By Lauren Opatrny, PT, DPT San Francisco, CA
What is Low Anterior Resection Surgery?
Colorectal cancer is the second leading cause of cancer-related death in the United States (1), and low anterior resection (LAR) is the preferred surgical treatment for rectal cancer. During this procedure, the part of the rectum with cancer will be removed, and the remaining part of the rectum will be reconnected to the colon(2). This reconnection of the remaining rectum to the colon is referred to as an anastomosis. In order to allow the anastomosis to heal, most patients will receive a temporary ileostomy. This ileostomy diverts stool from the colon and resected rectum to allow for healing of the anastomosis. The stool comes out of a stoma on the right side of the abdomen and into an ileostomy bag. The time someone has the temporary ileostomy varies greatly and can be anywhere from a few days to several months(3). Eventually, the ileostomy is reversed, allowing stool to continue passing down into the colon. This is usually when changes in bowel function are triggered, which is referred to as “Lower Anterior Resection Syndrome.”
What does the rectum do?
So, what does the rectum actually do? It functions as a storage vault for stool until we are able to go to the bathroom. Sounds simple, right? It’s actually much more sophisticated! Distension of the rectum sends a signal to our brains that we need to defecate. The internal anal sphincter will relax to allow some stool to descend, so the anal mucosa can “sample” the contents and distinguish if it’s loose or solid stool, or gas. Then, defecation can occur when it’s socially appropriate, or in the case of liquid stools, let us know we need to run to the bathroom! Since the rectum plays a crucial role in bowel function, it makes sense that when it’s removed, problems can ensue.
What is LARS? And how is bowel function affected after LAR surgery?
Unfortunately, bowel function can be significantly affected after rectal surgery. The spectrum of such dysfunction is broad, and can include:
- Fecal Incontinence
- Clustering of stools (high number of bowel movements in a short period of time)
- Increased frequency of bowel movements
- Extreme urgency of bowel movements
- Emptying difficulties
- Altered stool consistency
- Constipation
- Rectal pain
- Variable and unpredictable bowel function
All of these symptoms can have a severely negative impact on quality of life(3,4). These wide ranging symptoms after a resection and reconstruction of the rectum have been termed lower anterior resection syndrome, or “LARS”(4). The incidence of LARS in the United States ranges from 19-90%(1). Those suffering from LARS can have dozens of bowel movements per day, which can lead to skin irritation and further discomfort. In addition, discrimination between gas and stool is diminished, and can lead to more frequent toilet visits, as well as more instances of incontinence.
Simply eating a meal is strongly related to fecal urgency in people with LARS. When we eat a meal, it’s normal for the gastrocolic reflex to be activated, which is when motility of our lower digestive tract is stimulated in response to stretching of the stomach. In other words, after we eat something, we might feel the need to go poop! However, in those suffering from LARS, the gastrocolic reflex is found to be accentuated, meaning eating a meal can be quite triggering for their symptoms(3). Not everyone who has a low anterior resection experiences LARS, and incidence of symptoms are related to the confluence of anatomy, radiation treatment sites, time to ileostomy reversal, and surgical location, among other factors.
How can Pelvic Floor Physical Therapy help?
Although there is limited research about the role that pelvic floor physical therapy plays in treating patients suffering from LARS, results are encouraging! One systematic review found the majority of studies reported improvement in stool frequency, incontinence episodes, severity of fecal incontinence, and quality of life outcome measures after pelvic floor physical therapy(4).
Pelvic floor physical therapists are experts in the muscles and function of the pelvic floor. Depending on your symptoms, your physical therapist may address myofascial restrictions, motor control and coordination deficits, weakness, and even use bowel retraining techniques. Pelvic floor muscle training aims to restore muscular strength, coordination, and motor control. Biofeedback training can help provide the patient with information about the performance of their pelvic floor, and make improvements as needed. Rectal balloon training is used to increase the patient’s ability to perceive the rectal distension, which can be particularly useful in improving rectal sensitivity, reduce urgency, and work to counteract the recto-anal inhibitory reflex in response to rectal filling.
What are other treatment options?
“Anal continence is a complex interplay between the external anal sphincter, the internal anal sphincter, anorectal sensation, rectal compliance (stretch), rectal emptying and stool consistency”(3), so it makes sense that it would be beneficial to have a multimodal approach. Outcomes for patients with LARS can be improved by having a multidisciplinary care team to address the number of bowel changes that can occur. Diet and nutrition changes have been found to be helpful, so it could be useful to work with a dietitian, nutritionist, and/or naturopathic doctor for a more guided and individualized approach. Patient motivation and expectations can also play a large role in outcomes. It is important that patients are informed by their doctor of the risks and benefits of LAR surgery. It may be possible that addressing any pelvic floor and/or bowel dysfunction prior to surgery could improve the outcome, but more research is needed.
If you are dealing with LARS, ask your doctor about trying pelvic floor physical therapy!
References
- Siegel RL, Miller KD, Sauer AG, et al. Colorectal cancer statistics, 2020. CA Cancer J Clin. 2020;70:145– 164. https://doi.org/10.3322/caac.21601
- “About Your Low Anterior Resection Surgery.” Memorial Sloan Kettering Cancer Center, 12 July 2022, https://www.mskcc.org/cancer-care/patient-education/about-your-low-anterior-resection-surgery.
- Christensen, Peter, et al. “Management Guidelines for Low Anterior Resection Syndrome – the Manuel Project.” Colorectal Disease, vol. 23, no. 2, 2021, pp. 461–475., https://doi.org/10.1111/codi.15517.
- Visser, Wilhelmina S, et al. “Pelvic Floor Rehabilitation to Improve Functional Outcome after a Low Anterior Resection: A Systematic Review.” Annals of Coloproctology, vol. 30, no. 3, 21 May 2014, pp. 109–114., https://doi.org/10.3393/ac.2014.30.3.109.
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Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.