RU2840416C1 - Method for determining the need for high-frequency magnetic therapy in patients with defecation disorder - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to coloproctology, gastroenterology and physiology, and may be used to determine a further therapeutic approach to the patients with defecation disorders, such as anal incontinence, obstructive defecation etc. That is ensured by pre-forming a pattern of anterior abdominal wall muscle contraction and pelvic floor muscle relaxation by biological feedback therapy and magnetic stimulation. Biofeedback therapy is performed for 4 days in dose of 20 minutes a day. Then for following 4 days, the patient undergoes extracorporeal magnetic stimulation by a pulse train at frequency 5 Hz – 15 pulses in a packet, 10 packets at a packet interval of 6 seconds. When forming a pattern of anterior abdominal wall muscle contraction and pelvic floor muscle relaxation in a patient, high-frequency magnetic therapy is applied.

EFFECT: method provides the most accurate determination of the criterion facilitating the high-frequency magnetic stimulation in the patients with defecation disorders, which is the formation of a pattern of anterior abdominal wall muscles contraction and pelvic floor relaxation at the preliminary stage.

1 cl, 1 tbl, 2 ex

Description

The invention relates to medicine, namely to proctology, gastroenterology and physiology, and can be used in determining further treatment tactics for patients with defecation disorders, such as anal incontinence, obstructive defecation, etc.

Obstructive defecation is a fairly common problem encountered by proctologists and gastroenterologists in their practice. This condition bothers patients socially and psychologically and significantly worsens their quality of life. Despite the terminological differences in the designation of the etiopathogenetic causes of obstructive defecation syndrome (ODS), everything comes down to, in essence, two fundamental ones: functional (dysfunction and dyssynergia of the pelvic floor muscles) and mechanical (rectocele and rectal intussusception) and their combinations.

Constipation is a subjective symptom of various pathological conditions. It is known that more than 80% of people have had periods of constipation in their lives. A distinction is made between primary, or functional, constipation and secondary constipation, i.e. as a symptom of some disease.

Functional constipation is classified into slow-transit constipation and constipation with a violation of the act of defecation, designated in the literature as obstructive defecation. In Russian literature, such a condition as obstructive defecation is also found under the term "proctogenic" constipation. At the same time, patients with obstructive defecation syndrome (ODS) can have normal transit of contents through the colon.

Obstructive defecation syndrome (ODS) is characterized by a range of symptoms such as difficulty emptying the bowels and the need for excessive straining during defecation, a feeling of incomplete emptying, increased duration of defecation, pain, rectal bleeding and the need for manual assistance during stool (Fomenko O.Yu., Titov A.Yu., Biryukov O.M. et al. Diagnostics and conservative treatment of functional defecation disorders. Coloproctology. 2016; 3(57): 48-54; Fomenko O.Yu., Shelygin Yu.A., Poryadin G.V. et al. Functional state of the pelvic floor muscles in patients with obstructive defecation syndrome. Coloproctology. 2017; 2(60): 55-61; Preston D.M., Lennard-Jones J.E. Anismus in chronic constipation Dig Dis Sci. 1985; 30(5): 413-418; Rao S.S., Welcher K.D., Leistikow J.S. Obstructive defecation: a failure of rectoanal coordination. Am J Gastroenterol. 1998; 93: 1042-1050; Schwandner O., Stuto A., Jayne D. et al. Decision-making algorithm for the STARR procedure in obstructed defecation syndrome: position statement of the group of STARR Pioneers. Surg Innov. 2008; 15: 105-109). It has been established that approximately 20% of adult women suffer from this syndrome (Zhang B., Ding J.H., Yin S.H. et al. Stapled transanal rectal resection for obstructed defecation syndrome associated with rectocele and rectal intussusception. World J Gastroenterol. 2010; 16(20): 2542-2548).

The etiology of obstructive defecation is multifactorial and is the result of the interaction of many functional and anatomical causes affecting the evacuation mechanism (Fomenko O.Yu., Shelygin Yu.A., Popov A.A. et al. Genital prolapse and obstructive defecation. A view from the standpoint of functional diagnostics. Medical alphabet. Modern gynecology. 2017; 3(1): 39-44). Internal intussusception of the rectum and rectocele are the most common organic causes of obstructive defecation (Zhang B., Ding J.H., Yin S.H. et al. Stapled transanal rectal resection for obstructed defecation syndrome associated with rectocele and rectal intussusception. World J Gastroenterol. 2010; 16(20): 2542-2548).

In 25-50% of cases, the causes of ODS can be not only anatomical, but also functional defecation disorders (FDD) (Fomenko O.Yu., Shelygin Yu.A., Poryadin G.V., Titov A.Yu., Ponomarenko A.A., Mudrov A.A., Belousova S.V. Functional state of the pelvic floor muscles in patients with obstructive defecation syndrome. Coloproctology. 2017; 2(60): 55-61; Fomenko O.Yu. Mechanisms of impairment of evacuation and retention functions in diseases of the rectum and directions of pathogenetically substantiated diagnostics and therapy. Diss… MD, PhD. Moscow, 2018; Grossi U., Carrington E.V., Bharucha A.E. et al. Diagnostic accuracy study of anorectal manometry for diagnosis of dyssynergic defecation. Gut. 2016; 65(3): 447-455). In 2016, the updated Rome criteria for functional gastrointestinal disorders were presented. According to Rome criteria IV (Rao S.S.C., Bharucha A.E., Chiarioni G. et al. Anorectal Disorders. Gastroenterology. 2016; 150(6): 1430-1442.e4). In this case, the diagnosis of functional defecation disorder is established in the presence of criteria for functional constipation and/or irritable bowel syndrome with a predominance of constipation, as well as in the presence of the following signs of defecation disorder and include dyssynergic defecation (DD) and inadequate propulsion [Lacy BE, Mearin F, Chang L, et al. Bowel Disorders. Gastroenterology. 2016; 150(6): 1393-1407.e5.], (Drossman D.A. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features, and Rome IV. Gastroenterology. 2016; 150: 1262-1279; Rao S.S.C., Bharucha A.E., Chiarioni G. etal. Anorectal Disorders. Gastroenterology 2016; 150(6): 1430-1442.e4).

Anal sphincter insufficiency (ASI) is a partial or complete impairment of voluntary or involuntary retention of intestinal contents. Fecal incontinence (anal incontinence) is a recurring, uncontrolled passage of feces or gases for at least one month, including in children over 4 years of age (Clinical guidelines. Coloproctology / edited by Yu. A. Shelygin. Moscow: GEOTAR-Media, 2015. pp. 147-168; Shelygin Yu. A. Handbook of Coloproctology. Moscow: Litterra, 2012. pp. 191-199). Fecal incontinence is characterized as the involuntary passage of rectal contents (feces, gas) through the anal canal and the inability to delay bowel movements until reaching a socially acceptable place (toilet) and is a complex multifactorial clinical problem (Kaiser A.M. Colorectal surgery. Moscow: Panfilov Publishing House, 2011. Pp. 192-197).

The holding function depends on a number of factors: the functional state of the locking apparatus of the rectum, the consistency of the stool, the state of the central and peripheral nervous system responsible for the innervation of the pelvic organs and the muscles of the pelvic floor.

The main role in fecal retention belongs to the anal sphincter system - the locking apparatus of the rectum (LAR). The pressure created by the locking apparatus of the rectum at rest is due to the tonic activity of both the smooth muscles of the internal sphincter and the striated muscles of the external sphincter. In this case, 70-80% of it is determined by the work of the internal sphincter and only 20-30% is provided by the fibers of the external sphincter (Lestar B., Penninckx F., Rigauts H. et al. The internal anal sphincter can not close the anal canal completely. Int J Colorectal Dis. 1992; 7(3): 159-161; Yoo S.Y., Penninckx F., Rigauts H. et al. How important is the role of the internal anal sphincter in fecal continence? An experimental study in dogs. Int J Pediatr Surg. 1995; 30(5): 687-691).

At the same time, voluntary contraction of the anal sphincter is produced mainly by the striated muscles of the external sphincter and pelvic floor. The internal anal sphincter is in constant tonic tension and takes part in defecation, reflexively relaxing in response to filling of the intestine, which is known as the rectoanal inhibitory reflex (RAIR) (Sangwan Y.P., Solla J.A. Internal anal sphincter: advances and insights. Dis Colon Rectum. 1998; 41: 1297-1311).

The external anal sphincter and m. levator ani are largely responsible for the increase in pressure in the anal canal during compression or voluntary contraction, as well as in response to an increase in intra-abdominal pressure during coughing and sneezing (Delancey J.O., Toglia M.R., Perucchini D. Internal and external anal sphincter anatomy as it relates to midline obstetric lacerations. Obstet Gynecol. 1997; 90: 924-927; Rasmussen O.O., Christiansen J. Physiology and pathophysiology of anal function. Gastroenterol Suppl. 1996; 216: 169-174).

The problems of treating SOD and anal incontinence lie in the correct choice of conservative and surgical treatment methods or their combinations.

Conservative treatment of defecation disorders mainly consists of diet, laxatives, electrical stimulation of the pelvic floor muscles and psychotherapy, as well as biofeedback.

Biofeedback therapy as a first-line treatment for defecation disorder is recommended by the Fourth Rome Convention (Rao S.S.C., Bharucha A.E., Chiarioni G. et al. Anorectal Disorders. Gastroenterology. 2016; 150(6): 1430-1442.e4.), as well as by the Guidelines of the American and European Societies of Neurogastroenterology and Motility (Rao S.S.C., Benninga M.A., Bharucha A.E. et al. ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol Motil. 2015; 27(5): 594-609.).

Biofeedback therapy - BFB therapy - is a type of behavioral therapy with operant conditioning, i.e. a form of learning in which the correct response or behavior change is reinforced and becomes more likely in the future. During BFB therapy for bowel movement disorders, data on pelvic floor and rectal muscle contractions are converted into a visual signal that allows the patient to control the bowel movement and, in effect, relearn how to empty the rectum correctly. BFB therapy aims to eliminate dyssynergia or discoordination of the pelvic floor muscles (external anal sphincter and puborectalis muscle) during straining, as well as to enhance the neurosensory perception of the filling of the rectum.

State of the art

The state of the art knows many different methods for correcting defecation disorders.

Thus, methods of electrical stimulation of the internal anal sphincter are known (RU 2587951, RU 2280479).

The use of tibial neuromodulation is also known, which involves influencing the pudendal nerve emerging from the sacral plexus (S2-S4) by electrically stimulating the posterior tibial nerve in the lower extremities. By stimulating the autonomic, sensory and motor nerves, the technique improves the tone, contractility and neuroreflex activity of the posterior tibial nerve muscles (Clinical guidelines. Coloproctology. Anal sphincter insufficiency / edited by Yu.A. Shelygin. Moscow: GEOTAR-Media, 2015. Pp. 190-215).

There is a known drug treatment (Attapulgite, Loperamide), which helps to slow down intestinal motility and increase fluid absorption (Clinical guidelines. Coloproctology. Anal sphincter insufficiency / edited by Yu.A. Shelygin. Moscow: GEOTAR-Media, 2015. pp. 190-215).

Biofeedback therapy is known, which can be carried out at the initial stage of treatment of patients with impaired voluntary contraction of the anal sphincter, in whom it was not possible to achieve a positive effect with the help of diet and drug therapy. In the treatment of anal sphincter insufficiency, biofeedback therapy is aimed at developing self-regulation of the functional activity of the muscular structures of the perineum, developing the correct perception of sensations that can improve control over the function of holding intestinal contents (Clinical guidelines. Coloproctology. Insufficiency of the anal sphincter / edited by Yu. A. Shelygin. Moscow: GEOTAR-Media, 2015. pp. 190-215).

A method for treating defecation disorders is known, using the example of obstructive defecation syndrome, using the method of biological feedback (FOMENKO O.Yu. Mechanisms of impairment of the evacuation and retention function in diseases of the rectum and directions of pathogenetically substantiated diagnostics and therapy. Dissertation for the degree of Doctor of Medical Sciences. Moscow 2017, 257 p.).

In this work, biofeedback therapy was used to treat proctogenic constipation in order to teach patients to strain correctly. The procedure was performed using manometric sensors. The sensor with a latex balloon was calibrated according to pressure parameters after being placed in the anal canal. Surface electrodes were attached to the anterior abdominal wall. A latex balloon was additionally inserted into the patient's rectum and filled with air until the patient subjectively felt full. Then the patient was asked to strain the muscles of the anterior abdominal wall (strain) and not to strain, but, on the contrary, to relax the muscles of the pelvic floor and external sphincter, i.e. to imitate an attempt at defecation. After each procedure, the doctor necessarily studied and assessed the results obtained in order to estimate the number of successful attempts at straining.

However, all of the listed known treatment methods assume certain standards and do not take into account the characteristics of a particular patient in each specific case.

The technical problem that the presented invention is aimed at solving is the development of possible criteria that determine the choice of high-frequency magnetic therapy as the most effective treatment for patients with defecation disorders.

Disclosure of invention

The technical result of the invention consists in the most precise determination of the criterion that determines the possibility of conducting further pathogenetically justified physiotherapeutic treatment in patients with defecation disorders using the method of high-frequency magnetic therapy, which is the formation in the patient of a pattern of contraction of the muscles of the anterior abdominal wall and relaxation of the muscles of the pelvic floor, carried out at the preliminary stage.

The technical result of the invention is achieved by the proposed method for determining the need for high-frequency magnetic therapy in patients with defecation disorders, characterized by the fact that a pattern of contraction of the muscles of the anterior abdominal wall and relaxation of the muscles of the pelvic floor is preliminarily formed in the patient by means of biofeedback therapy and magnetic stimulation, wherein biofeedback therapy is carried out by inserting a latex balloon into the rectum and filling it with air, followed by inserting an electromyographic sensor (EMG sensor) into the rectum, additionally, two surface EMG sensors are fixed on the anterior abdominal wall, in the projection of the rectus abdominis muscles, followed by a series of repeated straining and resting cycles, which are carried out over 4 days, for 20 minutes a day,

then, over the next 4 days, extracorporeal therapy is performed

magnetic stimulation by means of a magnetic inductor, which is applied to the perineum, while magnetic stimulation is carried out

a series of pulses with a frequency of 5 Hz - 15 pulses per packet, 10 packets, inter-packet interval of 6 seconds and,

when a pattern of contraction of the anterior muscles is formed in the patient

abdominal wall and relaxation of the pelvic floor muscles, high-frequency magnetic therapy is carried out.

Implementation of the invention.

In patients with defecation disorders, a pattern of contraction of the muscles of the anterior abdominal wall and relaxation of the pelvic floor muscles is preliminarily formed.

For this purpose, the first stage is biofeedback therapy, in which, with the patient lying on his left side with his knees bent and legs pulled to his chest, a latex balloon is inserted into the rectum and then filled with 50 ml of air, then an electromyographic sensor (EMG sensor) is inserted into the rectum. Additionally, two surface EMG sensors are fixed to the anterior abdominal wall, in the projection of the rectus abdominis muscles, and the information reflecting the pressure or bioelectrical activity from the EMG sensor located in the rectum and the two surface EMG sensors is displayed on a screen in front of the patient's eyes.

BOS therapy begins 3 minutes after the EMG sensor is inserted, and BOS therapy includes 3 stages, which are performed sequentially:

- an introductory stage, during which the patient contracts the anal sphincter and pelvic floor muscles, inhales without straining the muscles of the anterior abdominal wall, holds his breath to the count of 1-2-3-4-5, then exhales and relaxes the anal sphincter and pelvic floor muscles, while at the moment of muscle contraction, an increase in pressure or bioelectrical activity (BEA) is recorded on the manometric/EMG recording channel of the sensor located in the projection of the sphincter apparatus, while the absence of an increase in BEA is noted on the EMG sensors located on the anterior abdominal wall;

- the first stage, in which the patient exhales and holds his breath for 10 seconds, tenses the muscles of the anterior abdominal wall by "pulling in" the abdomen, while keeping the anal sphincter relaxed, then relaxes the muscles of the anterior abdominal wall and returns to the starting position, restoring breathing, while the EMG channel recording activity from the anterior abdominal wall records an increase in BEA, the patient's attention is focused on the lack of work of the pelvic floor muscles - the muscles are not compressed and are in a relaxed state, and on the manometric/EMG channel of the sensor located in the projection of the anal sphincter, there are no changes or a short-term episode of increased pressure/BEA is recorded with its subsequent return to the original level;

- the second stage, in which the patient, while inhaling and holding his breath, tenses the muscles of the anterior abdominal wall by “pulling in” the abdomen, while the patient “forcefully” relaxes the muscles of the pelvic floor, then performs a forced exhalation, simultaneously contracting the abdominal muscles even more, and straining, with the aim of “pushing out” the latex balloon, while the manometric/EMG sensor, held in the projection of the anal sphincter, follows the movement corresponding to the excursion of the perineum; If the second stage is performed correctly, a significant increase in BEA is recorded on the EMG channel of the electrodes located on the anterior abdominal wall, a significant decrease in pressure is recorded on the manometric/EMG channel connected to the sensor in the projection of the anal sphincters, and with expulsion of the manometric sensor and partial expulsion of the latex balloon, a drop in pressure to almost zero is recorded, then the patient relaxes, restoring breathing.

BOS therapy is carried out over 4 days, 20 minutes a day.

Then, over the next 4 days, extracorporeal magnetic stimulation is performed using a magnetic inductor, which is applied to the perineum, with magnetic stimulation performed using a series of pulses with a frequency of 5 Hz - 15 pulses per pack, 10 packs, with an inter-pack interval of 6 seconds.

When a pattern of contraction of the anterior abdominal wall muscles and relaxation of the pelvic floor muscles is formed in the patient, high-frequency magnetic therapy is performed.

If the pattern has not been formed, then there is no need to conduct high-frequency magnetic stimulation in a patient with a bowel movement disorder, which is an indication for the generally accepted treatment tactics in this situation.

Thus, we have identified a criterion that allows us to assess the feasibility of further pathogenetically justified physiotherapeutic treatment using high-frequency magnetic therapy.

Clinical examples

Example 1

Patient R., 55 years old, complains of a feeling of incomplete evacuation, multiple-stage defecation, and the need to strain and use manual assistance. She also notes gas incontinence and the presence of enlarged hemorrhoids. These complaints have been bothering her for a long time, about 10 years. The patient has a history of 2 births.

Preliminary diagnosis: Functional constipation. Rectocele. Functional defecation disorder?

The patient was examined. According to defecography data: prolapse of the perineum in the stage of compensation of the pelvic floor muscles, anterior rectocele (evacuation time - 50 sec, residual volume - 20%, defecation is fractional).

Comprehensive functional examination

During the questionnaire: Wexner incontinence scale - 2 points, Scoring system for assessing disorders of the evacuation function of the colon - 9 points.

High-resolution anorectal manometry (HRAM) revealed a type III manometric pattern during straining (lack of sufficient - more than 20% - relaxation of the pelvic floor muscles under conditions of adequate propulsion).

During sphincterometry, the tone of the anal sphincters is reduced SD AKp - 30 mm Hg (norm 41-63 for women), the total contractile ability of the anal sphincters is also reduced relative to physiological norms MD AKv - 101 mm Hg (norm 110-178), the reflex reaction to a test with an increase in intra-abdominal pressure (cough) is weakened. The functional state of the locking apparatus of the rectum (manometric signs) corresponds to anal sphincter insufficiency of the second degree.

During stimulation ENMG, the latent period of the M-response of the external anal sphincter during excitation along the motor fibers of n. pudendus on the right is increased to 2.7 ms, on the left within the physiological norms - 2.3 ms (intravaginal location of the St. Mark's electrode, the norm is 1.55-2.54 ms). During additional study of the mixed reflex response (MRR) - on the left it is recorded both in the deep pudendal reflex (DPR) mode with a latency of 30.0 ms (with a norm of 36.18 ± 4.29 ms (21-41 ms)), and in the rhythmic stimulation mode. The bulbocavernosus reflex (BCR) response on the left - with an increased latency of up to 54.2 ms (norm 34.88 ± 4.29 ms (25-42 ms)). The identified changes, together with clinical complaints, may correspond to neuropathy of the p. pudendus on the right and the presence of disorders mainly along the afferent innervation link on the left.

Biofeedback was performed for 4 days, 20 minutes a day, then extracorporeal magnetic stimulation was performed for the next 4 days with a series of pulses at a frequency of 5 Hz - 15 pulses per pack, 10 packs, inter-pack interval of 6 seconds. The patient was noted to have developed a pattern of contraction of the muscles of the anterior abdominal wall and relaxation of the muscles of the pelvic floor, in connection with which a decision was made to perform high-frequency magnetic therapy.

Example 2

Patient L., 42 years old, complained of gas incontinence and traces of feces on underwear, alternating constipation and loose stool, and multiple-stage defecation. She began to notice the appearance of incontinence symptoms about 3 years ago. She has had 2 uncomplicated births. She has not had any surgery.

Upon examination of the anal area, the skin is unchanged, there are no scratches or macerations. The anus is closed. During digital examination, internal hemorrhoids are slightly expressed. The sphincter tone is slightly reduced, volitional efforts are satisfactory. Prolapse of the anterior wall of the rectum to the level of the vestibule of the vagina is determined.

During the questionnaire - 8 points according to the Cleveland Incontinence Scale (Wexner). During defecography in a sitting position, the rectum is located 5.6 cm below the pubococcygeal line. During voluntary contraction, the intestine shifts upward and is located 4 cm below the pubococcygeal line. During emptying, during straining, the intestine descends down to 6.5 cm. A rectocele up to 3.5 cm deep is formed along the anterior wall. The direction vector is oriented towards the rectocele and partially towards the anal canal. Defecation is fractional. The evacuation time of the rectum is 35 seconds. The residual volume is about 30%, part of the contrast is retained in the rectocele. Conclusion: R-signs of anterior rectocele of the 2nd degree, prolapse of the perineum at the stage of compensation of the pelvic floor muscles.

During a comprehensive sphincterometry study of the rectal sphincter apparatus, the total tone of the anal sphincters and their contractile ability are reduced. Muscle fatigue of the external sphincter is increased. The reflex response to a test with increased intra-abdominal pressure (cough) is weakened. During straining, relaxation of the pelvic floor muscles is revealed. Conclusion: The functional state of the rectal sphincter apparatus according to manometric signs corresponds to grade II anal sphincter insufficiency with signs of weakening reflex reactions.

Below in Table 1 are the results of the measurements performed on this patient and the reference values.

BOS therapy was performed for 4 days, 20 minutes per day, then for the next 4 days extracorporeal magnetic stimulation was performed with a series of pulses with a frequency of 5 Hz - 15 pulses per pack, 10 packs, inter-pack interval of 6 seconds. The patient was noted to have formed a pattern of contraction of the muscles of the anterior abdominal wall and relaxation of the muscles of the pelvic floor, in connection with which a decision was made to perform high-frequency magnetic therapy.

Claims (1)

A method for determining the need for high-frequency magnetic therapy in patients with defecation disorders, characterized by the fact that a pattern of contraction of the muscles of the anterior abdominal wall and relaxation of the muscles of the pelvic floor is preliminarily formed in the patient by means of biofeedback therapy and magnetic stimulation, wherein biofeedback therapy is carried out by inserting a latex balloon into the rectum and filling it with air, followed by inserting an electromyographic sensor (EMG sensor) into the rectum, in addition, two surface EMG sensors are fixed on the anterior abdominal wall, in the projection of the rectus abdominis muscles, followed by a series of repeated straining and resting cycles, which are carried out over 4 days, for 20 minutes a day, then over the next 4 days, extracorporeal magnetic stimulation is carried out by means of a magnetic inductor, which is applied to the perineum, wherein magnetic stimulation is carried out with a series of pulses with a frequency of 5 Hz - 15 pulses per pack, 10 packs, the interval between packs is 6 seconds, and when the patient forms a pattern of contraction of the muscles of the anterior abdominal wall and relaxation of the muscles of the pelvic floor, high-frequency magnetic therapy is performed.