Schouten and coworkers recently described the perineo-rectal reflex, i. e. a rectal contraction elicited by stimulating the perianal skin (Dis. Colon Rectum 2004), thus explaining how females with rectocele evacuate after self digitation.
On this basis, it is interesting to report that Shafik Shafik et al (Arch Surg 2006) wrote on the functional and anatomical pathway in the reflex occurring in the opposite direction. If stimulated, the rectum elicits a contraction of both deep and superficial traverse perineal muscles, up to now never deeply investigated by means of any study, to my knowledge.
Cutaneousvisceral and visceral-muscular links show how close is the sensorial and motor connection between the pelvi-perineal structures which may be altered in disease but also therapeutically regulated. This is a kind of cybernetic system, with complex mutual interactions and any specialist dealing with constipation and incontinence should be aware of it (Tate). Tate et al., Arch Phys Rehabil 2006.
As questioned in another article pelvic floor rehabilitation may well considered both an art and a science. After all, as stated by the philosopher Bertrand Russell in his book “Search for happiness”, two ways which may help an individual to be happy are to be either on artist or a scientist. Having said that, a perineologist would like to have such a Leonardo Da Vinci among his or her physiotherapists.
The July 2006 Pelvic Floor Digest includes a large number of papers in several areas of interest. Cross discipline fertilisation of techniques and ideas is a feature of the Pelvic Floor Digest and in this issue there are several reports pertaining to stem cell therapy.
Chen et al studied the relationship between apical support, levator ani impairment and anterior vaginal wall prolapse. Powers, Shah and Hanson review the role of pessaries in three separate papers.
With each issue of the PFD new papers appear with reports of anatomical and functional outcomes following reconstructive surgery. De Tayrac reports 2 year results after rectocoele repair with mesh. Silva et al report uterosacral ligament vault suspension. A number of papers look at sling techniques, complications and outcomes.
Glavind et al performed an interesting study looking at urine flow and voiding difficulty after a TVT procedure. They found that residual urine measurements that were increased three months after surgery were back to preop levels within a few years but abnormal flow parameters did not improve with time.
Stoutjesdijk et al show that sexual function generally improves after vaginal reconstructive surgery. I am sure that this will not be the last word on this subject.
In the August 2006 edition of the Pelvic Floor Digest readers will find a wide range of interesting papers which relate to all aspects of pelvic medicine. Valaitis et al discuss the ability of surgeons to keep pace with new technologies and maintain surgical competence. Dumoulin looks again at rehabilitation in the treatment of incontinence and asks if there is more that we can do in obstetrics to provide postnatal pelvic floor training.
Dietz predicts that ultrasound will help predict the risk of obstetric trauma to the pelvic floor while Kudish confirms the extra risk provided by midline episiotomy and forceps delivery. A number of other papers assess imaging in the pelvis.
Wallner et al describe the anatomy of the levator ani nerve and consider the implications for nerve block or damage. Alperin and Moalli explore the possibilities of remodelling vaginal connective tissue. Is this the future or just another dead end ?
Surgery for stress incontinence is always evolving. Foglia et al look at a transfascial sling which does not require a blind passage through the retropubic space or obturator canal.
Hart et al look at surgery for incontinence and prolapse at the same time. Casale et al also looks at surgery to address urinary and faecal incontinence at the same time. In two separate papers Zutshi et al and Ripetti et al consider total colectomy with ileorectal anastomosis as treatment of slow transit constipation. Is this a valid treatment or going too far ?