer help her. Ruth would not accept this. I suggested that she try external electrical stimulation to the peri-rectal area and levator ani. External electrodes (stickers) were placed around her anus region and the stimulation unit facilitated a stronger contraction for her. It is called NMES-neuromuscular electrical stimulation. She worked on this unit at home for several weeks and had a follow-up with her colorectal surgeon.
He was thrilled and said that she had gained significant return of anorectal strength and to continue with physical therapy. Ruth returned to me and we tested her. In fact, she had gained about 2 grades of strength in her sphincter and levator ani muscles. Her fecal incontinence had improved significantly although she still was having a few episodes. Ruth works diligently at her home program and I commend her for her hard work. It is a pleasure to be a part of her rehab process.
Tune in soon for another update…….
