RU2752370C1 - Method for correcting functional disorders of anal sphincter and pelvic floor muscles in patients with pelvic organ prolapse in combination with obstructive defecation and presence or absence of anal incontinence - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to coloproctology, and can be used in the treatment of patients with functional disorders of the muscles of the anal sphincter and pelvic floor, accompanied by prolapse of the pelvic organs in combination with obstructive defecation and the presence or absence of anal incontinence. For this, patients with identified disorders perform a set of physical exercises in a certain sequence, adding new exercises every 2 weeks.

EFFECT: invention provides adequate correction of functional disorders of the anal sphincter and pelvic floor muscles in patients with pelvic organ prolapse with incontinence and obstructive defecation by performing in a certain sequence the set of exercises developed by us, which takes into account the need for gradual restoration of the functional state of the anal sphincter and pelvic floor muscles in patients of various age categories, with varying degrees of severity of the patient's condition and their rehabilitation potential.

1 cl, 8 dwg, 3 tbl, 2 ex

Description

The invention relates to medicine, namely to coloproctology, and can be used in the treatment of patients with functional disorders of the muscles of the anal sphincter and pelvic floor, accompanied by prolapse of the pelvic organs in combination with obstructive defecation and the presence or absence of anal incontinence.

Currently, the problem of genital prolapse and associated anatomical and functional manifestations, despite the constant attention of gynecologists, proctologists, urologists, and the resulting multidisciplinary approach, remains relevant and unresolved.

This can be explained by the unclear mechanisms of the development of pathological changes and the mosaic nature of clinical manifestations.

The weakness of the ligamentous-muscular apparatus of the pelvic floor that develops during life, its damage during complicated labor leads to prolapse or prolapse of the pelvic organs with a violation of their function. Thus, there is a characteristic symptom complex associated with a violation of fixation of the pelvic organs - perineal prolapse syndrome (POP). This term is most often used in proctological practice. As a rule, damage to the pelvic floor occurs in the area of the rectovaginal septum, which is accompanied by the development of rectocele (Fomenko O.Yu., Shelygin Yu.A., Popov A.A., Poryadin G.V., Titov A.Yu., Berseneva E. A., Mudrov A.A., Belousova S.V. The functional state of the pelvic floor muscles in patients with rectocele.Russian Bulletin of Obstetrician-Gynecologist. 2017; 17 (3): 43-48).

It is known that rectocele is detected during a dispensary gynecological examination in 40-80% of women who do not present any complaints. And among women with complaints of impaired rectal emptying, the prevalence of rectocele, according to different authors, ranges from 7 to 56.5% (Shelygin Yu.A., Titov A.Yu., Dzhanaev Yu.A., Biryukov O. M., Mudrov A.A., Krasnopolskaya I.V.Peculiarities of the clinical picture and the nature of neuro-functional disorders in patients with rectocele.Coloproctology. 2012; 4 (42): 27-32; Block IR Transrectal repair of rectocele using obliterative suture. Dis Colon Rectum. 1986; 29: 707-711; Savoye-Collet C, Savoye G, Koning E, Leroi AM, Dacher JN Defecography in symptomatic older women living at home. Age Aging. 2003, 32: 347-350).

Rectocele (rectocele: Latin rectum - rectum; Greek cele - protrusion, hernia, swelling) is a diverticulum-like protrusion of the rectal wall towards the vagina (anterior rectocele) and / or along the posterior semicircle of the intestine (posterior rectocele). The anterior rectocele can be presented as an isolated form, or in combination with the posterior rectocele and internal invagination of the rectum (Shelygin Yu.A. Handbook of coloproctology. M: Littera, 2012. S. 191-193; Krasnopolsky V.N., Ioseliani M .N., Rizhinashvili ID, Slobodyanyuk AI Modern aspects of surgical treatment of prolapse and prolapse of internal genital organs in women. Obstetrics and gynecology. 1990; 8: 58-61; Popov AA, Slavutskaya O.S. , Ramazanov M.R.Modern aspects of diagnostics and surgical treatment of prolapse and prolapse of genitals in women.Endoscopic surgery. 2002; 6: 13-15; Bharucha A.E., Pemberton JH, Locke GR et al. American Gastroenterological Association: technical review on constipation.Gastroenterology. 2013; 144 (1): 218-238; Clinical guidelines.Coloproctology / edited by Yu.A. Shelygin.M: GEOTAR-Media, 2015. S. 147-168).

According to the literature, rectocele is found in 40-80% of women who do not complain about their condition. In other cases, rectocele is manifested by impaired emptying of the rectum with the development of obstructive defecation syndrome (ODS). In almost half of patients, constipation is caused by outlet obstruction or obstructive defecation (OD) (Rosen A. Obstructed Defecation Syndrome: Diagnosis and Therapeutic Options, with Special Focus on the STARR Procedure. Isr Med Assoc J. 2010; 12 (2): 104-106; Fomenko O.Yu.Mechanisms of violation of the evacuation and retention function in diseases of the rectum and directions of pathogenetically justified diagnostics and therapy.Dis.Med.Sc. M., 2018). OD, as defined by D. Bartolo (Bartolo D., Roe A. Obstructed defaecation. Br J Hosp Med. 1986; 35: 228-236), a broad concept defined as difficulty in evacuating rectal contents, with dyschezia symptoms and subjective anal sensation blockade during bowel movements.

Obstructive defecation syndrome (SOD) is characterized by a spectrum of symptoms, such as difficulty in emptying and the need for excessive straining during bowel movements, a feeling of incomplete emptying, an increase in the duration of bowel movements, pain, rectal bleeding and the need for manual assistance in stool (Fomenko O.Yu., Titov A.Yu. ., Biryukov O.M. et al. Diagnostics and conservative treatment of functional disorders of defecation.Coloproctology. 2016; 3 (57): 48-54; Fomenko O.Yu., Shelygin Yu.A., Poryadin G.V. et al. Functional state of the pelvic floor muscles in patients with obstructive defecation syndrome Coloproctology. 2017; 2 (60): 55-61; Preston DM, Lennard-Jones JE Anismus in chronic constipation. Dig Dis Sci. 1985; 30 (5): 413 -418; Rao SS, Welcher KD, Leistikow JS Obstructive defecation: a failure of rectoanal coordination.Am J Gastroenterol. 1998; 93: 1042-1050; Schwandner O., Stuto A., Jayne D. et al. Decision-making algorithm for the STARR procedure in obstructed defecation syndro me: position statement of the group of STARR Pioneers. Surg Innov. 2008; 15: 105-109). It has been found that approximately 20% of adult women suffer from this syndrome (Zhang B., Ding JH, Yin SH et al. Stapled transanal rectal resection for obstructed defecation syndrome associated with rectocele and rectal intussusception. World J Gastroenterol. 2010; 16 (20) : 2542-2548).

The etiology of SOD is multifactorial, and is the result of the interaction of many functional and anatomical causes affecting the evacuation mechanism (Fomenko O.Yu., Shelygin Yu.A., Popov AA, et al. Genital prolapse and obstructive defecation. View from the standpoint of functional diagnostics . Medical alphabet. Modern gynecology. 2017; 3 (1): 39-44). Internal intussusception of the rectum and rectocele are most common as an organic cause of obstructive defecation (Zhang B., Ding JH, Yin SH et al. Stapled transanal rectal resection for obstructed defecation syndrome associated with rectocele and rectal intussusception. World J Gastroenterol. 2010; 16 ( 20): 2542-2548).

In 25-50% of cases, the causes of SOD can be not only anatomical, but also functional defecation disorders (FDD) (Fomenko O.Yu., Shelygin Yu.A., Poryadin G.V., Titov A.Yu., Ponomarenko A. A., Mudrov A.A., Belousova S.V. The functional state of the pelvic floor muscles in patients with obstructive defecation syndrome.Coloproctology. 2017; 2 (60): 55-61; Fomenko O.Yu. in diseases of the rectum and directions of pathogenetically substantiated diagnostics and therapy.Diss ... MD, M., 2018; Grossi U., Carrington EV, Bharucha AE et al. Diagnostic accuracy study of anorectal manometry for diagnosis of dyssynergic defecation Gut 2016; 65 (3): 447-455). In 2016, the updated Rome criteria for functional digestive disorders were presented According to the Rome IV criteria (Rao S.S.C., Bharucha A.E., Chiarioni G. et al. Anorectal Disorders. Gastroenterology. 2016; 150 (6): 1430-1442.e4). In this case, the diagnosis of functional defecation disorder is established in the presence of criteria for functional constipation and / or irritable bowel syndrome with a predominance of constipation, as well as in the presence of the following signs of defecation disorder and include dyssynergic defecation (DD) and inadequate propulsion [Lacy BE, Mearin F, Chang L, et al. Bowel Disorders. Gastroenterology. 2016; 150 (6): 1393-1407.e5.], (Drossman DA Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features, and Rome IV. Gastroenterology. 2016; 150: 1262-1279; Rao SSC, Bharucha AE, Chiarioni G. etal. Anorectal Disorders. Gastroenterology. 2016; 150 (6): 1430-1442.e4) (Table 1).

Diagnostic criteria for functional defecation disorder (Rome IV. 2016, as amended (Lacy B.E., Mearin F., Chang L. et al. Bowel Disorders. Gastroenterology. 2016; 150 (6): 1393-1407.e5).

It is possible to diagnose FRD using anorectal manometry, defecography, or EMG.

The main method for diagnosing functional defecation disorder is anorectal manometry - a functional diagnostic study that allows real-time monitoring of the pressure distribution in the rectum and anal canal. The study is carried out using balloon water-perfusion or solid-state sensors. Anorectal manometry devices differ in the number of channels, that is, in the number of levels (distance from the anus) at which pressure analysis is carried out. The first studies were carried out on 6-, 8- and 12-channel transducers, however, recently the main method has become high-resolution anorectal manometry (HRAM), which allows you to estimate pressure at 24 levels and build a "color map" (computer graphics of Klose) of pressure distribution in the rectum and anal canal, clearly demonstrating possible pathological changes. Depending on the nature of the pathological changes detected by anorectal manometry, four manometric patterns of functional defecation disorder are distinguished. The fourth Rome criteria distinguish between "insufficient propulsion during defecation" (subtype F3a, including types II and IV) and "dyssynergic defecation" proper (subtype F3b, including types I and III).

Dyssynergic defecation (DD) (F3b) is the discoordination of the muscles that carry out the normal act of defecation. Normally, during bowel movements, intrarectal pressure increases, and pressure in the anal canal decreases due to relaxation of the anal sphincters and pelvic floor muscles. DD is defined as a paradoxical contraction of the pelvic floor or relaxation of less than 20% of the resting pressure of the sphincter with sufficient propulsive force during defecation attempts. Insufficient propulsive force with or without paradoxical contraction or relaxation of less than 20% of the resting pressure of the sphincter when trying to defecate refers to F3a - inadequate propulsion (Rao SSC, Bharucha AE, Chiarioni G. et al. Anorectal Disorders. Gastroenterology. 2016; 150 (6): 1430-1442.e4).

According to the consensus of the AIGO / SICCR Association (Italy, 2012) (Bove A., Pucciani F., Bellini M. et al. Consensus statement AIGO / SICCR: diagnosis and treatment of chronic constipation and obstructed defecation (part I: diagnosis). World J Gastroenterol. 2012; 18 (14): 1555-64) the main cause of obstructive defecation is inadequate anal sphincter relaxation, sometimes associated with paradoxical contraction during straining.

When conducting anorectal manometry in patients with FRD, four types of patterns of pressure changes in the anal canal and rectum during straining attempts can be recorded (Carrinigton EV, Brokjer A., Craven N. et al. Traditional measures of normal anal sphincter function using high resolution anorectal manometry (HRAM) in 115 healthy volunteers Neurogastroenterol Motil 2014; 26 (5): 625-635; Conklin J., Pimentel M. Soffer E. Color Atlas of High Resolution Manometry Springer: Los Angeles 2011; p. 104; Noelting J., Ratuapli SK, Bharucha AE et al. Normal values for high-resolution anorectal manometry in healthy women: effects of age and significance of rectoanal gradient.Am J Gastroenterol. 2012; 107: 1530-1536; Ratuapli SK, Bharucha AE, Noelting J. et al. Phenotypic identification and classification of functional defecatory disorders using high-resolution anorectal manometry. Gastroenterology. 2012; 144: 314-322): Type I pattern is characterized by the fact that in conditions x adequate propulsion (increase in intrarectal pressure up to 45 mm Hg. and more) there is a synchronous increase in pressure in the anal canal. This type is also referred to in the literature as a spasm of the puborectal loop, or anism.

Type II pattern - associated with the lack of a sufficient increase in intrarectal pressure when trying to defecate in combination with a paradoxical increase in pressure in the anal canal. Type II pattern is referred to as inadequate propulsion.

Type III pattern - with an adequate increase in intrarectal pressure (<45 mm Hg), the pressure in the anal canal does not decrease or decreases insufficiently (less than 20% of the pressure at rest). Thus, the pelvic floor muscles are like a "rigid" structure, unable to fully perform the function of evacuation.

Type IV - an inadequate increase in pressure in the rectum (<45 mm Hg), accompanied by an insufficient decrease in pressure in the anal canal (less than 20% of the initial pressure).

Moreover, I and III types of patterns are defined as dyssynergic defecation (F3b), II and IV - as inadequate propulsion (F3a).

It is important to emphasize that anorectal manometry, being an informative tool in identifying the pathogenesis of obstructive defecation, also helps in the development of a program for conservative treatment of dyssynergic defecation and serves for a dynamic assessment of the results of biofeedback therapy and physiotherapeutic methods of influence (Bove A., Pucciani F., Bellini M. et al. Consensus statement AIGO / SICCR: diagnosis and treatment of chronic constipation and obstructed defecation (part I: diagnosis). World J Gastroenterol. 2012; 18 (14): 1555-64; Fomenko O.Yu., Titov A.Yu. ., Biryukov OM et al. Diagnosis and conservative treatment of functional disorders of defecation. Coloproctology. 2016; 3 (57): 48-54).

BFB therapy as a first-line treatment for functional defecation disorder is recommended by the Fourth Rome Agreement (Rao SSC, Bharucha A.E., Chiarioni G. et al. Anorectal Disorders. Gastroenterology. 2016; 150 (6): 1430-1442. e4.), as well as the Guidelines of the American and European Societies of Neurogastroenterology and Motor (Rao SSC, Benninga M.A., Bharucha A.E. et al. ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol Motil. 2015; 27 (5): 594-609.). However, the Rome Agreement and the recommendations of the World Gastroenterological Organization emphasize that instrumental examinations in order to detect defecation disorder should be performed only if there is insufficient response to conservative treatment. Prior to anorectal manometry and other (often expensive) examination, the patient is interviewed about the need to ensure a regular balanced diet, the intake of fluids and plant fibers with food is increased, balanced dietary fiber preparations are prescribed, and an attempt is made to stop drugs that contribute to constipation. In addition to the typical symptoms (the need for excessive and prolonged straining, a feeling of incomplete emptying during bowel movements and the need for manual assistance), the results of a digital examination allow us to suspect a functional disorder of defecation: in one of the studies, a digital examination revealed the absence of relaxation of the puborectal muscle and the external sphincter with 75% sensitivity and 87% specificity (Tantiphlachiva K., Rao P., Attaluri A. et al. Digital Rectal Examination Is a Useful Tool for Identifying Patients With Dyssynergia. Clin Gastroenterol Hepatol. 2010; 8 (11): 955-960.). The simplest method for detecting functional defecation disorder is the push-out test (evacuation test). To do this, the patient is injected into the rectum with a 50 ml canister filled with water or air, which must be expelled while sitting or lying on the left side (Minguez M., Herreros B., Sanchiz V. et al. Predictive value of the balloon expulsion test for excluding the diagnosis of pelvic floor dyssynergia in constipation. Gastroenterology. 2004; 126 (1): 57-62). The test results when measured lying or sitting coincide in 79% of cases (Ratuapli S., Bharucha A.E., Harvey D. et al. Comparison of rectal balloon expulsion test in seated and left lateral positions. Neurogastroenterol Motil. 2013: 25 (12 ): e813-20.). In the prone position, dyssynergy is detected more often, however, in most centers the test is performed in a sitting position. The technique of the evacuation test is not sufficiently standardized: a number of authors state ineffective defecation when it is impossible to push the balloon out in 1 minute (Rao SSC Dyssynergic defecation. Gastroenterol Clin North Am. 2001; 30 (1): 97-114, Rao SSC, Kavlock R., Rao S. Influence of Body Position and Stool Characteristics on Defecation in Humans. Am J Gastroenterol. 2006; 101 (12): 2790-2796.), Other authors in 2 minutes (Chiarioni G., Kim SM, Vantini I. et al. Validation of the Balloon Evacuation Test: Reproducibility and Agreement With Findings From Anorectal Manometry and Electromyography. Clin Gastroenterol Hepatol. 2014; 12 (12): 2049-2054.).

In gynecological practice, the term "genital prolapse" is used - a disease in which there is a prolapse or prolapse of the pelvic organs through the vagina. Prolapse or prolapse of the pelvic organs refers to the uterus, bladder, rectum, or small intestine.

Pelvic organ prolapse is the definition of anatomical changes. All pelvic organs (bladder, uterus and rectum) are supported by a hammock complex of muscles and ligaments that attach to the pelvic bones. When they weaken, then under the influence of gravity and with an increase in intra-abdominal pressure, first the prolapse occurs, and then the complete loss of one or another organ through the vagina.

So, the condition in which the bladder descends through the anterior wall of the vagina is called cystocele. This is the most common type of prolapse. In addition, prolapse of the uterus is common. If the uterus has been removed, the vaginal dome may descend. The prolapse of the rectum through the posterior wall of the vagina is called rectocele, prolapse of the loops of the small intestine through the posterior fornix of the vagina is called enterocele. Thus, despite the different terminological concepts among gynecologists and proctologists, the problem remains the same.

Rectocele may be accompanied by impaired emptying of the rectum, while obstructive defecation syndrome (ODS) develops, which is manifested by difficulty in defecation in the form of prolonged straining, a feeling of incomplete emptying of the rectum, the need to use a manual aid.

When rectocele is manifested by a violation of rectal emptying, obstructive defecation syndrome (ODS) develops, which is manifested by difficulty in defecation, accompanied by prolonged straining, a feeling of incomplete emptying of the rectum, the use of a manual aid for emptying the rectum.

In addition to impaired emptying of the rectum, dyspareunia occurs, which disrupts the sexual function of patients. Women with rectocele may complain of a feeling of pressure on the vagina and the presence of a round formation in this area, recurrent pain in the lower abdomen and lower back, urinary and gas incontinence during exercise, coughing or sneezing.

From the prior art, there are many different methods for correcting disorders of the functional state of the muscles of the anal sphincter and pelvic floor, which, with varying degrees of disturbance, can be accompanied by prolapse of the pelvic organs with the consequent complications in the form of obstructive defecation with or without incontinence.

Thus, methods of electrical stimulation of the internal anal sphincter are known (RU 2587951, RU 2280479).

However, these methods require the use of both certain devices and the observation of the procedure by specially trained medical personnel, and the premises where such procedures are carried out, which requires patients with such a pathology to visit the polyclinic more than once, and this is quite problematic for these patients.

It is also known to use tibial neuromodulation, which consists in acting on the pudendal nerve emerging from the sacral plexus (S2-S4) by electrical stimulation of the posterior tibial nerve in the lower extremities. By stimulating autonomic, sensory and motor nerves, the technique improves tone, contractility and neuro-reflex activity of the ZAIK muscles (Clinical guidelines. Coloproctology. Insufficiency of the anal sphincter / edited by Yu.A. Shelygin. M: GEOTAR-Media, 2015. P . 190-215).

Known biofeedback therapy, which can be carried out at the initial stage of treatment of patients with obstructive defecation and / or anal incontinence both in the mode of coordination of the impaired work of the muscles of the anterior abdominal wall and pelvic floor during straining, and in the mode of increasing the contractility and endurance of the muscles of the anal sphincter and the pelvic floor during contraction. This applies to those patients who have failed to achieve a positive effect with diet and drug therapy. In the treatment of patients with obstructive defecation and insufficiency of the anal sphincter, biofeedback therapy is aimed at the development of self-regulation of the functional activity of the muscular structures of the perineum, the development of correct perception of sensations that can improve control over the function of keeping intestinal contents (Clinical guidelines. Coloproctology. Insufficiency of the anal sphincter / ed. By Yu. A. Shelygina, Moscow: GEOTAR-Media, 2015, pp. 190-215).

However, these methods either require the presence of trained medical personnel, or are economically unprofitable due to the high cost of medications, which, moreover, do not, in fact, eliminate the cause of the occurrence of violations.

The closest analogue is the method described in the article by S.P. Degtyarenko "Exercises to strengthen the anal sphincter", 09/18/2020, http://proktolog-odessa.info/kak-ukrepit-slabyiy-sfmkter/. This article deals with the correction of disorders of the muscles of the anal sphincter by performing a set of exercises. Special exercises help to strengthen the locking apparatus, the pelvic floor muscles. A large number of exercises involve pulling in the anus muscles. Exercises are mainly aimed at training the muscles of the press, pelvic floor. Combine them with breathing exercises. The set of exercises is selected individually. Gymnastics is performed daily. Medication is aimed at stimulating nerve connections.

However, this method does not take into account the correlation of the coordination of the work of the muscles of the anal sphincter / pelvic floor and the muscles of the anterior abdominal wall with the phases of breathing, which in this case is most effective. In addition, patients with varying degrees of impairment require an individual, differentiated approach, which is excluded from the set of exercises specified in the article.

The technical result provided by the invention we propose is to provide adequate correction of functional disorders of the muscles of the anal sphincter and pelvic floor in patients with pelvic organ prolapse in combination with obstructive defecation with or without incontinence by performing in a certain sequence the set of exercises developed by us, which takes into account the need to gradually restore the functional state of the muscles of the anal sphincter and pelvic floor in patients of different age categories, with varying degrees of severity of the patient's condition and their rehabilitation potential.

The specified technical result is provided by using a method for correcting functional disorders of the muscles of the anal sphincter and pelvic floor in patients with pelvic organ prolapse with incontinence or obstructive defecation, including the performance of physical exercises, characterized in that the following complex is performed as physical exercises:

0) Basic exercise: starting position (PI) lying on the back, legs straight shoulder-width apart, the anal sphincter is relaxed, one hand is placed on the stomach, the other on the sternum, involuntary breathing,

- exhale, hold their breath, tighten the muscles of the anterolateral abdominal wall and draw in the abdomen, while the anal sphincter is relaxed,

- relax the abdominal muscles and return to the PI,

- repeat 3-5 times,

moreover, exercise 0 is performed before each subsequent exercise and at the end of the entire complex;

1.1) PI - sitting on the floor, legs are apart shoulder-width apart, bent at the knee and hip joints and rest on the feet, hands are fixed outside the knees, the anal sphincter is relaxed, breathing is involuntary,

- squeeze the anal sphincter and inhale, hold their breath and create resistance with their hands, while trying to spread the knees, fix the position at the count of 1 -2-3-4,

- exhale and return to the IP,

- repeat 4 times;

1.2) PI - sitting on the floor, legs are apart shoulder-width apart, bent at the knee and hip joints and rest on the feet, hands rest against the floor from behind, the anal sphincter is relaxed, breathing is involuntary,

- squeeze the anal sphincter and inhale, hold your breath and press your knees against each other at a count of 1-2-3-4,

- exhale and return to the IP,

- repeat 10 times;

2.1) PI - standing with an emphasis on the knees and hands, the anal sphincter is relaxed, the legs are shoulder-width apart, the face is directed to the floor, breathing is involuntary,

- squeeze the anal sphincter, take a breath, hold their breath,

- straighten the right leg, lifting it above the floor, without bending the back, and perform circular movements with the leg 4 times,

- exhale, relax the anal sphincter and return to the PI,

- repeat the exercise with the left leg,

- the cycle with the movements of both legs is repeated 2 times;

2.2) PI - standing with an emphasis on the knees and hands, the anal sphincter is relaxed, the legs are shoulder-width apart, the face is directed to the floor, breathing is involuntary.

- squeeze the anal sphincter, take a breath, hold your breath.

- straighten the right leg, lifting it above the floor, without bending the back,

- keeping the anal sphincter compressed, exhale and return the leg to its original position,

- do the exercise with the other leg,

- relax the anal sphincter and switch to involuntary breathing,

- the cycle with the movements of both legs is repeated 3 times;

2.3) PI standing with an emphasis on the knees and hands, the anal sphincter is relaxed, the legs are shoulder-width apart, the face is directed to the floor, breathing is involuntary,

- squeeze the anal sphincter, inhale, hold the breath,

- straighten the right leg, raising it above the floor, without bending the back, and extend the left arm above the head,

- exhale, relaxing the anal sphincter and returning the leg and arm to the PI,

- squeeze the anal sphincter, inhale, holding the breath,

- straighten the left leg, raising it above the floor, without bending the back, and extend the right arm above the head,

- exhale, relaxing the anal sphincter and returning the leg and arm to the PI,

- relax the anal sphincter and switch to involuntary breathing,

- repeat the cycle 3 times with movements of opposite arms and legs;

3) PI - lying on his stomach, hands under his head, face lying on hands, legs straight, anal sphincter relaxed, involuntary breathing,

- squeeze the anal sphincter, inhale, hold their breath,

- Exercise "scissors" - raise both straight legs above the floor, without bending the lower back and without raising your head, make 3 crossing movements with your legs,

- exhale and return to the IP,

- repeat 2 times:

4) PI - sitting on the floor, legs extended, hands resting on the foam, involuntary breathing,

- move forward on the buttocks, then backward, 10 seconds; while the set of exercises is performed in the following order:

- for the first 2 weeks, patients perform exercises 0, 1.1, 1.2,

- 3-4 weeks - add exercises 2.1,2.2,

- 5-6 weeks - add exercises 2.3, 3, 4.

The method is explained by graphic materials:

Rice. 1 - characterizes the basic exercise 0

Rice. 2 - characterizes exercise 1.1

Rice. 3 - characterizes exercise 1.2

Rice. 4 - characterizes exercise 2.1

Rice. 5 - characterizes exercise 2.2

Rice. 6 - characterizes exercise 2.6

Rice. 7 - characterizes exercise 3

Rice. 8 - characterizes exercise 4

The method is carried out as follows.

The patient at home or in a medical institution performs a set of exercises.

For this complex, a flat floor is required, but a bed can be used if the patient is unable to stand up, and a rug to lay on the floor.

The following complex is performed as physical exercises: 0) Basic exercise (Fig. 1): initial position (IP) lying on the back, legs are straight shoulder-width apart, the anal sphincter is relaxed, one hand is placed on the stomach, the other on the sternum, involuntary breathing,

- exhale, hold their breath, tighten the muscles of the anterolateral abdominal wall and draw in the abdomen, while the anal sphincter is relaxed,

- relax the abdominal muscles and return to the PI,

- repeat 3-5 times.

Basic exercise 0 is performed before each subsequent exercise and at the end of the entire complex.

Exercise 1.1) PI - sitting on the floor, legs are apart shoulder width apart, bent at the knee and hip joints and rest on the feet, hands are fixed outside the knees, the anal sphincter is relaxed, breathing is involuntary,

- squeeze the anal sphincter and inhale, hold their breath and create resistance with their hands, while trying to spread the knees, fix the position at the count of 1 -2-3-4,

- exhale and return to the IP,

- repeat 4 times (fig. 2).

Exercise 1.2) PI - sitting on the floor, legs are apart shoulder-width apart, bent at the knee and hip joints and rest on the feet, hands rest on the back of the floor, the anal sphincter is relaxed, breathing is involuntary,

- squeeze the anal sphincter and inhale, hold your breath and press your knees against each other at a count of 1-2-3-4,

- exhale and return to the IP,

- repeat 10 times (fig. 3).

Exercise 2.1) PI - standing with an emphasis on the knees and hands, the anal sphincter is relaxed, the legs are shoulder-width apart, the face is directed to the floor, breathing is involuntary,

- squeeze the anal sphincter, take a breath, hold their breath,

- straighten the right leg, lifting it above the floor, without bending the back, and perform circular movements with the leg 4 times,

- exhale, relax the anal sphincter and return to the PI.

- repeat the exercise with the left leg,

- the cycle with the movements of both legs is repeated 2 times (Fig. 4).

Exercise 2.2) PI - standing with an emphasis on the knees and hands, the anal sphincter is relaxed, the legs are shoulder-width apart, the face is directed to the floor, breathing is involuntary,

- squeeze the anal sphincter, take a breath, hold their breath,

- straighten the right leg, lifting it above the floor, without bending the back,

- keeping the anal sphincter compressed, exhale and return the leg to its original position,

- do the exercise with the other leg,

- relax the anal sphincter and switch to involuntary breathing,

- the cycle with the movements of both legs is repeated 3 times (Fig. 5).

Exercise 2.3) PI standing with an emphasis on the knees and hands, the anal sphincter is relaxed, the legs are shoulder-width apart, the face is directed to the floor, breathing is involuntary,

- squeeze the anal sphincter, inhale, hold the breath,

- straighten the right leg, raising it above the floor, without bending the back, and extend the left arm above the head,

- exhale, relaxing the anal sphincter and returning the leg and arm to the PI,

- squeeze the anal sphincter, inhale, holding the breath,

- straighten the left leg, raising it above the floor, without bending the back, and extend the right arm above the head,

- exhale, relaxing the anal sphincter and returning the leg and arm to the PI,

- relax the anal sphincter and switch to involuntary breathing,

- repeat the cycle 3 times with movements of opposite arms and legs (Fig. 6). Exercise 3) PI - lying on your stomach, hands under your head, face lying on your hands, legs

straight, anal sphincter relaxed, involuntary breathing,

- squeeze the anal sphincter, inhale, hold their breath,

- Exercise "scissors" - raise both straight legs above the floor, without bending the lower back and without raising your head, make 3 crossing movements with your legs,

- exhale and return to the IP,

- repeat 2 times (fig. 7).

Exercise 4) PI - sitting on the floor, legs extended, hands resting on knees, involuntary breathing,

- move forward on the buttocks, then backward, 10 seconds (Fig. 8). The set of exercises is performed in the following order:

- for the first 2 weeks, patients perform exercises 0, 1.1, 1.2,

- 3-4 weeks - add exercises 2.1, 2.2,

- 5-6 weeks - add exercises 2.3, 3, 4.

The sequence of the exercises is based on a change in the initial position of the body in space (first lying on the back, then sitting, etc.). As you adapt to physical activity, which in most cases is 2 weeks of constant exercise, the initial complex is supplemented with exercises in the manner described above.

Example 1

Patient I., 47 years old, complained of severe constipation, multiple bowel movements, periodically - a feeling of incomplete bowel movement and spastic abdominal pain. Notes the need for strong straining and the use of a manual aid during bowel movements. She regulates the stool with the help of irregular intake of large doses of lactulose preparations and manual allowance, due to the lack of independent stool, she asked for medical help. These complaints have been disturbing for 1 year, appeared against the background of increased constipation and stress. History of 1 childbirth.

On digital examination, the internal hemorrhoids are slightly expressed, the sphincter tone and volitional efforts are satisfactory. Determined by the prolapse of the anterior rectal wall to the level of the vestibule; spasm in the projection of m.levator ani when straining?

When questioning - 21 points according to the Scoring System for violations of the evacuation function of the colon (Shelygin Yu.A., Biryukov O.M., Titov A.Yu., Fomenko O.Yu., Mudrov A.A. Are there predictors of surgical treatment outcomes? rectocele? Coloproctology. 2015; 1 (51): 64-69).

With defecography in a sitting position, the rectum is located 4.5 cm below the level of the pubococcygeal line. With a volitional contraction, the intestine shifts upward and is located 3 cm below the pubococcygeal line. During emptying during straining, the intestine drops down to 5.5 cm. A rectocele up to 1.5 cm deep is formed along the anterior wall. Defecation is fractional. Rectum evacuation time - up to 1 minute.

The residual volume is about 30%, part of the contrast is retained in the rectocele. Conclusion: R-signs of the anterior rectocele of I degree, prolapse of the perineum in the stage of compensation of the pelvic floor muscles.

When conducting high-resolution anorectal manometry (HRAM) against the background of a slight increase in spontaneous activity, the pressure in the anal canal at rest and with voluntary contraction of the sphincter is within physiological norms. The cough reflex is not changed. Fatigue of the muscles of the external sphincter is not increased. The rectoanal inhibitory reflex of the internal sphincter is recorded. The threshold of the first sensitivity of the rectum to filling is not changed - 30 ml. Straining under conditions of adequate propulsion revealed an increase in pressure in the anal canal (type I manometric pattern). Conclusion: Manometric type I pattern during straining (dyssynergic defecation).

Table 2 below shows the results of the measurements performed on this patient and the reference values.

The evacuation test with the pushing out of the 50 ml balloon in the sitting position is negative.

Based on the data of anorectal manometry and a negative evacuation test in accordance with the Rome IV criteria, the patient can think about the presence of functional disorders of defecation type I (dyssynergic defecation, spasm of the puborectal loop).

The patient was prescribed a course of physiotherapy exercises in the form of a set of exercises according to the proposed method. It is also recommended to change the regimen of lactulose intake - to a daily low dose. After 4 weeks, the effectiveness of this course was noted: subjectively, the patient noted the absence of abdominal pain, normalization of the urge to defecate, and an independent ribbon-like stool - 6 points upon repeated questioning.

With control anorectal manometry after 6 weeks of performing a set of exercises, there is a positive dynamics in the ratio of pressure indicators in the anal canal during straining and at rest with the transformation of the manometric pattern into type III (56/49 (relaxation 12%) - incomplete relaxation in conditions of adequate propulsion.

Example 2

Patient V., 30 years old, complained of constipation, feeling of incomplete bowel emptying, feeling of a foreign body in the vagina, gas incontinence, stress urinary incontinence, periodically notes the appearance of traces of feces on the linen. Also notes the need for strong straining and the use of manual assistance during defecation by pressing on the back wall of the vagina. The stool is regulated with a laxative diet and manual allowance. These complaints have been troubling for 3 years, appeared against the background of constipation after childbirth. Childbirth - 2, uncomplicated.

When examining the area of the anus, the skin is not changed, there is no scratching and maceration. With a digital examination, the prolapse of the anterior rectal wall beyond the level of the vestibule of the vagina is determined. When questioning - 4 points on the Cleveland scale for assessing the degree of incontinence (Wexner) (Jorge JM, Wexner SD Etiology and management of fecal incontinence. Dis Colon Rectum. 1993; 1: 77-97. Validized in Russia: Clinical guidelines. Coloproctology / ed. Shelygina Yu.M .: GEOTAR-Media, 2015; P. 528), 11 points according to the Scoring system for violations of the evacuation function of the colon.

With defecography in a sitting position, the rectum is located 5.6 cm below the level of the pubococcygeal line. With a volitional contraction, the intestine shifts up and is located 4 cm below the pubococcygeal line. During emptying, when straining, the intestine drops down to 7 cm. A rectocele up to 4 cm deep is formed along the anterior wall. The directional vector is oriented in the rectocele and partially in the anal canal. Defecation is instantaneous. Rectum evacuation time is 25 seconds. The residual volume is about 55%, part of the contrast is retained in the rectocele. Conclusion: R-signs of II degree anterior rectocele, perineal prolapse in the stage of pelvic floor muscle compensation.

When conducting high-resolution anorectal manometry (HRAM), the pressure in the anal canal at rest is reduced, with voluntary contraction of the sphincter - within physiological norms. The cough reflex is weakened. Fatigue of the muscles of the external sphincter is increased. The rectoanal inhibitory reflex of the internal sphincter is recorded. The threshold of the first sensitivity of the rectum to filling is increased to 60 ml. Straining revealed inadequate propulsion (intrarectal pressure 34 mm Hg) with an increase in pressure in the anal canal relative to the pressure at rest (type II manometric pattern). Conclusion: Manometric signs of decreased tone and contractility of the anal sphincter and weakening of its reflex reactions. Type II manometric pattern during straining (inadequate propulsion).

Based on the data of anorectal manometry and defecography in accordance with the Rome IV criteria, the patient can think of the presence of functional disorders of defecation type II (inadequate propulsion).

Table 3 below shows the results of the measurements performed on this patient and the reference values.

In a complex sphincterometric study of the obturator apparatus of the rectum, the total tone of the anal sphincters is reduced to 37 mm Hg, the contractility of the anal sphincters is reduced to 104 mm Hg. Fatigue of the muscles of the external anal sphincter is increased. The reflex reaction to the test with an increase in intra-abdominal pressure (cough) is weakened. Straining revealed indirect signs of functional disorders of defecation. Conclusion: The functional state of the obturator of the rectum by manometric signs corresponds to the insufficiency of the anal sphincter of the 1st degree.

The patient was prescribed a course of physiotherapy exercises in the form of a set of exercises according to the proposed method. After 4 weeks, the effectiveness of this course was noted: subjectively, the patient noted a decrease in discomfort in the rectum, the frequency of episodes of gas incontinence (and the complete absence of kata blots on the linen) and the frequency of episodes of incomplete bowel emptying - upon repeated questioning, 2 battles and 5 points, respectively.

With control anorectal manometry after 6 weeks of performing a set of exercises, normalization of the fatigue time of the external anal sphincter, a positive dynamics of the ratio of pressure indicators in the anal canal during straining and at rest with the transformation of the manometric pattern into type IV (36/30 (18%)) - relaxation 18 % while maintaining a reduced intrarectal pressure of 35 mm Hg. During the control sphincterometry, positive dynamics was noted with normalization of pressure indicators during volitional contraction and the time of fatigue of the external anal sphincter and pelvic floor muscles.

Claims (47)

A method for correcting functional disorders of the muscles of the anal sphincter and pelvic floor in patients with pelvic organ prolapse in combination with obstructive defecation and the presence or absence of anal incontinence, including the performance of physical exercises, characterized in that the following complex is performed as physical exercises: 0) Basic exercise: starting position (PI) lying on the back, legs straight shoulder-width apart, the anal sphincter is relaxed, one hand is placed on the stomach, the other on the sternum, involuntary breathing, - exhale, hold their breath, tighten the muscles of the anterolateral abdominal wall and draw in the abdomen, while the anal sphincter is relaxed, - relax the abdominal muscles and return to the PI, - repeat 3-5 times, moreover, exercise 0 is performed before each subsequent exercise and at the end of the entire complex; 1.1) PI - sitting on the floor, legs are apart shoulder-width apart, bent at the knee and hip joints and rest on the feet, hands are fixed outside the knees, the anal sphincter is relaxed, breathing is involuntary, - squeeze the anal sphincter and inhale, hold their breath and create resistance with their hands, while trying to spread the knees, fix the position at the count of 1-2-3-4, - exhale and return to the IP, - repeat 4 times; 1.2) PI - sitting on the floor, legs are apart shoulder-width apart, bent at the knee and hip joints and rest on the feet, hands rest against the floor from behind, the anal sphincter is relaxed, breathing is involuntary, - squeeze the anal sphincter and inhale, hold your breath and press your knees against each other at a count of 1-2-3-4, - exhale and return to the IP, - repeat 10 times; 2.1) PI - standing with an emphasis on the knees and hands, the anal sphincter is relaxed, the legs are shoulder-width apart, the face is directed to the floor, breathing is involuntary, - squeeze the anal sphincter, take a breath, hold their breath, - straighten the right leg, lifting it above the floor, without bending the back, and perform circular movements with the leg 4 times, - exhale, relax the anal sphincter and return to the PI, - repeat the exercise with the left leg, - the cycle with the movements of both legs is repeated 2 times; 2.2) PI - standing with an emphasis on the knees and hands, the anal sphincter is relaxed, the legs are shoulder-width apart, the face is directed to the floor, breathing is involuntary, - squeeze the anal sphincter, take a breath, hold their breath, - straighten the right leg, lifting it above the floor, without bending the back, - keeping the anal sphincter compressed, exhale and return the leg to its original position, - do the exercise with the other leg, - relax the anal sphincter and switch to involuntary breathing, - the cycle with the movements of both legs is repeated 3 times; 2.3) PI standing with an emphasis on the knees and hands, the anal sphincter is relaxed, the legs are shoulder-width apart, the face is directed to the floor, breathing is involuntary, - squeeze the anal sphincter, inhale, hold the breath, - straighten the right leg, raising it above the floor, without bending the back, and extend the left arm above the head, - exhale, relaxing the anal sphincter and returning the leg and arm to the PI, - squeeze the anal sphincter, inhale, holding the breath, - straighten the left leg, raising it above the floor, without bending the back, and extend the right arm above the head, - exhale, relaxing the anal sphincter and returning the leg and arm to the PI, - relax the anal sphincter and switch to involuntary breathing, - repeat the cycle 3 times with movements of opposite arms and legs; 3) PI - lying on his stomach, hands under his head, face lying on hands, legs straight, anal sphincter relaxed, involuntary breathing, - squeeze the anal sphincter, inhale, hold their breath, - Exercise "scissors" - raise both straight legs above the floor, without bending the lower back and without raising your head, make 3 crossing movements with your legs, - exhale and return to the IP, - repeat 2 times; 4) PI - sitting on the floor, legs extended, hands resting on knees, involuntary breathing, - move forward on the buttocks, then backward, 10 seconds; while the set of exercises is performed in the following order: - for the first 2 weeks, patients perform exercises 0, 1.1, 1.2, - 3-4 weeks - add exercises 2.1, 2.2, - 5-6 weeks - add exercises 2.3, 3, 4.

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