EFFICACY OF PELVIC FLOOR REHABILITATION FOR BOWEL DYSFUNCTION AFTER ANTERIOR RESECTION FOR COLORECTAL CANCER: A SYSTEMATIC REVIEW

K.Y.C. Chan^1,2, M. Suen^1,3, S. Coulson¹, J. Vardy^1,2

Background: Colorectal cancer (CRC) is the third most commonly diagnosed cancer. Total mesorectal excision (TME) with anal sphincter preservation is widely performed to minimise the need for a permanent colostomy. Although sphincter-preserving surgery allows the restoration of bowel continuity, bowel function is often compromised. Up to 80% of CRC survivors experience bowel habit changes, including incontinence, frequency, urgency and emptying difficulties with 40% reporting severe symptoms. Some spontaneous recovery usually occurs in the first 6-12 months after bowel reconstruction but improvement often then plateaus. Ongoing bowel disturbance often leads to physical and psycho-social health consequences, placing substantial restrictions on the cancer survivor’s daily activities and impacting their quality-of-life. Pelvic floor rehabilitation (PFR) consists of pelvic floor muscle exercises, biofeedback, rectal balloon retraining and electrostimulation, and may improve pelvic floor muscle strength, rectal sensation and coordination, with goals of treatment to improve anorectal function and optimise overall physical function.

Purpose: The aim of this systematic review is to examine the design of PFR programs in the literature, and to evaluate effectiveness of PFR on bowel dysfunction after anterior resection surgery for CRC. The review will examine the design of PFR programs to identify discrepancies in current practice and gaps between evidence and application. 

Methods: MEDLINE, CINHAL, PUBMED, EMBASE, Scopus, PsycINFO, Web of Science, PEDRO and Cochrane Library were searched from inception to June 2019. Randomised controlled trials (RCTs), cohort studies, case-control studies and case series of bowel dysfunction after CRC surgery and PFR were eligible for review. Outcome measures were bowel function changes measured by patient-reported outcomes and manometric measurement. Risk of bias assessments using Methodological Index for Non-Randomized Studies (MINORS) tool and Newcastle Ottawa Scale (NOS) were conducted.

Results: Eleven trials met eligibility criteria: four retrospective studies and seven prospective, non-randomised controlled studies. A total of 516 participants were included, of which 455 received PFR. Functional outcomes were measured by bowel functional outcome questionnaires, patient diary, anorectal manometry, and three studies measured quality-of-life. Faecal incontinence and bowel frequency were improved. Improvement on anal manometry measures were demonstrated. The mean MINORS score was 10 (8-13) out of 16 in non-comparative groups and 18 (16-22) out of 24 in comparative groups; the NOS was 4.2 (3-7) out of 9. The overall risk of bias was high in most studies.

Conclusion(s): PFR appears to be beneficial for improving bowel function after CRC surgery. However, the studies included had methodological limitations, heterogeneity of treatment protocols and outcome measures. Suggestions for future trials include randomisation, standardisation of treatment protocols and measuring tools to provide robust evidence concerning the effectiveness of PFR for bowel dysfunction after CRC surgery and treatment.

Implications: By identifying current limitations of PFR in CRC management, results of this systemic review can assist in study design of future PFR trial to better bridge the gap between evidence and practice, and the development of future care pathways for CRC survivors who have bowel dysfunction.

Funding, acknowledgements: This work is unfunded 

Keywords: pelvic floor rehabilitation, bowel dysfunction, colorectal cancer

Topic: Pelvic, sexual and reproductive health

Did this work require ethics approval? No

Institution: n/a

Committee: n/a

Reason: This is a systematic review