Download PELVIC FLOOR INVESTIGATIONS AND CONSERVATIVE

PELVIC FLOOR INVESTIGATIONS AND CONSERVATIVE INTERVENTIONS
This curriculum and logbook is designed for trainees in pelvic floor surgery to record their exposure
to and understanding of pelvic floor investigations and associated conservative interventions.
Most pelvic floor trainees will not be required to perform these procedures but rather display
competency in deciding when to use them, explain them to patients and interpret the results with a
view to future management.
Objectives
The main objectives of completing this module are:
1. To record investigations and interventions that have been observed
2. To be able to make decisions on appropriate and timely investigations of pelvic floor
disorders
3. To give clear explanations to patients about when and how tests and interventions are
conducted
4. To be able to interpret and explain basic investigation results and relate them to underlying
disorders/patient symptoms
Achievements
Investigations that trainees are expected to observe and understand are:
1. Anorectal Physiology
a. Manometry
b. Electrophysiology
2. Radiology
a. Defaecating proctogram
b. Endoanal ultrasound
Conservative interventions that trainees are expected to have an understanding of are:
1.
2.
3.
4.
5.
6.
7.
Dietary advice
Medication and laxative use
Biofeedback
Per-anal irrigation
Percutaneous tibial nerve stimulation (PTNS)
Psychotherapy
Pain management
Learning Resources
Duthie, G. and Gardiner, A. (eds.) (2004) Physiology of the Gastrointestinal Tract. London: Whurr
Publishers Ltd
Lindsey I, Nugent K, Dixon T. Pelvic floor disorders for the colorectal surgeon. Oxford University
Press.
Interpreting anorectal physiology results. Bristol Royal Infirmary guide.
Association of GI physiologists website. www.bsg.org.uk
Cohen R and Windsor A. Anus: Surgical Pathology and Treatment. Springer. ?NICE guidelines.
Assessment Case based discussion following observations
CURRICULUM FOR ANORECTAL PHYSIOLOGY
Manometry
1. Describe the basic equipment set up for anal manometry
2. Knowledge of the variety of equipment used in different centres:
a. high resolution manometry
b. conventional manometry
c. water-perfused catheters
d. solid state catheters
e. channel/transducer number and distribution
3. Describe the process a patient will undergo:
a. history
b. positioning
c. digital examination
d. intubation
4. Knowledge of the measurements that can be taken during anal manometry:
a. station or continuous pull-through
b. resting and squeeze pressures with duration of squeeze
c. sphincter and high pressure zone length
d. cough and strain pressures
e. resting motility
f.
rectoanal inhibitory reflex
g. rectal sensation volumes
h. sphincter pressure at call to stool
5. Describe a balloon expulsion test
6. Interpret a report including sphincter manometry describing the sphincter complex (with
reference to the normal population)
a. at rest
b. on squeeze
7. Interpret a report including rectal manometry describing:
a. rectoanal inhibitory reflex
b. rectal sensation (first sensation, desire to defaecate and maximum tolerated)
c. cough reflex
d. straining pressures
8. The ability to summarise an anorectal manometry report and describe how it may be used to
influence further management regarding both conservative and surgical intervention
9. Have an understanding of the limitations of anorectal physiology
Electrophysiology
1. Describe the measurement and interpretation of pudendal nerve terminal motor latencies
2. Describe the measurement of anal sensation and its limitations
3. Describe a way of performing electromyography and its utility in faecal incontinence and
anismus
CURRICULUM FOR CONSERVATIVE INTERVENTIONS
Bowel Management
1. Have an understanding of the bowel management advice available, including
a. diet
b. toilet posture
c. regularization
2. Have a broad understanding of the effects of common medications on the bowel including
a. opiates
b. laxatives
c. anti-motility agents
d. local preparation.
Biofeedback
1. Describe the procedure involved for biofeedback (and equipment used) and how this can be
used to improve
a. evacuatory disorders
b. incontinence disorders
2. Understanding of the limitations of biofeedback
3. Describe the benefit of using biofeedback alongside other interventions / knowledge of why
biofeedback is necessary alongside other interventions
4. Knowledge of when biofeedback may be necessary/beneficial post-surgical procedure
(anterior resection, stoma reversal etc) Be able to demonstrate knowledge of the appropriate
timing of biofeedback, per-anal irrigation and PTN
5. Understanding of the conservative treatment pathway (NICE guidelines)
Per-anal irrigation
1. Knowledge of contraindications to per-anal irrigation
2. Knowledge of the merits, disadvantages of the systems available
Percutaneous Tibial Nerve Stimulation (PTNS)
1. Describe the patient and equipment set up for PTNS
2. Knowledge of the treatment course and top up protocol
3. Understanding of the type of patients which may be benefited by PTNS
4. Knowledge of contraindications to PTNS