Evaluating Access and Efficacy of Pelvic Floor Physical Therapy in Pediatric Hirschsprung Disease

Abstract

Background

In patients with Hirschsprung disease (HD), pelvic floor physical therapy (PFPT) is recommended for persistent incontinence or constipation refractory to other treatment, but there are no studies on utilization of PFPT. We aimed to assess clinical and sociodemographic factors associated with successful establishment of PFPT and outcomes following PFPT.

Methods

We performed a single-institution, retrospective chart review of patients with HD referred to PFPT between 2020 and 2023, involving both exercise and biofeedback. Data were collected on clinical factors, sociodemographics, and symptoms before and after PFPT. Those who “saw PFPT,” defined as at least one in-person appointment, were compared to those who did not see PFPT; symptoms were also compared. A p-value of 0.05 was considered significant.

Results

There were 83 patients, of which 37 (44.6%) saw PFPT. There were no differences in age, transition zone, prior interventions, or symptoms. Half of the patients who saw PFPT only completed an initial visit; one-fifth completed the series. Most common reason for failure to see PFPT was scheduling issues. Patients who failed to see PFPT had financial stressors (42.5% vs. 16.1%, p = 0.02) and required formal support systems (28.2% vs. 3.3%, p = 0.02). In patients seeing PFPT, incontinence significantly improved (81.1% before vs. 40.5% after, p = 0.001).

Conclusion

Although PFPT is recommended in children with HD, those with financial stressors or scheduling issues may have barriers to access. However, those who see PFPT have improved symptoms. This suggests a need for improved accessibility of pediatric PFPT to children with HD, such as integration of PFPT into colorectal clinics.

Keywords

aganglionosis - pediatric colorectal surgery - healthcare utilization - Hirschsprung disease - pelvic floor physical therapy

• References

• 1 Ahmad H, Levitt MA, Yacob D. et al. Evaluation and management of persistent problems after surgery for Hirschsprung disease in a child. Curr Gastroenterol Rep 2021; 23 (11) 18
• 2 Ahmad H, Yacob D, Halleran DR. et al. Evaluation and treatment of the post pull-through Hirschsprung patient who is not doing well; update for 2022. Semin Pediatr Surg 2022; 31 (02) 151164
• 3 Langer JC, Rollins MD, Levitt M. et al; American Pediatric Surgical Association Hirschsprung Disease Interest Group. Guidelines for the management of postoperative obstructive symptoms in children with Hirschsprung disease. Pediatr Surg Int 2017; 33 (05) 523-526
• 4 Sun X, Wang R, Zhang L, Li D, Li Y. Efficacy of pelvic floor muscle training for the treatment of fecal incontinence after Soave procedure for Hirschsprung disease. Eur J Pediatr Surg 2012; 22 (04) 300-304
• 5 Rao SSC, Seaton K, Miller M. et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol 2007; 5 (03) 331-338
• 6 Zar-Kessler C, Kuo B, Cole E, Benedix A, Belkind-Gerson J. Benefit of pelvic floor physical therapy in pediatric patients with dyssynergic defecation constipation. Dig Dis 2019; 37 (06) 478-485
• 7 van Engelenburg-van Lonkhuyzen ML, Bols EMJ, Benninga MA, Verwijs WA, de Bie RA. Effectiveness of pelvic physiotherapy in children with functional constipation compared with standard medical care. Gastroenterology 2017; 152 (01) 82-91
• 8 Ladi-Seyedian SS, Sharifi-Rad L, Manouchehri N, Ashjaei B. A comparative study of transcutaneous interferential electrical stimulation plus behavioral therapy and behavioral therapy alone on constipation in postoperative Hirschsprung disease children. J Pediatr Surg 2017; 52 (01) 177-183
• 9 Muddasani S, Moe A, Semmelrock C. et al. Physical therapy for fecal incontinence in children with pelvic floor dyssynergia. J Pediatr 2017; 190: 74-78
• 10 Washington BB, Raker CA, Sung VW. Barriers to pelvic floor physical therapy utilization for treatment of female urinary incontinence. Am J Obstet Gynecol 2011; 205 (02) 152.e1-152.e9
• 11 Green R, Mardon AK, Beaumont T, Phillips K, Chalmers KJ. The accessibility of pelvic health physiotherapy for adolescents with persistent pelvic pain: a qualitative framework analysis. Physiother Theory Pract 2024; 40 (05) 973-982
• 12 Gala T, Johnston L, Solanki D. et al. Anorectal manometry—how to perform and interpret manometry. Continence (Amst) 2024; 10: 101214
• 13 Child Opportunity Index (COI) | diversitydatakids.org. Accessed October 31, 2022 at: https://www.diversitydatakids.org/child-opportunity-index
• 14 Smith CA, Rollins MD, Durham MM, Rosen N, McCracken KA, Wood RJ. Speaking the same language in multi-center research: Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) updated colorectal definitions for 2022. J Pediatr Surg 2023; 58 (05) 1020-1025
• 15 McKenna PH, Herndon CD, Connery S, Ferrer FA. Pelvic floor muscle retraining for pediatric voiding dysfunction using interactive computer games. J Urol 1999; 162 (3 Pt 2): 1056-1062 , discussion 1062–1063
• 16 Meinds RJ, Eggink MC, Heineman E, Broens PMA. Dyssynergic defecation may play an important role in postoperative Hirschsprung's disease patients with severe persistent constipation: analysis of a case series. J Pediatr Surg 2014; 49 (10) 1488-1492
• 17 Saadai P, Trappey AF, Goldstein AM. et al; American Pediatric Surgical Association Hirschsprung Disease Interest Group. Guidelines for the management of postoperative soiling in children with Hirschsprung disease. Pediatr Surg Int 2019; 35 (08) 829-834
• 18 Brown HW, Barnes HC, Lim A, Giles DL, McAchran SE. Better together: multidisciplinary approach improves adherence to pelvic floor physical therapy. Int Urogynecol J 2020; 31 (05) 887-893
• 19 Chernoff RG, Ireys HT, DeVet KA, Kim YJA. A randomized, controlled trial of a community-based support program for families of children with chronic illness: pediatric outcomes. Arch Pediatr Adolesc Med 2002; 156 (06) 533-539
• 20 Gouin JP, da Estrela C, Desmarais K, Barker ET. The impact of formal and informal support on health in the context of caregiving stress. Fam Relat 2016; 65 (01) 191-206
• 21 Weier RC, Gardner W, Conkol K, Pajer K, Kelleher KJ. Partners for kids care coordination: lessons from the field. Pediatrics 2017; 139 (Suppl. 02) S109-S116
• 22 Zoorob D, Higgins M, Swan K, Cummings J, Dominguez S, Carey E. Barriers to pelvic floor physical therapy regarding treatment of high-tone pelvic floor dysfunction. Female Pelvic Med Reconstr Surg 2017; 23 (06) 444-448
• 23 Burgio KL. Update on behavioral and physical therapies for incontinence and overactive bladder: the role of pelvic floor muscle training. Curr Urol Rep 2013; 14 (05) 457-464
• 24 Price N, Dawood R, Jackson SR. Pelvic floor exercise for urinary incontinence: a systematic literature review. Maturitas 2010; 67 (04) 309-315
• 25 Scott KM. Pelvic floor rehabilitation in the treatment of fecal incontinence. Clin Colon Rectal Surg 2014; 27 (03) 99-105
• 26 Collins L, Collis B, Trajanovska M. et al. Quality of life outcomes in children with Hirschsprung disease. J Pediatr Surg 2017; 52 (12) 2006-2010
• 27 Aguirre F, Heft J, Yunker A. Factors associated with nonadherence to pelvic floor physical therapy referral for the treatment of pelvic pain in women. Phys Ther 2019; 99 (07) 946-952