Pelvic Floor Muscle Training improves bowel symptoms after Total Mesorectal Excision in rectal cancer

Belgium: The findings of a recent Multicentre Randomized Controlled Trial justified the beneficial role of Pelvic Floor Muscle Training (PFMT)for faster recovery of bowel symptoms up to 6 months after Total Mesorectal Excision (TME) and highlighted its consideration as a first-line treatment after Rectal Cancer (RC).

The findings of the trial were published in the Annals of Surgery.

Many patients of TME suffer from burdensome bowel symptoms, which adversely impact the quality of the patient's life. These bowel symptoms are related to increased frequency of bowel movements, urgency, clustering, and fecal incontinence. Low anterior resection syndrome (LARS) summarizes this condition's symptoms and life quality. Some assessment tools include the LARS score (quick screening), ColoRectal Functioning Outcome, and a stool diary. These tools are questionnaire-based and are needed to understand the clinical picture comprehensively.

A brief about PFMT is mentioned in the recent guidelines on RC, while in noncancer patients, it remains highly recommended for managing fecal incontinence. The data relating to PFMT investigations in RC patients remains limited due to limited studies, low methodological quality, etc.

To answer the above limitations taken into consideration and to assess PFMT's role in RC patients, a study was conducted by a team of researchers led by Dr. Anne and Dr. Hoore from the Department of Rehabilitation Sciences at KU Leuven—the University of Leuven and the Department of Abdominal Surgery from University Hospitals Gasthuisberg Leuven and KU Leuven to investigate the effectiveness of PFMT on LARS in RC patients after TME.

The study measured primary and secondary outcomes 1, 4, 6, and 12 months after TME/stoma closure. The primary outcome calculated the proportion of participants showing improvement in the LARS category at four months. The secondary outcomes were bowel symptoms evaluated by the COREFO questionnaire, a Numeric Rating Scale (NRS), and a stool diary. The quality of life was assessed by Short Form 12 (SF-12).

The key points of the study are:

• 370 patients were assessed for eligibility.

• 104 patients were randomized at one month after TME/stoma closure.

• 50 patients were in the experimental group and 54 in the control group.

• The intervention group had 12 weeks of PFMT, with each session performed by a specialized and expert physiotherapist.

• Nine individual treatments (once a week during the first six weeks and three sessions over the last six weeks) were included in the intervention group.

• The sessions began with an assessment and evaluation of bowel symptoms (stool diary, patient education, pelvic floor muscle exercises, electrical stimulation, and rectal balloon training).

• The control group did not receive any PFMT.

• The department of abdominal surgery did the monitoring of every participant during follow-up.

• In the LARS category, the improvement was statistically more remarkable after PFMT compared with controls at four months and was reported as 38.3% vs. 19.6% with a P value of 0.0415.

• The statistically significant difference in the intervention and control group at six months was 47.8% vs. 21.3%, with a P value of 0.0091

• At 12 months, the difference between the two groups was 40.0% vs. 34.9%, with a P value of 0.3897 and were no longer significant.

• The continuous LARS score and COREFO score differed significantly between both groups, with P values of 0.0496 and 0.0369, respectively, at four months.

• The parameters recorded better at four months in the intervention group were the average frequency of bowel movements/24 hours, the average frequency of solid stool leakage at day and night time and the average number of clusters per day assessed (with the stool diary) with P values of 0.0277,0.0241 (day),0.0496 (night) and 0.0369 respectively.

• The intervention and control groups reported no significant difference in secondary outcome variables such as NRS scores, SF-12 scores, and the remaining stool diary items.

• No serious adverse events related to PFMT were recorded during the study.

• No patient withdrawal was reported in the study.

The researchers explained that the pathophysiology of LARS is multifactorial and is a complicated interplay between anatomical, neurological, physiological, and psychological factors. Nearly 38 % of patients benefit from the PFMT approach.

The author wrote, "To date, we do not know about factors pertaining to success or failure of PFMT, and it is advisable to implement PFMT early on to check spontaneous recovery before exploring invasive and costly treatment options."

Our study is the first RCT justifying the use of PFMT in improving bowel symptoms. According to our study, the condition requires a natural tendency for improvement in function, which PFMT could accelerate with evidential improvement in LARS at 4 and 6 months.

The present study highlighted the benefits of PFMT on stool frequency, incontinence, and clustering.

Further reading:

Asnong, Anne, D'Hoore, André ; Van Kampen, Marijke ; Wolthuis, Albert ; Van Molhem, Yves; Van Geluwe, Bart; Devoogdt, Nele ; De Groef, An PT, Guler Caamano Fajardo, Ipek; Geraerts, Inge PT. The Role of Pelvic Floor Muscle Training on Low Anterior Resection Syndrome: A Multicenter Randomized Controlled Trial. Annals of Surgery: November 2022 - Volume 276 - Issue 5 - p 761-768