Current and Novel Treatment Options for Pelvic Floor Disorders
Presented by Satish Rao, MD, PhD, FRCP, FACG, AGAF
Anorectal and Pelvic floor disorders affect 25% of the population and cause significant distress including effects in quality of life. This includes many conditions such as dyssynergic defecation, and fecal incontinence, and rarely descending perineum syndrome, rectal mucosal intussusception/prolapse, solitary rectal ulcer syndrome and levator ani syndrome. First step is to take a detailed history. Because of the irregularity of bowel function, new digital Phone APPs such as Constipation Stool diary, My GI App and Fecal Incontinence stool diary can be very useful tools for patients and clinicians for accurate record and monitoring of bowel symptoms. Diagnosis of these problems remains largely clinical supported by radiology and/or manometric tools. Today there are excellent novel tools for diagnostic evaluation, including high resolution anorectal manometry, high definition 3-D anorectal manometry that uses TachArray and 256 pressure sensor probe. Additional tools including translumbosacral anorectal magnetic test for neurophysiology and balloon expulsion and colon transit studies.
Randomized Control Trials (RCTs) have shown that biofeedback therapy is effective for treatment of dyssynergic defecation, and a recent study showed that home biofeedback therapy is as effective as office biofeedback therapy and is cost-effective. In a recent RCT, both syringe and barostat assisted sensory training were useful in treating rectal hyposensitivity associated with dyssynergic defecation, but barostat training was more convenient and superior. Although biofeedback therapy remains the mainstay for treatment of fecal incontinence, newer treatments such as Dextranomer beads when injected into the anal region has been shown to be more efficacious than placebo. Sacral nerve stimulation has also been shown to be useful in fecal incontinence and home biofeedback with a new device has been shown to be as useful as office biofeedback. Most recently a novel treatment using repetitive magnetic stimulation holds promise and in a randomized controlled trail, translumbosacral neuromodulation therapy was shown to be effective and safe and improve both neuropathy and symptoms.
In conclusion, there is a new ray of hope for patients with these disorders as new tools for diagnosis are evolving, and efforts are being made to better characterize symptoms and phenotypes, and novel approaches of treatment are being developed some of whom are undergoing RCTs.
About Dr. Rao:
Professor Satish Rao is the J. Harold Harrison, MD, Distinguished University Chair in Gastroenterology and Founding Director of the Digestive Health Center and Digestive Health Clinical Research Center and Director, Neurogastroenterology/Motility and tenured Professor of Medicine at Augusta University, USA. He served as the Chief, Division of Gastroenterology/Hepatology, Director, GI Service line and GI Fellowship Program Director. Previously, he was Professor of Medicine & Director, Neurogastroenterology/motility at University of Iowa Carver College of Medicine, Iowa.
Satish Rao received his MBBS from Osmania Medical College, Hyderabad, India, his PhD from the University of Sheffield, UK, and Fellowship of the Royal College of Physicians (FRCP), UK. He completed his internal medicine training at several centers and a clinical research fellowship at the University of Liverpool, UK. He is American Board certified in Medicine and Gastroenterology. He is past President, American Neurogastroenterology/Motility Society.
His research interests in the field of Neurogastroenterology/Motility have focused on gaining mechanistic insights, developing novel diagnostic tools and pioneering innovative treatments for common disorders especially constipation, dyssynergic defecation, fecal incontinence, IBS, food intolerance, gas and bloating and small intestinal bacterial and fungal overgrowth (SIBO/SIFO) and visceral pain. He is credited with discovering dyssynergic defecation, a problem that affects 1/3rd of constipated patients and its remedy, biofeedback therapy as well as novel treatments, sensory adaptation training for rectal hypersensitivity. He has pioneered several novel tests, translumbosacral anorectal magnetic stimulation for pelvic floor neuropathy, esophageal balloon distension for chest pain, fructose and fructan breath tests. He developed the first method for examining bi-directional gut and brain interactions in humans. His latest invention translumbosacral neuromodulation therapy (TNT) is revolutionizing treatment for fecal incontinence. He has been awarded 4 patents.
Dr. Rao is a National Institutes of Health funded principal investigator for 20 years and currently holds $ 10.6 million NIH UO-1 and 3.8 million RO-1 grants. Dr. Rao has edited 10 books, including Handbook of GI Motility (2015), and Clinical and Basic Neurogastroenterology & Motility (2020). He has published over 500 peer reviewed articles with 22,300 citations, a H index of 87 and i10 index of 235. An astute clinician, Dr. Rao has been selected as one of the “Best Doctors in America” and as Americas’ Top Doctors for over 25 years. He has mentored over 100 Physicians from across the world, many of whom are leaders and professors in their own countries. Thirty of his mentees have received national/ international research awards- a testament of his dedication as a distinguished mentor. He has been invited to lecture in 35 countries as visiting professor. These include live demonstrations of motility procedures and novel TNT procedures, and to train gastroenterologists and fellows globally and at multiple institutes in India and all 5 continents.
Dr. Satish Rao has received the 3 highest meritorious honors from the American Gastroenterological Association (AGA), the AGA Distinguished Clinician Award, AGA Masters Award for Outstanding Clinical Research and AGA Distinguished Educator Award. He received the American College of Gastroenterology Auxiliary Research Award, the International Foundation for Functional GI Disorders Senior Clinical Investigator Award, University of Iowa Regents Distinguished Award for Faculty Excellence, “Dr. PN Chuttani Oration”, the highest honor from Indian Society of Gastroenterology, and the Augusta University Distinguished Research Award and the Medical College of Georgia Distinguished Faculty Award and Mexican Society Gastroenterology Honorary Diplomate/Fellow. Dr. Rao is one of a rare breed of academicians referred to as a tripled threat, and has excelled as an internationally renowned researcher, distinguished educator and outstanding physician.