Colorectal Surgery – Pelvic Floor Physical Therapy for Prehab, Rehab, or Both?
Doug is a 63-year-old male who was recently diagnosed with colon cancer and will be undergoing surgical removal of the cancerous tissue, which is the primary treatment for colorectal cancer. He understands that this procedure is necessary to save the healthy tissue that he has remaining and, more importantly, save his life. However, Doug’s doctor explained that he would likely experience changes after his operation, including fecal incontinence (leakage) and sexual dysfunction. Doug asked his doctor if there were any proactive means to reduce the intensity of his post-operative health risks. Thankfully there is a way to help prevent and reduce risk, so his doctor recommended that he see a pelvic floor physical therapist.
The third most diagnosed cancer in the world is colorectal cancer. Common post-operative bowel side effects include stool frequency, stool urgency, difficulty with evacuation (emptying), and varying degrees of fecal incontinence (FI) that can affect quality of life (QoL). Fecal incontinence and urgency have a significant impact on social functioning. Urgency alone can negatively affect mental and general health perception. There is typically a 20-40% reduction in functional overall health capacity that can take up to several months to regain after an operation. This means that colorectal cancer is a very long journey that massively impacts functional abilities and quality of life. It is important to know the journey that lies ahead to prepare well before and after procedures to help ensure a healthy recovery and a quality of life that is still enjoyable to live.
People who choose to undergo rehabilitation before their colorectal operation, called prehabilitation, typically experience improved healing times post-operatively as compared to those who attend rehabilitation after surgery. Seventy-seven patients were split into two groups with one group receiving prehabilitation beginning 4 weeks prior to surgery and an additional 8 weeks after surgery. The other rehabilitation group received only intervention immediately after surgery for 8 weeks. Patients were provided with moderate aerobic and resistance exercises, nutritional counseling, and relaxation exercises. Those who participated in the prehabilitation group had a higher functional walking capacity (improved ability to live life and walk around) and were able to walk significantly further in a 6-minute timeframe as compared to the rehabilitation group. Also, the prehabilitation group recovered to or above baseline exercise capacity at 8 weeks compared to the rehabilitation group, which remained below baseline! 2 This means prehabilitation massively protects individuals’ quality of life and ability to move and life as they please after colorectal surgery.
Thankfully, about 50-80% of patients with colorectal cancer can undergo sphincter-preserving surgery (saving the “butthole”) following bowel resection (removal) in order to avoid a permanent colostomy bag (a bag that collects fecal matter). About 90% of patients will experience a change in bowel habits following a low anterior resection (LAR). These bowel habit changes can include fecal incontinence, increased frequency, and difficulty emptying. A systematic review (very high-quality evidence) looked at a total of 321 patients; 286 of the patients underwent pelvic floor strength training following a LAR. Pelvic floor strength training was found to be helpful in improving functional outcome after a LAR by reduced fecal incontinence (leakage), reducing stool frequency, and improved quality of life.
Sexual function is a common concern in those who experience cancer and undergo cancer treatment. Concerns in this area can include lack of erectile dysfunction, vaginal lubrication, painful intercourse, lack of libido, and difficulty with arousal and orgasm. Because those who have been treated for colorectal cancer are living longer following treatment, it is important to address quality of life, bowel function, and sexual function as 60-80% of men and women will experience an incidence of sexual dysfunction after colorectal surgery. Erectile dysfunction is more common in males and vaginal dryness is more common in females due to the change in blood flow. 5 Additionally, fatigue, difficulty with sleep, anxiety, depression, and an individual’s relationship with a partner can be contributing factors to sexual function concerns.
Pelvic physical therapy can address all of these quality of life concerns: fecal incontinence, fecal urgency, difficulty emptying bowels, erectile dysfunction, vaginal dryness, painful intercourse, lack of libido, and difficulty with orgasm by addressing the nerve and muscle function in the pelvic area to improve overall function. Typically, an external examination is performed which looks at how the body works together, such as spinal and leg range of motion and strength, as well as posture and walking patterns. After the external examination, an internal rectal or vaginal examination is performed to look at pelvic floor pain, strength, endurance, control and muscle tone. Treatment should be based on the findings of an individual’s exam and can include both external and internal interventions. 4 Treatment can include manual massage on the pelvic floor muscle/abdominal/glute/leg region, pelvic floor/abdominal/hip muscle strength training with biofeedback equipment, toileting techniques, fluid intake, basic nutritional needs, pressure management, positional changes, return to physical activity, and specific exercise routines or intimacy. Think of it this way, the more you practice, the better your body and mind are at performing a specific task, so why would you not start practicing before a major surgery and recovery? Leaking fecal matter and or always having to rush to a bathroom is no way to live, but thankfully pelvic floor PTs do exist, and we are here to help men and women suffering from these post-op concerns that can occur with colorectal cancer procedures. If you or a friend is battling colorectal cancer please listen to and share this research based information to help prevent awful and common risks after colorectal cancer treatment.
Written by Jordan Schmidt, PT, DPT
Edited by Molly Hart, PT, DPT
References
1. Sakr, A., Sauri, F., Alessa, M., Zakarnah, E., Alawfi, H., Torky, R., Kim, H. S., Yang, S. Y., & Kim, N. K. (2020). Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer. Chinese medical journal, 133(15), 1824–1833. https://doi.org/10.1097/CM9.0000000000000852
2. Gillis, C., Li, C., Lee, L., Awasthi, R., Augustin, B., Gamsa, A., ... & Carli, F. (2014). Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology, 121(5), 937-947.
3. Visser, W. S., Te Riele, W. W., Boerma, D., van Ramshorst, B., & van Westreenen, H. L. (2014). Pelvic floor rehabilitation to improve functional outcome after a low anterior resection: a systematic review. Annals of coloproctology, 30(3), 109–114. https://doi.org/10.3393/ac.2014.30.3.109
4. Lindau, S. T., Abramsohn, E. M., Baron, S. R., Florendo, J., Haefner, H. K., Jhingran, A., Kennedy, V., Krane, M. K., Kushner, D. M., McComb, J., Merritt, D. F., Park, J. E., Siston, A., Straub, M., & Streicher, L. (2016). Physical examination of the female cancer patient with sexual concerns: What oncologists and patients should expect from consultation with a specialist. CA: a cancer journal for clinicians, 66(3), 241–263. https://doi.org/10.3322/caac.21337
5. Albaugh, J. A., Tenfelde, S., & Hayden, D. M. (2017). Sexual Dysfunction and Intimacy for Ostomates. Clinics in colon and rectal surgery, 30(3), 201–206. https://doi.org/10.1055/s-0037-1598161
