Female, approximately 35 years of age, suffering from pain in the lower left abdomen after laparoscopy and a difficult evacuation of feces. She wants to ease the defecation process and reduce her abdominal pain.
The patient had a laparoscopy whereby a cyst was removed from the ovary causing a reduction in the defecation urge and a difficult evacuation of feces. The patient also experiences pain during intercourse.
The patient has a normal fluid intake of around 2 litres. Defecation takes place daily and regularly. The urge for defecation is abnormal but she does go to the toilet as she feels pressure. She regularly sits on the toilet for 30 minutes or goes several times in succession. The Bristol Stool scale classification is 2-5, whereby the tip is regularly hard and the rest soft. Straining frequently takes place during a bowel movement and manual removal of stool is sometimes required. Continued rectal pressure, sometimes long after defecation. She has tried various laxative products.
Evidence of over activity was found during an internal vaginal examination with reduced strength, limited lift and closing movement and delayed incomplete relaxation. The muscles are very stiff and non-flexible; no pain is reported and there are no trigger points. An internal anal examination indicates normal sphincter function with an overactive levator ani. There is a noticeable but weak contraction of 3 seconds; yet upon recurrence of the contraction, tension is not always achieved. Relaxation is delayed and incomplete. Muscle stretch is laborious; non-painful however is sensitive and causes an urge.
During the anal diagnostic measurement (lateral position) with the MAPLe, it was notable that the resting value – an average of 7.3 µV – is far too high, particularly with the levator ani at ring 3-4. This corresponds with findings from the internal examination. Halfway through (image 1) she tries to tense but is aware that she’s unsuccessful and there is no clear contraction to be seen on the image.
Image 1: Diagnosing using the MAPLe
The aim is to reduce the pain and improve defecation by means of awareness and relaxation.
The first part of the treatment focuses on explaining the problem to the patient, providing pelvic floor re-education, toilet behaviour and remedial therapy and relaxation techniques.
In the second part of the treatment (7 treatments), the MAPLe is used to provide functional electrostimulation (FES). The objective is for the patient herself to experience where she needs to relax. The settings used are: ring 2 to ring 5, phase duration of 300 µsec, frequency 2Hz for 6 to 10 minutes. This frequency creates a “twitch-contraction” sensation, a throbbing sensation that is clearly felt at a muscular level.
The resting value fell sharply to an average of 3.3 µV. In particular, the increased activity in the levator ani (ring 3-4) fell sharply (see image 2). The patient is able to feel the contraction better and it is also much more visible on the measurement.
The feces now pass through a lot quicker and there is an improved urge and sense of relaxation. She now spends no longer than 15 minutes on the toilet. The pressure she felt after defecation is significantly reduced as is the abdominal pain (VAS 6 to 4). The patient has indicated that for her, the anal FES-treatments have been the most effective. She felt that the relaxation techniques were more effective after the FES.
Thanks to the local stimulation provided by the MAPLe at the level of the levator ani, the patient was better able to feel where she needed to relax. This would not have been possible using current conventional equipment.
Image 2: Diagnosing using the MAPLe