Galuszka G1, Wroński S2
1Rehab Center Galuszka & Romanowski, Bielsko-Biala, Poland, 2Jan Biziel Memorial University Hospital No 2, Urology, Bydgoszcz, Poland
Background: Authors present surgical procedure and rehabilitation process of the patient after massive pelvic injury with urethral distraction and total fecal incontinence.
Purpose: Restore self-control of neosphincter activity using appropriate cooperation between surgeons and physiotherapists.
Methods: 25 years-old male underwent complex reconstructive procedure for massive perineal injury. 2 years earlier, he sustained severe polytrauma after speed-bike accident. Following several life-saving surgeries patient presented with cystostomy and transversostomy due to urethral destruction and severe fecal incontinence. The former as a result of the anal sphincter direct impalement trauma and denervation (sacral nerves roots damage). After careful planning one stage reconstructive procedure was implemented. Operation started with urethral reconstruction. Transperineal anastomotic urethroplasty with extensive scar excision, urethral mobilisation, corporal body separation, bladder neck reconstruction and urethro-bladder anastomosis was performed. Next, anal neosphincter” reconstruction was performed using left gracillis muscle transposition. The muscle with neurovascular bundle was brought under groin and next around the anus. Sling encircling anus was reattached to the left ischial tuberosity. Loop was adapted to form perceptible tone around finger placed into the rectum.Recovery was uneventful. Two weeks after surgery patient started gradual rehabilitation of the neosphincter. Electromyographic and electromanometic recorders visualised activity of the abdominal and transposed muscles to mimic defecation and control neosphincter tone.
The primary goal of rehabilitation was to improve and coordinate pelvic floor and neosphincter” tone to start an effective function according to a protocol collectively developed by surgeon and physiotherapists. Protocol: initial four weeks with three sessions per week; next: 1-3 sessions (20-45 min. each) per week within six months. Using LunaEMG with intra-anal electrode patient was tought to contract and/or to relax abdominal and transposed gracillis muscle to mimic natural defecation reflex. Patient initiated voluntary contraction of neosphincter under EMG-recording to visualise its tension. EMG feedback (2-6 canals) facilitated to focus on selective tightening of the pelvic floor muscles. Training included neo-sphincter relaxation in response to Valsalva manoeuvre and rectal distension and to counteract abdominal-pelvic-anal pressure with a voluntary anal squeeze. Exercises progressed from non-gravity to anti-gravity positions. Patients was instructed to perform exercises daily at home settings.
Results: After 7 months of rehabilitation, clinical examination revealed appropriate self-control of neosphincter activity. Test with opaque artificial stool (defecography”) was arranged and presented satisfactory passage of the material and emptying of the anal canal. Transversostomy was closed and colon continuity was restored. Oral nutrition was gradually introduced. The clinical observation showed satisfactory neosphincter function and control of the defecation. Patient is continent for solid stool, while partial incontinence for liquid stool gradually decreased.
Conclusion(s):
1) Discussed case presents gracilloplasty as a valuable option for the treatment of the posttraumatic fecal incontinence.
2) EMG biofeedback helps the patient and physiotherapist to control and to lead treatment plan.
Implications: A thorough cooperation between the surgeons and physiotherapists is an indispensable prerequisite of the therapeutic success in the treatment of severely injuried patients.
Keywords: fecal incontinence, gracilloplasty, EMG biofeedback
Funding acknowledgements: None
Purpose: Restore self-control of neosphincter activity using appropriate cooperation between surgeons and physiotherapists.
Methods: 25 years-old male underwent complex reconstructive procedure for massive perineal injury. 2 years earlier, he sustained severe polytrauma after speed-bike accident. Following several life-saving surgeries patient presented with cystostomy and transversostomy due to urethral destruction and severe fecal incontinence. The former as a result of the anal sphincter direct impalement trauma and denervation (sacral nerves roots damage). After careful planning one stage reconstructive procedure was implemented. Operation started with urethral reconstruction. Transperineal anastomotic urethroplasty with extensive scar excision, urethral mobilisation, corporal body separation, bladder neck reconstruction and urethro-bladder anastomosis was performed. Next, anal neosphincter” reconstruction was performed using left gracillis muscle transposition. The muscle with neurovascular bundle was brought under groin and next around the anus. Sling encircling anus was reattached to the left ischial tuberosity. Loop was adapted to form perceptible tone around finger placed into the rectum.Recovery was uneventful. Two weeks after surgery patient started gradual rehabilitation of the neosphincter. Electromyographic and electromanometic recorders visualised activity of the abdominal and transposed muscles to mimic defecation and control neosphincter tone.
The primary goal of rehabilitation was to improve and coordinate pelvic floor and neosphincter” tone to start an effective function according to a protocol collectively developed by surgeon and physiotherapists. Protocol: initial four weeks with three sessions per week; next: 1-3 sessions (20-45 min. each) per week within six months. Using LunaEMG with intra-anal electrode patient was tought to contract and/or to relax abdominal and transposed gracillis muscle to mimic natural defecation reflex. Patient initiated voluntary contraction of neosphincter under EMG-recording to visualise its tension. EMG feedback (2-6 canals) facilitated to focus on selective tightening of the pelvic floor muscles. Training included neo-sphincter relaxation in response to Valsalva manoeuvre and rectal distension and to counteract abdominal-pelvic-anal pressure with a voluntary anal squeeze. Exercises progressed from non-gravity to anti-gravity positions. Patients was instructed to perform exercises daily at home settings.
Results: After 7 months of rehabilitation, clinical examination revealed appropriate self-control of neosphincter activity. Test with opaque artificial stool (defecography”) was arranged and presented satisfactory passage of the material and emptying of the anal canal. Transversostomy was closed and colon continuity was restored. Oral nutrition was gradually introduced. The clinical observation showed satisfactory neosphincter function and control of the defecation. Patient is continent for solid stool, while partial incontinence for liquid stool gradually decreased.
Conclusion(s):
1) Discussed case presents gracilloplasty as a valuable option for the treatment of the posttraumatic fecal incontinence.
2) EMG biofeedback helps the patient and physiotherapist to control and to lead treatment plan.
Implications: A thorough cooperation between the surgeons and physiotherapists is an indispensable prerequisite of the therapeutic success in the treatment of severely injuried patients.
Keywords: fecal incontinence, gracilloplasty, EMG biofeedback
Funding acknowledgements: None
Topic: Women's & men's pelvic health; Critical care
Ethics approval required: No
Institution: Informed consent was given
Ethics committee: Dept of Urology, University Hospital No 2, Bydgoszcz, Poland
Reason not required: Case study is based on acceplable treatment policy
All authors, affiliations and abstracts have been published as submitted.
