Neurophysiology of the pelvic floor muscles. Entering clinical practice

AIM: to develop methods of conservative treatment of proctological patients based on pelvic floor muscles (PFM) neurophysiology.PATIENTS AND METHODS: thirty-seven patients with pudendal neuropathy manifested by anal incontinence (AI) and/or obstructive defecation and/or neurogenic pelvic pain (and their combination) included in the prospective cohort study. There were 5 patients (13.5%) with proctogenic constipation as the main complaint, 12 (32.4%) with AI, 14 (37.9%) with neurogenic pelvic pain; 6 (16.2%) with combined disorders. There were 22 (59.5%) women, 15 (40.5%) men, aged 47.1 ± 15.7 years. All patients underwent a comprehensive checkup by a proctologist, colonoscopy, gynecologist/urologist. The neurophysiological tests were performed according to the developed algorithm, including stimulation EMG (PNMTL) with the late phenomena and bulbocavernosus reflex (BCR), as well as interference EMG to identify dysfunction of the PFM. Patients with obstructive defecation additionally underwent high-resolution anorectal manometry, defecography and evacuation test. Patients with AI underwent complex sphincterometry. All patients underwent conservative treatment, which depended on the obtained diagnostic data.RESULTS: according to PNTML, pudendal neuropathy were diagnosed only by an increase in the latency of the M-response in 21 patients (56.8%). In this case, all had a unilateral change (up to 3.6 ± 1.1 ms on the right in 6/21 (28.6%) and up to 3.2 ± 0.6 ms on the left in 15/21 (71.4%). Based on the increase in the latency of late phenomena, pudendal neuropathy was detected in another 10 (27%) patients — up to 52.6 ± 9.1 ms on the right and up to 51.4 ± 7.1 ms on the left; based on the increase in the latency of the BCR in 6 (16.2%) people — up to 52.3 ± 5.4 ms on the right and up to 51.9 ± 7.3 ms on the left. All patients underwent interference EMG. EMG-signs of PFM dysfunction during the push-test were detected in 24 (64.9%) patients, which coincided with the data of high-resolution anorectal manometry (HRAM) — among them were not only patients with predominant complaints of proctogenic disorders, but also from other groups: 10 (41.6%) with obstructive defecation, 7 (29.2%) with neurogenic pelvic pain, 3 (12.5%) with AI, 4 (16.7%) — with mixed manifestations. Signs of AI according to sphincterometry data were detected in 20/22 women (resting pressure 34.4 ± 4.0 mmHg, squeezing pressure 99.4 ± 22.0 mmHg) and in 11/15 men (37.7 ± 2.4 mmHg and 122.0 ± 39.0 mmHg). The clinical output of the algorithm we created was the development of a biofeedback (BFB) technique on a myographic complex of diagnostic profile with high-intensity magnetic stimulation (HIMS).CONCLUSION: patients with pudendal neuropathy may have concomitant dysfunctions in the form of AI, obstructive defecation and neurogenic pelvic pain. Given the dominant nature of the pain syndrome, obstructive defecation and anal incontinence are undiagnosed conditions and, in some cases, have a latent manifestation, which requires targeted questioning of patients and additional examination, including PNTML, interference EMG, HRAM, complex sphincterometry, defecography. The use of biofeedback on a diagnostic myographic complex in combination with HIMS allows for adequate training of patients in the synergistic work of the PFM and the abdominal muscles for proper defecation/urination and faeces/urine retention.