What is the recommended treatment approach for a patient with a history of anal fistulas and possible sphincter reconstruction, considering pelvic floor therapy?

Pelvic Floor Therapy in Anal Fistula Management with Sphincter Reconstruction

Pelvic floor therapy with biofeedback should be integrated into the treatment plan for patients with anal fistulas and sphincter reconstruction, particularly when fecal incontinence is present or anticipated, as it significantly improves sphincter function, reduces muscle hypertonicity, and enhances continence outcomes. 1, 2

Stepwise Treatment Algorithm

Initial Conservative Management (First-Line)

• Begin with conservative measures including dietary modifications (increased fiber 25-30g daily), adequate fluid intake, and bowel training programs, which benefit approximately 25% of patients with fecal incontinence. 1
• These measures should be implemented for at least 3 months before escalating to more invasive interventions. 1

Integration of Pelvic Floor Therapy

• Pelvic floor retraining with biofeedback therapy is specifically recommended for patients with fecal incontinence who do not respond to initial conservative measures. 1
• For patients with chronic anal fissures and pelvic floor dysfunction (which commonly coexists with fistula disease), pelvic floor physical therapy with electromyographic biofeedback for 8 weeks significantly reduces resting pelvic floor muscle tone (mean reduction of 1.88 µV), improves dyssynergia, and reduces pain. 2
• The therapy achieves 55.7% healing rates in chronic fissures and provides sustained improvement at 20-week follow-up. 2

Timing Relative to Sphincter Reconstruction

Pre-operative Phase:

• All patients with rectovaginal fistula or complex anal fistula should undergo preoperative evaluation for occult sphincter defects using endoanal ultrasound and/or anal manometry. 3
• Patients with clinical or anatomic sphincter defects identified preoperatively benefit most from combined sphincteroplasty with levatoroplasty (96% success rate versus 33% without levatoroplasty). 3

Post-operative Phase:

• Pelvic floor therapy should be initiated after sphincter reconstruction once initial healing has occurred, particularly for the 32% of patients who report varying degrees of fecal incontinence preoperatively. 4, 5
• Fistulotomy with sphincter reconstruction improves continence scores from 7.2 to 2.0 (p=0.008) in incontinent patients, and pelvic floor therapy can further optimize these outcomes. 4

Specific Clinical Scenarios

For Patients with Pre-existing Incontinence:

• Sphincter reconstruction combined with pelvic floor therapy is especially suitable, as 70% of incontinent patients improve after surgery, and biofeedback therapy addresses residual pelvic floor dysfunction. 4, 5
• Maximum resting pressure improves from 65.5 mmHg to 70.6 mmHg, and maximum squeeze pressure improves from 148 mmHg to 154.8 mmHg post-operatively. 4

For Continent Patients Undergoing Reconstruction:

• Even in fully continent patients, 12.5-16.6% may develop minor alterations in continence post-operatively (Wexner score <4), making prophylactic pelvic floor therapy reasonable. 4, 5
• Pelvic floor therapy does not compromise continence in already-continent patients and may prevent deterioration. 2, 4

For Recurrent Fistulas:

• In the 32% of patients with recurrent fistulas, fistulotomy with sphincter reconstruction combined with pelvic floor therapy is particularly effective, as these patients often have underlying pelvic floor dysfunction contributing to both recurrence and incontinence. 5

Critical Implementation Details

Duration and Frequency:

• Implement 8-week structured pelvic floor physical therapy programs with electromyographic biofeedback sessions. 2
• Schedule follow-up assessments at 8 weeks and 20 weeks to monitor sustained improvement. 2

Monitoring Parameters:

• Track resting electromyographic values of the pelvic floor (target reduction >1.88 µV). 2
• Assess continence using the Wexner Continence Grading Scale (0-20) at baseline and follow-up. 4, 5
• Perform anal manometry at 3 months, 12 months, and every 2 years thereafter. 5

Common Pitfalls to Avoid

• Do not proceed with endorectal advancement flap repairs in patients with sphincter defects and history of previous repairs, as success rates drop to 33% compared to 88% with sphincteroplasty. 3
• Avoid manual dilatation entirely due to high risk of permanent incontinence (up to 30% temporary and 10% permanent incontinence rates). 1, 6
• Do not delay pelvic floor therapy beyond 3 months of failed conservative management, as this represents the optimal window for intervention before considering more invasive options like sacral nerve stimulation. 1

Long-term Outcomes

• Long-term follow-up (median 32 months) demonstrates sustained improvement in both continence scores and manometric values when sphincter reconstruction is combined with appropriate pelvic floor rehabilitation. 4, 5
• Recurrence rates remain low at 5.7-8.5% with proper technique and adjunctive pelvic floor therapy. 4, 5