Varovanje zdravja žensk / Women's health Fizioterapija 2015, letnik 23, suppl 1 77 Fizioterapevtska obravnava pri disfunkciji odvajanja blata – poročilo o primeru viš. pred. mag. Darija Šćepanović, viš. fiziot. Univerzitetni klinični center Ljubljana, Ginekološka klinika, Ljubljana Korespondenca/Correspondence: Darija Šćepanović; e-pošta: darija.scepanovic@kclj.si Uvod: Zaprtje je subjektiven izraz, ki se uporablja za opis težav pri odvajanju blata, bodisi zaradi nerednega odvajanja majhnih količin trdega blata bodisi zaradi čezmernega napenjanja med odvajanjem ali obojega (1). Prevalenca zaprtja pri odraslih ženskah je med 3 in 17 odstotki. Številni dejavniki, ki so povezani z zaprtjem, so povezani tudi s slabšo funkcijo mišic medeničnega dna. Ponavljajoče se čezmerno napenjanje med odvajanjem blata lahko poslabša že prisotno slabšo funkcijo, kar ima lahko za posledico šibkost mišic medeničnega dna, čezmeren spust presredka med napenjanjem in sekundarne anatomske spremembe (2). Prikaz primera: 32-letna pacientka je bila napotena na fizioterapijo z napotno diagnozo zaprtje. Težave so se začele pred nekaj leti, ko je nekega dne zavrla poziv na blato in po tem dogodku deset dni ni odvajala. Neredno odvajanje blata se je občasno še ponovilo. Pred dvema letoma pa so se težave začele stopnjevati do te mere, da je blato odvajala samo enkrat na teden, in še to le z vbrizganjem vode v rektum. Konsistenca blata je bila navadno trda (ocena 1 po lestvici Bristol) (3), zato je bilo pri odvajanju blata prisotno čezmerno napenjanje. Pacientka je predhodno že opravila kolonoskopijo in ultrazvok abdomna, ki nista pokazala posebnosti. Opravila je tudi magnetnoresonačno dinamično slikanje medeničnega dna, ki je pokazalo relaksacijo medeničnega dna prve stopnje (blaga), prolaps rektuma druge stopnje (zmeren) in blago anteriorno rektokelo. Fizioterapevtski pregled je obsegal oceno perineja, anusa, vagine in anorektuma v mirovanju, med kontrakcijo mišic medeničnega dna in med napenjanjem navzdol. Pri napenjanju se je pojavil spust perineja, večji od 2 do 3 cm. Pri rektalnem pregledu smo ugotovili blago paradoksno kontrakcijo mišic medeničnega dna. Pri oceni vzorca odvajanja blata smo ugotovili nepravilen vzorec z nepravilnim položajem telesa in čezmerno koncentrično aktivnostjo mišice rectus abdominis. Fizioterapevtska obravnava je vključevala učenje pravilnega vzorca odvajanja blata, katerega namen je bil povečati anorektalni kot in zmanjšati čezmerno napenjanje. Za učenje relaksacije mišic medeničnega dna smo uporabili biološko povratno zvezo z rektalno EMG-sondo. Za simulacijo odvajanja blata smo uporabili rektalni balon, napolnjen z vodo. Pri tem smo pacientko naučili tehnik za stabilizacijo perineja in korekcijo rektokele med napenjanjem. Fizioterapevtska obravnava traja pol leta, enkrat na mesec in še ni končana. Pacientka zdaj poroča o občasnem odvajanju tudi dvakrat na teden, pri odvajanju ji ni treba vedno vbrizgavati vode v rektum. Paradoksna kontrakcija mišic medeničnega dna je ob poskusu odvajanja navzoča le še občasno, koncentrična kontrakcija mišice rectus abdominis pa ne več. Pri večini poskusov odvajanja blata rektalni balon, napolnjen z vodo, pacientki izpade iz rektuma. Pacientka je na zbirniku za oceno zaprtja (4) pred fizioterapijo zbrala 25 točk (od možnih 30 točk), po pol leta pa 19 točk (nad 15 točk je zaprtje). Zaključki: Zaradi večletnega čezmernega napenjanja med odvajanjem blata so pri pacientki verjetno nastale anatomske spremembe medeničnega dna, ki so bile ugotovljene s preiskavami. Posledica je bil spremenjen vzorec odvajanja. Cilj fizioterapevtske obravnave je bil vzpostaviti pravilen vzorec odvajanja z namenom učinkovite izpraznitve rektuma in preprečevanja nastanka sekundarnih anatomskih sprememb. V pol leta je pacientka vzpostavila pravilen vzorec odvajanja, ki se kaže tudi v učinkovitejšem in pogostejšem odvajanju blata. Ključne besede: disfunkcija odvajanja blata, zaprtje, ocena vzorca odvajanja blata, vadba, biološka povratna zveza. Varovanje zdravja žensk / Women's health 78 Fizioterapija 2015, letnik 23, suppl 1 Physiotherapy treatment in bowel dysfunction – case report Introduction: Constipation is a subjective term used to describe difficulty in defecation, either because of the infrequent passage of small hard stools, or because of straining at defecation, or both (1). The prevalence of constipation in adult women is between 3 and 17%. Many of the factors that are associated with constipation are also linked to dysfunction of the muscles of the pelvic floor. Repeated straining at stool is thought to exacerbate the damage, and can result in weakness of the pelvic floor, perineal descent during straining, and secondary anatomical changes (2). Case report: A 32-year-old nulliparous patient was referred to physiotherapy due to constipation. The problems started a few years ago when she voluntarily restrained a call to stool and has then not defecated for 10 days. Her irregular bowel movements repeated occasionally. Two years ago the issue escalated to the point that she could only defecate once a week with the help of injecting water into the rectum. The consistency of the stool was usually hard (Type 1 on the Bristol scale) (3), which caused excessive straining while passing stools. The patient previously underwent a colonoscopy and abdominal ultrasonography, which were both unremarkable. The patient had a dynamic MRI scan that showed a Stage 1 pelvic floor relaxation (mild), Stage 2 rectal prolapse (moderate) and a mild anterior rectocele. Physiotherapy examination included an assessment of the perineum, anus, vagina and anorectum at rest, during a contraction of the pelvic floor muscles and during straining. The following is a summary of our findings: during straining there is an occurrence of perineal descent of more than 2 to 3 cm; rectal examination revealed a mild paradoxical contraction of the pelvic floor muscles; assessment of her defecation pattern revealed an incorrect pattern of bowel movements with an incorrect body position and excessive concentric activity of rectus abdominis muscle. Physiotherapy treatment included teaching the patient the correct pattern of bowel movements, the purpose of which was to increase the anorectal angle and reduce excessive straining. We taught relaxation of the pelvic floor muscles using biofeedback with an EMG rectal probe. For the stimulation of the bowel movements, we used a rectal balloon filled with water. At the same time we taught the patient techniques for stabilizing the perineum and correcting the rectocele during straining. We have been treating the patient for half a year now, with once a month visits, the treatment is still ongoing. The patient reports that now occasionally she defecates twice a week and it is not always necessary to inject water into the rectum. Paradoxical contraction of the pelvic floor muscles is only present occasionally during bowel movements; concentric contractions of rectus abdominis muscle are not present any more. During most bowel movements the rectal balloon, filled with water, falls out of the rectum. The Constipation System Score improved from 25 (out of a possible 30) to 19 (4). Conclusions: Due to several years of excessive straining during bowel movements there were anatomical changes of the pelvic floor, which were established through various diagnostic procedures. The changes led to a changed pattern of bowel movements. The aim of the physiotherapy treatment was to establish a correct pattern of bowel movements for the purpose of efficiently emptying the rectum and to prevent the occurrence of secondary anatomical changes. In a period of six months, the patient has established the correct pattern of defecation, which also reflected in more efficient and more frequent bowel movements. Key words: dysfunctional defecation, constipation, assessment of defecation pattern, training, biofeedback. Literatura/References: 1. Chiarelli PE. Constipation. In: Laycock J, Haslam J, eds. (2008). Therapeutic management of incontinence and pelvic pain. Pelvic organ disorders. London: Springer-Verlag London Limited: 213–22. 2. Swash M, Snooks SJ, Henry MM (1985). Unifying concept of pelvic floor disorders and incontinence. J R Soc Med: 78: 906–11. 3. Amarenco G. (2014). Bristol Stool Chart. Prospective and monocentric study of "stools introspection" in healthy subjects. Prog Urol 14: 24: 708–13. 4. Agachan F, Chen T, Pfeifer J, Reissman P, Wexner SD (1996). A constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum 39: 681–5.