DOI: 10.1111/tog.
12695 2020;22:275–83
The Obstetrician & Gynaecologist
http://onlinetog.org
Pelvic floor functional bowel disorders in gynaecology
MRCOG, *
a b
Marika Britton Sushil Maslekar MD FRCS,
a
Consultant Obstetrician and Gynaecologist, Northumbria Healthcare NHS Trust, North Shields NE27 0QJ, UK
b
Consultant Colorectal Surgeon, Leeds Teaching Hospitals Trust, Leeds LS9 7TF, UK
c
Consultant Urogynaecologist, Leeds Teaching Hospitals Trust, Leeds LS9 7TF, UK
*Correspondence: Marika Britton. Email: marikanemcova@doctors.org.uk
Accepted on 18 November 2019. Published online 16 September 2020.
Key content
 Many women with pelvic floor problems have a mixture of
urogynaecological and colorectal symptoms.
 The most common conditions include faecal incontinence,
constipation, obstructive defaecation syndrome, haemorrhoids and
anal fissures.
 Investigations specific to these pelvic floor disorders comprise
imaging (endoanal ultrasound and defaecating proctography,
including dynamic magnetic resonance imaging), and physiology
(anorectal manometry, pudendal nerve terminal motor latency and
colonic transit studies).
 There is a close relationship between the urogynaecology and
colorectal specialties; here, we provide guidance with respect to the
care of women with pelvic floor functional bowel problems.
Please cite this paper as: Britton M, Maslekar S, Marsh F. Pelvic floor functional bowel disorders in gynaecology. The Obstetrician & Gynaecologist
2020;22:275–83. https://doi.org/10.1111/tog.12695
Introduction
Pelvic floor disorders, which are often multifactorial, include
defaecatory, urinary and sexual dysfunction, urinary and
faecal incontinence, pelvic organ prolapse and pelvic pain.
Approximately 23% of women experience at least one form
of pelvic floor disorder. Of these, 16% experience urinary
incontinence, 9% experience faecal incontinence and almost
3% experience symptomatic pelvic organ prolapse.
The proportion of women reporting at least one disorder
increases incrementally with age, ranging from 10% in
women between the ages of 20 and 39, to 50% in those aged
80 or older.1 Twenty-eight percent of women attending
gynaecology clinics report anal incontinence.2 Incontinence
in adults (both urinary and faecal) accounts for
approximately 2% of the UK’s total annual
healthcare budget.3
As a result, a multidisciplinary approach to the
management of pelvic floor dysfunction streamlines
appointments and reduces disjointed care. This article
discusses the most common pelvic floor bowel disorders
seen in gynaecology clinics, their investigations and
their treatment.
ª 2020 Royal College of Obstetricians and Gynaecologists
Review
c
Fiona Marsh MD MRCOG
Learning objectives
 To be aware of the most common low intestinal tract conditions
that gynaecology patients present with.
 To be able to undertake a relevant consultation, order
investigations and formulate an appropriate management plan.
Ethical issues
 Ineffective and delayed management of women with pelvic floor
problems leads to considerable deterioration of quality of life.
 Inappropriate treatment has medico-legal consequences.
Keywords: colorectal / multidisciplinary / pelvic floor / quality of
life / urogynaecology
Faecal incontinence
Faecal incontinence is a symptom or a sign and not a
diagnosis.4 Anal incontinence is a complaint of involuntary
loss of faeces or flatus (gas), whereas faecal incontinence is
the involuntary loss of liquid or solid stool. Flatal
incontinence describes loss of flatus5 and is more prevalent.
Urge incontinence is an inability to resist the urge to
defaecate, which results in not making it to the toilet on time.
The faecal continence mechanism requires intact anal
sphincter function, rectal sensation, adequate rectal capacity
and compliance, colonic transit time, stool consistency,
cognitive and neurologic factors. Incontinence occurs when
any one or more of these things are affected.6
Faecal incontinence is very common and affects 10% of
adults4 and up to 50% of patients in nursing homes.7 Because
faecal incontinence is a socially stigmatising condition,
healthcare professionals should actively, yet sensitively,
enquire about symptoms in high-risk groups, including
women following childbirth, or patients with urinary
incontinence and pelvic organ prolapse. Other groups
include women with diarrhoea, women who have had
colonic resection, anal surgery or radiotherapy and those
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with learning disabilities or severe cognitive impairment.4,
However, faecal incontinence is under-reported – often
because of embarrassment7 – and symptoms may only
become apparent on direct questioning. It has a negative
impact on physical and psychological wellbeing and can lead
to social isolation, stress, avoidance of sexual activity, anxiety
and depression. The most common strategies employed to
handle the stress of faecal incontinence include restricting
activity, denial, knowing the location of toilets when out in
public and using sanitary pads.8 Quality of life
questionnaires, such as St. Mark’s or Vaizey scoring, are
often used to assess the impact that anal incontinence has on
patients’ quality of life and may provide a measure of the
treatment outcome (see Table 1).7
Assessment
Initial assessment involves taking a thorough history. The
nature of incontinence, onset, duration and effect on quality
of life should also be noted. Detailed obstetric history,
including complications during labour and delivery, is
important, since 13–25% of women who had vaginal
Table 1. St Mark’s Incontinence Score sheet6
Score
Frequency (score)
Never (0)
Incontinence for solid stool
Incontinence for liquid stool
Incontinence for gas
Alteration in lifestyle
Yes/No (score)
Yes (0)
Need to wear a pad or plug
Taking constipating medicine
Yes (0)
Lack of ability to defer defaecation for 15 min
Never: no episodes in the last 4 weeks. Rarely: one episode in the past 4 weeks. Sometimes: more than one episode in the past 4 weeks and less than
one a week. Weekly: one or more episodes a week but not daily. Daily: one or more episodes a day. Score: 0 = perfect continence. 24 = totally
incontinent.
276
delivery can be affected by anal incontinence.8 Trauma to
the perineum and surgery should be noted, as well as medical
conditions (diabetes, neurological and inflammatory bowel
disease). Examination involves abdominal palpation,
assessment for pelvic organ prolapse and anorectal
examination. The focus should be on warning signs for
gastrointestinal cancer, prolapse, acute disc prolapse or cauda
equina syndrome (associated with anal sensation loss).
Neurological and cognitive assessment may also be required.9
Initial management
All patients experiencing faecal incontinence should be
offered initial conservative management through lifestyle
changes or pharmacological agents.
Initial management involves dietary changes to ensure
balanced overall nutrient intake. Women with hard stools
should aim to drink at least 1.5 L of fluid per day.4
Completing a food diary may help to discover dietary
triggers to avoid; common offenders are caffeine, fructose
and lactose. Eating small meals rather than large ones can
decrease the sense of urgency.8
Rarely (1) Sometimes (2) Weekly (3) Daily (4)
No (2)
No (4)
ª 2020 Royal College of Obstetricians and Gynaecologists

Faecal incontinence can be improved by ensuring women
have bowel movements at specific times during the day. Use
of the Bristol Stool Chart should be considered to provide an
objective record of the woman’s stool form.10 Women are
encouraged to use the toilet after a meal, have access to
private toilet facilities and sit or squat where possible. Advice
should be given regarding easily removable clothing and help
should be readily available for patients who are dependent on
others. Their home/mobility should be assessed, if
appropriate. Women should be offered disposable pads,
anal plugs, disposable gloves and skincare advice. A RADAR
key allows them to access disabled toilets via the National Key
Scheme. Women should be provided with emotional and
psychological support, including counselling and therapy.4 In
terms of pharmacological agents, loperamide is the first-line
treatment for loose stools. It can be used long term, but it
should not be prescribed to patients with hard or infrequent
stools or acute onset of diarrhoea. People who are unable to
tolerate loperamide should be offered codeine phosphate or
co-phenotrope instead.4
Other conservative measures include pelvic floor muscle
training, bowel retraining, biofeedback, electrical stimulation
and rectal irrigation.4 If patients continue to experience faecal
incontinence despite initial treatment, specialised
management should be offered. This is usually considered
following investigations including endoanal ultrasound,
anorectal physiology and pudendal nerve testing.
Investigations
Endoanal ultrasound
Endoanal ultrasound is considered to be a standard
investigation to evaluate sphincter pathology.11 The probe
is gently inserted into the anal canal to a depth of up to
approximately 6 cm, then withdrawn and cross-sectional
images are obtained. Sphincter length; damage to the internal
anal sphincter and external anal sphincter, puborectalis,
longitudinal muscles and anal mucosa; and other
abnormalities are assessed.12
Anorectal manometry
Anorectal manometry objectively measures the pressure of
the anal sphincter muscles at rest and during squeeze. The
internal sphincter muscles account for 52–85% of the
pressure in the resting period, with a normal range of
65–85 mmHg.13 The maximal resting pressure is in the
region of 1–1.5 cm above the anal verge.14 Squeeze pressure
is created by contracting the external sphincter muscle and
the puborectalis muscle. Normal values should be
approximately double the value of the resting pressure.13
Resting and/or squeeze pressures are generally reduced in
faecal incontinence.
ª 2020 Royal College of Obstetricians and Gynaecologists
Britton et al.
Pudendal nerve terminal motor latency
Pudendal nerve terminal motor latency involves using an
electrode to stimulate the pudendal nerve as it traverses over
the ischial spine. The delay is measured between the
stimulation and contraction. A normal value is 1.90.2 ms,
and higher values are associated with pudendal nerve
injury.13 Elevated values are seen in anal incontinence,
injury of the external anal sphincter muscles, rectal ulcer
syndrome and treatment-resistant constipation.13
Further management
Percutaneous tibial nerve stimulation
The aim of percutaneous tibial nerve stimulation (PTNS) is
to achieve a neuromodulatory effect similar to that of sacral
nerve modulation but through a less invasive route. However,
its exact mechanism of action remains unclear. A fine needle
electrode is inserted approximately 5 cm cephalad to the
medial malleolus and posterior to the tibia, with a surface
electrode on the arch of the foot; stimulation at a current
level of 0.5–9 mA at 20 Hz is performed. Women receive a
series of one 30-minute session per week for 12 weeks. Since
the evidence is limited, further research is needed to support
its efficacy and to help to define the patients for whom it is
most likely to be effective.4
Sacral nerve modulation
Sacral nerve modulation (SNM) is an invasive, effective
technique for idiopathic and acquired faecal incontinence. It
uses chronic, low-level electrical stimulation of the sacral
nerves, or neuromodulation, to produce a beneficial effect on
the distal colon and rectum, the pelvic floor and the anal
sphincter muscles. SNM is a two-stage procedure: diagnostic-
stage temporary percutaneous nerve evaluation and a
permanent sacral nerve modulation. An electrode is placed
through the sacral foramen and an electric current is then
applied to one of the sacral nerves (either S3 or S4) via an
external stimulator. Women then keep a diary over a 2-week
period; if there is at least a 50% improvement in symptoms,
then they are offered a permanent SNM insertion, with both
the lead and the battery placed subcutaneously. Studies
indicate complete continence is achieved in 41–75% of cases
and 75–100% of patients experience a decrease of 50% or
more in the number of incontinence episodes.15
Surgery
Women with a full-length external anal sphincter defect that is
90 or greater on ultrasound (with or without an associated
internal anal sphincter defect) should be considered for anal
sphincter repair.4 This procedure is performed perineally and
has a success rate (success defined as control of solid and
liquid stools) of approximately 70% at 5 years.9 However, with
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time results deteriorate such that the success rate at 10 years is
only around 10%.4 Patients with internal sphincter defects,
pudendal neuropathy, external sphincter atrophy, loose stool
or irritable bowel syndrome should be advised that these
factors are likely to decrease the effectiveness of anal sphincter
repair. Generally, patients undergoing a sphincter repair do
not need a temporary stoma.4
Bulking agents such as collagen, carbon beads and silicone
particles can be injected in three or four places just above the
dentate line, usually under local anaesthetic. By reproducing
the anal cushions, they are used to stop passive leakage. There
remains a lack of good quality data on the efficacy of
the procedure.16
Although now outdated, stimulated graciloplasty and
artificial anal sphincter are two surgical techniques that
offer the patient a chance of restored continence and
improved quality of life, if the trial of the sacral nerve
modulation is not successful. 4 However, women can
experience evacuatory disorders and/or serious
infections, which may necessitate removal of the device.
For patients with faecal incontinence that severely restricts
lifestyle, a stoma is considered only when all other
appropriate nonsurgical and surgical options have
been considered.4
Chronic constipation
Chronic constipation is a symptom-based disorder used to
describe bowel movements that are infrequent and/or
incomplete and/or a need for a frequent straining or
manual assistance to defaecate.5 It is very common,
affecting up to 14% of the population.17 Severe
constipation ismore common in pregnant women, with a
prevalence of 40%,18 and in elderly women, who are two to
three times more likely to be affected than men.19 Chronic
constipation has a major effect on quality of life, physical and
emotional wellbeing.19 The Rome criteria can be used to aid
diagnosis of constipation (see Box 1).10
Primary (idiopathic) constipation describes chronic
constipation with no known cause. There are four groups:
Box 1. Rome IV criteria for constipation10*
a. Straining during at least 25% of defecations
b. Lumpy or hard stools in at least 25% of defecations
c. Sensation of incomplete evacuation for at least 25% of defecations
d. Sensation of anorectal obstruction/blockage for at least 25% of
defecations
e. Manual manoeuvres to facilitate at least 25% of defaecations
(e.g. digital evacuation, support of the pelvic floor)
f. Fewer than three defaecations per week; loose stools rarely present
without laxatives
*To fulfil the criteria, the symptoms must have been present for the last
3 months, with symptom onset at least 6 months before diagnosis.
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Box 2. Drugs as possible causes of constipation10
 Aluminium-containing antacids; iron or calcium supplements
 Analgesics, such as opiates and nonsteroidal anti-inflammatory
drugs
 Antimuscarinics, such as procyclidine and oxybutynin
 Antidepressants, such as tricyclic antidepressants; antipsychotics,
such as amisulpride, clozapine or quetiapine
 Antiepileptic drugs, such as carbamazepine, gabapentin,
oxcarbazepine, pregabalin or phenytoin
 Antihistamines, such as hydroxyzine
 Antispasmodics, such as dicycloverine or hyoscine
 Diuretics, such as furosemide; calcium-channel blockers, such as
verapamil.
slow transit constipation, obstructed defaecation syndrome,
constipation predominant irritable bowel syndrome and
mixed slow transit and obstructed defaecation. Secondary
constipation is caused by other identifiable factors, such as
drugs (see Box 2),10 or an underlying medical condition
(hypothyroidism, hypercalcaemia, etc.). It can also be seen in
patients with painful haemorrhoids, ulcers or anal fissures.
Slow transit constipation
Slow transit constipation is present in 15–30% of all women
with constipation.20 The cause is thought to be dysmotility of
the colon; however, the aetiology of and explanation for this
dysmotility is poorly understood.21
Anismus
Anismus describes a condition in which the cause of
obstructed defaecation is functional rather than anatomical.
Paradoxical contraction of the external sphincter and
puborectalis muscle occurs when trying to defaecate.
Women experiencing anismus often need to undergo
further investigations including anorectal manometry and
defaecating proctogram.22
Assessment
Patients usually complain of passing a stool fewer than three
times per week, accompanied by straining, abdominal pain or
bloating. There may be a history of hard, lumpy stool with
faecal overload. Often, there is also a history of vaginal or
rectal digitation, whereby women use their fingers in the
vagina or rectum to manually assist in evacuation of stool
contents. Splinting refers to support of the perineum or
buttocks to assist in manual evacuation.5
Conservative management
Dietary habits should be reviewed because simple
adjustments, including increasing fibre to 30 g per day,
adequate fluid intake, good toilet habits and exercise, can
considerably improve the symptoms. Advice to increase
ª 2020 Royal College of Obstetricians and Gynaecologists

dietary content of whole grains, fruits high in sorbitol and
vegetables should be given. It may take several weeks for the
beneficial effects of increased dietary fibre to be seen.10
Medication
If there is no response to lifestyle measures, treatment with
oral laxatives can be considered in a stepwise approach. Bulk-
forming laxative (e.g. isphagula) is used as a first-line
treatment. If stools remain hard or difficult to pass, add or
switch to osmotic laxative (e.g., lactulose, macrogol) then add
a stimulant laxative (e.g. senna) if needed.10 If the patient has
opioid-induced constipation, bulk-forming laxatives should
be avoided because they can cause abdominal colic and –
albeit rarely – bowel obstruction.23 In pregnancy and
breastfeeding, management should start with lifestyle
changes as mentioned above, followed by the same stepped
approach with oral laxatives. If this fails, consider prescribing
a glycerol suppository.10 There is very little epidemiological
information on the potential risks associated with laxative use
in pregnancy; however, most laxatives have minimal systemic
absorption and are commonly used in pregnancy. If needed,
they should be used for short periods of time, as they may
induce electrolyte imbalance during pregnancy.18 Laxatives
can be used short-term when breastfeeding.
Prucalopride (5HT4-receptor agonist) and lubiprostone
(chloride channel activator) may be considered when other
laxatives fail to produce an adequate response. However, they
should only be prescribed by clinicians who are experienced
in treating chronic constipation.24,25
Laxatives should not be stopped suddenly; they should be
reduced gradually – for example, after 2–4 weeks when
regular bowel movements are comfortable, with soft-formed
stools. Weaning off laxatives can take several months.10
In patients with slow transit constipation, biofeedback,
sacral nerve stimulation, segmental colectomy and subtotal
colectomy with various anastomoses have all been used.21
In women with anismus, 20 U of botulinum toxin can be
injected into the puborectalis muscle and external sphincter;
further injections can be administered 3 months after the
initial dose. If there is no response to the treatment,
examination under anaesthetic is indicated to rule out a
rectal prolapse not diagnosed with the proctogram.22
Obstructed defaecation
Obstructed defaecation defines a group of conditions that
present with a normal desire to defaecate but an inability to
satisfactorily evacuate the rectum. Possible mechanical causes
include rectocele, enterocele, sigmoidocele, rectal
intussusception and rectal prolapse. Functional obstructed
defaecation syndrome may be caused by a failure to relax,
resulting in anismus. Typically, women give a history of
straining, sensation of blockage, digitation and splinting.5
ª 2020 Royal College of Obstetricians and Gynaecologists
Britton et al.
Investigations
Investigations include colonic transit studies, defaecating
proctogram/dynamic magnetic resonance imaging (MRI) and,
sometimes, anorectal physiology. These investigations assist in
differentiating between slow transit constipation, obstructed
defaecation, irritable bowel syndrome, rectocele, pelvic
dyssynergy, rectal intussusception and pelvic floor descent.
Colonic transit studies
A radio-opaque marker test is the most widely used method
and is simple to perform. A capsule is swallowed with 20
radio-opaque markers, then on day 5, an abdominal X-ray is
performed. If more than 80% of the markers remain in the
colon on day 5, a diagnosis of slow transit constipation
is made.
Defaecating proctogram
A defaecating proctogram evaluates in real time the
morphology of the rectum and anal canal. A thick barium
paste is injected into the rectum and is subsequently
evacuated. The vagina may also be opacified to provide
further information; an anterior outpouching of the anterior
rectal wall bulges and dislocates the opacified lumen during
straining and defaecating. Retention of stool within the
rectocele may lead to a sense of incomplete emptying and the
need for digital evacuation.26 This investigation provides
information about functional and anatomical abnormalities
and helps to determine the best surgical methods. Recently,
there has been an increased interest in dynamic MRI
defaecography because of its superior soft tissue contrast; it
is used to visualise the pelvic viscera and supporting tissue
structures without the radiation burden of conventional
fluoroscopic defaecography.27
Conservative management
Conservative measures include increasing dietary fibre and
use of laxatives and enemas. Physiotherapy, using an altered
position (e.g., ‘squatty potty’), or a rectal irrigation system
can be used to improve bowel emptying and
complete evacuation.
Surgical management
Rectocele repair can be performed via transvaginal or
transrectal routes. A transvaginal approach is recommended
when patients require the repair of cystocele, uterine or vault
prolapse at the same time. Postoperative dyspareunia will be
present in 25% of patients and this procedure has a
recurrence rate requiring reoperation of 10%.28 When the
transrectal approach is used, dyspareunia is reported less
often. In this case, patients may undergo surgery for
coexisting anorectal pathologies, such as haemorrhoids,
anal fissures and anterior mucosal prolapse, which are
present in 80% of patients.28
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 Bowel disorders in gynaecology
Internal rectal prolapse, or intussusception, is defined as a
full-thickness prolapse of the rectum that does not protrude
through the anus. Rectal prolapse is an extrusion of the full
thickness of the wall of the rectum beyond the anal verge.
Various surgical procedures are used to correct the defect,
including Delorme’s procedure, which is associated with a
high recurrence rate of 37%,9 stapled transanal rectal
resection and laparoscopic ventral mesh rectopexy, which
has a much lower recurrence rate of 10%.29
Anal fissure
Anal fissure is one of the most common causes of anorectal
symptoms. An anal fissure is a longitudinal tear in the skin of
the anal canal distal to the dentate line (see Figure 1). Acute
fissures are superficial tears of the mucosa. These can become
chronic if they extend through the submucosa, exposing
internal and external sphincter muscle and hypertrophied
anal papilla,30 and if they do not heal after 4–8 weeks of
conservative therapy.31 In about 90% of cases they lie
posteriorly, which is the area least perfused in the anal canal.
However, most gynaecology clinic patients present with the
fissure in the anterior position; these are associated with
pelvic floor straining, which often occurs during childbirth. If
fissures are lateral, they may be associated with Crohn’s
disease, tuberculosis, infections (e.g. HIV/AIDS, syphilis) or
malignancy.31 The main complaint is that of pain on
defaecation, with a streak of blood on the toilet tissue.
Diagnosis can be made by history and examination; fissures
can be visualised by parting the buttocks. Note that per
rectum examination should not be performed because it can
cause excruciating pain.
Figure 1. Anal disorders.
280
Management
Treatment involves increasing dietary fibre intake (to 25–
30 g/day) and adequate fluid intake. Increasing dietary fibre
has been shown to heal up to 87% of acute fissures.30 This
should be increased gradually to avoid bloating and
flatulence. Warm baths may improve the perfusion of the
perineum. Medical therapies include stool softeners and
analgesia (paracetamol and ibuprofen). If defaecation is
painful, consider prescribing a short course of 1–2-ml topical
anaesthetic (lidocaine 5% ointment) for use before passing a
stool.32 Other preparations include glyceryl trinitrate (GTN)
and calcium channel blockers. GTN is associated with
headaches and is often discontinued by patients. Diltiazem
cream is the most commonly used calcium channel blocker,
although it is not licensed for this condition33. Botulinum
toxin type A (e.g., Botox) blocks the release of acetylcholine
and other neurotransmitters from presynaptic nerve endings
at the myoneuronal junctions. This causes the muscle to
relax, as well as decreasing anal pressures and improving local
blood flow.30 One or two local injections of 20 U Botox are
used and the effect lasts for approximately 3 months. Surgery
comprises permanently dividing the internal sphincter,
fissurectomy and anal advancement flap. Lateral
sphincterectomy has an 85% success rate, but a risk of
flatal incontinence of 30% and faecal incontinence of 3–5%.9
Haemorrhoids
Haemorrhoids (piles) are enlarged mucosal ‘venous cushions’
of the anus, which become symptomatic. The prevalence
among the whole population is 13–36%; however, the number
is likely to be lower because study data is often self-reported
ª 2020 Royal College of Obstetricians and Gynaecologists

Table 2. Grades of haemorrhoids35
Grade Description
First degree Haemorrhoids project into the lumen of the anal
(Grade 1) canal but do not prolapse
Second degree Haemorrhoids protrude beyond the anal canal on
(Grade 2) straining but spontaneously reduce when
straining is stopped
Third degree Haemorrhoids protrude outside the anal canal and
(Grade 3) reduce fully on manual pressure
Fourth degree Haemorrhoids protrude outside the anal canal and
(Grade 4) cannot be reduced
and, as such, other anorectal symptoms may be wrongly self-
diagnosed as haemorrhoids.34
Haemorrhoids can be internal or external, depending on
their relation to the dentate line (see Figure 1). Internal
haemorrhoids are usually not painful because they are
covered with columnar epithelium with no pain fibres.
However, if they become prolapsed or strangulated they can
cause severe pain. External haemorrhoids are covered by
anoderm that is richly innervated with pain fibres.35 There
are several classifications of internal haemorrhoids. The
National Institute for Health and Care Excellence (NICE)
recommends grading by degree of prolapse; four grades are
widely used (see Table 2).
Assessment
Predominant symptoms of haemorrhoids are bleeding (after
passing stool), pain, mucus, lumps or itching. The severity of
symptoms is often unrelated to the size of the haemorrhoids;
small can be very painful but large and asymptomatic piles
are often incidentally found in elderly patients because of low
anal pressures.9 It is extremely important to exclude other
causes of bleeding, including polyps, inflammatory disease or
malignancy. Pain can be caused by fistulae, fissures or an anal
abscess and ‘lumps’ may be warts, skin tags or a rectal prolapse.
Patients are usually examined in the lateral position.
Internal haemorrhoids may not be visible unless prolapsed.
Digital rectal examination should be performed to exclude
masses, tenderness, blood or mucus; however, digital
examination may not reveal internal haemorrhoids because
they are soft. Proctoscopy is used to support the diagnosis
and will also help to rule out other conditions.35
Conservative management
Treatment should start with conservative measures, ensuring
the stools are soft and easy to pass. Women should be advised
ª 2020 Royal College of Obstetricians and Gynaecologists
Britton et al.
to increase fluid intake and dietary fibre. This alone can
improve the bleeding from grade 1 and 2.36 The affected area
should be kept clean and dry; careful perianal cleansing with
moistened towelettes or baby wipes is recommended.35
Medical treatment consists of simple analgesics (although
avoid opioids, which cause constipation, and nonsteroidal
anti-inflammatory drugs if bleeding) and stool softeners to
avoid straining. Other nonsurgical treatments include rubber
band ligation, which has a success rate of 65–85% and
recurrence of 20% requiring repeat procedure at 6 months.
Injection sclerotherapy, infrared coagulation and bipolar
diathermy aim to decrease the haemorrhoidal tissue.35
Surgery
Stapled haemorrhoidectomy uses a stapling gun to excise a ring
of mucosa from the upper anal canal and lift the haemorrhoidal
cushions back into the canal.37 It is more accurately termed
‘haemorrhoidopexy’ because the haemorrhoids are not excised,
but are relocated within the canal. Haemorrhoidal artery
ligation requires a proctoscope to identify and ligate the
haemorrhoidal arteries with sutures. This procedure is an
efficacious alternative to haemorrhoidopexy in the short and
medium term.35
Solitary rectal ulcer
Solitary rectal ulcer syndrome is a rare and underdiagnosed
condition. Prevalence is approximately 1–3 cases per 100 000
per year and may be misdiagnosed as cancer or inflammatory
disease.38 It is caused by straining and increased pressure
during defaecation. This increased pressure causes the
anterior portion of the rectal lining to be forced into the
anal canal (an internal rectal intussusception). The lining of
the rectum is repeatedly damaged by this friction, resulting
in ulceration.39
Assessment
Patients present with rectal bleeding, passage of mucus, pain,
constipation, incomplete emptying with unsatisfactory
defaecation and, mainly, straining. It is called ‘a disease of
three lies’ because it is often not solitary (up to 30% of cases
can be multiple ulcerated lesions), they can be located in the
sigmoid or descending colon and can appear polypoid rather
than ulcerated on histology.40
Treatment
Treatment depends on symptoms and should include change of
diet, bulking agents and biofeedback.41 Improvements have been
achieved using topical treatments, including sucralfate, salicylate,
corticosteroids, sulphasalazine, mesalazine and topical fibrin
sealant.42 Surgical procedures include local excision, rectopexy,
stoma and anterior resection.9
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The role of the multidisciplinary team
Conditions such as pelvic organ prolapse, urinary or faecal
incontinence and obstructive defaecation4 often co-exist, and a
multidisciplinary approach is of a great value43. Multidisciplinary
team (MDT) meetings are recommended by NICE;44 they are
usually attended by urogynaecologists, colorectal surgeons,
urologists, radiologists, physicists, physiotherapists and
specialist nurses. The whole team reviews the patient’s history,
examination findings and investigations, and the most
appropriate treatment options are deliberated. The patients
discussed in the MDT are then seen in the pelvic floor clinic
attended by the above healthcare professionals. These meetings
and clinics aim to improve patient outcomes as a result of sharing
specialist skills and understanding of complex pelvic floor
conditions. Women benefit from individualised treatment and
continuity of care, which is known to improve compliance with
the treatment suggested. The MDT provides opportunities for
improved training and education, which is not exclusive to the
meetings and clinics, but also involves joint operating
theatre sessions.
Conclusion
The overlap of pathology and function between anterior,
middle and posterior compartments of the pelvic floor is
well documented. Patients often present with a combination
of symptoms, and the complex nature of their condition
means they may need a multidisciplinary approach.
Healthcare professionals should be aware of the physical,
emotional and psychological effects these conditions have
on a woman’s life. It is important to manage patients’
expectations by providing information about the complexity
of their diagnosis and the extent to which a satisfactory
outcome can be achieved.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
MB performed literature searches, drafted and revised the
paper. SM and FM made critical revisions to the manuscript.
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