Martyna Romanowska-Naimska1, 2, Małgorzata Kołodziejczak1
The role of sphincter and pelvic floor rehabilitation in the recovery of a patient after a road traffic sphincter injury – a case report
Znaczenie rehabilitacji mięśni zwieraczy i dna miednicy w powrocie do zdrowia pacjenta po urazie komunikacyjnym zwieraczy – opis przypadku
1Warsaw Proctology Centre, Saint Elisabeth Hospital, Warsaw
2PELVITA – Pelvic Floor Physiotherapy Clinic in Warsaw
Streszczenie
Autorzy przedstawiają przypadek 23-letniego pacjenta po urazie wielonarządowym po wypadku komunikacyjnym, w wyniku którego doszło m.in. do rozległego uszkodzenia aparatu zwieraczowego. W trybie ostrym zaopatrzono urazy ortopedyczne (złamanie kości miednicy), rany krocza, wykonano laparotomię zwiadowczą, w trakcie której stwierdzono uszkodzenie jelit, pacjent miał wyłonioną stomię.
Po roku od wypadku pacjent trafił do naszego ośrodka na konsultację, gdzie miał wykonaną szczegółową diagnostykę proktologiczną i został zakwalifikowany do planowej rekonstrukcji zwieraczy. Po całkowitym zagojeniu rany pacjenta skierowano do fizjoterapeuty w celu poprawy funkcji czynnościowej zeszytych mięśni i możliwości odtworzenia ciągłości przewodu pokarmowego. Wykonano diagnostykę funkcjonalną, a także zaplanowano ćwiczenia rehabilitacyjne. Metody terapeutyczne i diagnostyczne obejmowały: elektrostymulację doodbytniczną oraz zewnętrzną, EMG (elektromiografię) Biofeedback, USG (ultrasonografię) Sonofeedback, trening mięśni dna miednicy, radiofrekwencję INDIBA i reedukację oddechową. Uzyskano znaczną poprawę funkcji zwieraczy, jednakże w związku ze sporadycznym odczuciem wyciekania śluzu z odbytu przed zamknięciem stomii zadecydowano o wykonaniu niewielkiego zabiegu naprawczego poprawiającego szczelność odbytu (plikacja mięśni sposobem Blaisdella). Po odtworzeniu ciągłości przewodu pokarmowego pacjent trzyma dobrze stolec, ma niewielkie nietrzymanie gazów. Ze względu na utrzymujące się zaburzenia erekcji zaplanowano wszczepienie implantu prącia.
Leczenie operacyjne uszkodzeń zwieraczy powinno być uzupełnione fizjoterapią, wówczas można się spodziewać dobrego wyniku terapeutycznego.
Summary
We present a case of a 23-year-old male patient with multi-organ trauma after a road traffic accident, including extensive damage to the sphincter apparatus. Orthopaedic injuries (pelvic bone fracture) and perineal wounds were treated as an emergency, an exploratory laparotomy was performed, during which intestinal damage was found, and a stoma was created.
One year after the accident, the patient reported to our centre for a consultation, where he had a detailed anorectal diagnosis performed and was qualified for elective sphincter repair. After the wound healed completely, the patient was referred to a physiotherapist to improve the function of the sutured muscles and allow for restoring gastrointestinal continuity. Functional diagnosis was performed, and rehabilitation exercises were planned. Therapeutic and diagnostic methods included rectal and external electrostimulation, biofeedback EMG (electromyography), Sonofeedback (ultrasound), pelvic floor muscle training, INDIBA radiofrequency and respiratory re-education. Significant improvement in sphincter function was achieved; however, due to occasional mucus leak from the rectum before stoma closure, it was decided to perform a minor repair to improve rectal tightness (muscle plication using the Blaisdell’s method). Since the restoration of gastrointestinal continuity, the patient has had good continence, with only slight gas incontinence. Due to persistent erectile dysfunction, implantation of a penile implant was planned.
Surgical treatment of sphincter injuries should be supplemented with physiotherapy if good therapeutic outcome is expected.
Case report
A 23-year-old man participated a traffic accident in 2021. He suffered a multiorgan injury. The pelvic bones, the perineal area (about 50% of sphincter circumference was damaged), the penis and testicles, the thoracic spine were damaged, and he also suffered an abdominal injury that resulted in intestinal perforation. Orthopaedic injuries (pelvic bone fracture) and perineal wounds were treated as an emergency, an exploratory laparotomy was performed, during which intestinal damage was found, and a stoma was created.
After hospital discharge, the patient underwent intensive functional rehabilitation, which allowed him to regain mobility, as well as enabled him to resume work and education. A slight paresis of the right lower limb persisted, which gradually subsided after several months.
The fact of having a stoma (1, 2) and persistent erectile dysfunction (3), resulting from structural damage (scarring in the area around the base of the penis, the dorsal part of the penis itself, and damage to the veins) were important factors compromising the quality of life. Additionally, due to unilateral testicular trauma, the patient experienced reduced testosterone production and was supplemented with testosterone. The patient had an erection, but it was not sufficient for penetrative intercourse. One year after the accident, the patient reported to our centre for a consultation, had a detailed anorectal diagnosis performed, and was scheduled for elective sphincter repair.
Diagnostic imaging (transrectal ultrasonography) was performed before the procedure (fig. 1a, b).
Fig. 1a, b. Endosonographic findings: full-thickness rupture of the distal part of the external sphincter medially from the front with a width of 2 mm (a); rupture of the internal sphincter at 50% of the anterior circumference in the middle part of the canal (b). The pubococcygeus muscle was unchanged
Type of surgery – anal canal plasty with scar excision and wedge resection of the rectal mucosa. Sphincter repair using the overlap technique
Description of the surgery: the patient was placed in the prone position. The scar covering the entire anterior circumference was excised and a wedge resection of the rectal mucosa was performed. The sphincter muscles were mobilized – a defect of about 40% of the circumference; the muscles were sutured using the overlap method, the remaining perineal muscles and the overlying anoderm were also sutured. Full rectal compactness was achieved. The perimeter of the wound was left to heal open. Control of haemostasis, dressing.
The postoperative period was uneventful. The patient was discharged from the hospital on day 3 in good overall and local condition.
Six weeks after the procedure, once the wound had healed completely, the patient was referred to pelvic floor rehabilitation (4-6) to improve perineal muscle function and prepare for possible restoration of gastrointestinal continuity.
The first physiotherapy consultation included a detailed history, functional diagnosis and establishing a treatment plan together with the patient.
The functional diagnosis consisted of:
• static and dynamic posture assessment,
• gait assessment,
• palpation assessment of the mobility of scar tissue in the pelvic and trunk area,
• assessment of respiratory diaphragm function.
Functional diagnosis of the perineal region and sphincter apparatus was carried out according to the modified PERFECT scheme (7) and the modified OXFORD scale (8, 9), and included external and internal rectal examination, which was performed with the patient in the Sims position (on the left side) (10).
The Oxford scale is a 6-point measurement system to rate pelvic floor muscle contraction, where:
0 – no contraction,
1 – minor muscle “flicker”,
2 – weak muscle contraction, impossible to maintain,
3 – moderate muscle contraction,
4 – good muscle contraction,
5 – strong muscle contraction.
Contraction is assessed during vaginal examination in women, and rectal examination in men. During the examination, it is recommended to squeeze and pull up of the pelvic floor towards the inside of the body. At the same time, it is necessary to differentiate between normal and abnormal movement based on straining.
The Oxford scale is one of the components of a broader tool known as PERFECT, where:
P – power: representing power (or force) of contraction of the pelvic floor muscles measured using the Oxford scale. P > 3 is considered normal,
E – endurance: measured in seconds. This is the length of time the muscles can remain strongly contracted without fatigue. The norm is about 8 seconds,
R – repetition: the number of rapid and strong consecutive muscle contractions. The strength of each repetition must be the same. The test includes 10 repetitions,
F – fast: the number of rapid muscle contractions that can be performed until the muscles become fatigued,
E – elevation: contraction of the deep layer of the pelvic floor. It may only be assessed as present or absent,
C – cocontraction: an assessment of simultaneous activation of abdominal muscles during pelvic floor activation,
T – timing: reflex activation/precontraction of pelvic floor muscles during an increase in intra-abdominal pressure/cough.
Based on such extensive diagnostic work-up, a preliminary diagnosis of the condition of the pelvic floor could be made.
The parameters recorded during the patient’s first visit are shown below.
External evaluation – the bulbospongiosus muscle and the ischiocavernosus muscle: voluntary contraction present, low amplitude of movement, difficulty in sustaining contraction.
Internal rectal evaluation:
• external sphincter – voluntary contraction present, but significantly weakened,
• reduced resting tone in the anal canal,
• the pubococcygeal muscle – normal contraction,
• no cocontraction with other muscles, such as gluteal, adductor or abdominal muscles (in supine position),
• the overall strength of contraction – OXFORD 2 (0-5) (11),
• lack of full relaxation after contraction,
• phasic contractions – a maximum of 8 repetitions without a 50% loss of contraction strength,
• tonic contractions of 50% MVC – 5 repetitions of up to 5 s,
• inability to sustain contraction beyond 10 s,
• cough reflex (precontraction) present,
• during an attempt at straining, palpable relaxation of the puborectalis loop – no dyssynergia (4).
During this visit, therapy was also started, focusing initially on improving proprioception and learning how to properly relax the perineal muscles. Techniques used:
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