The effect of pelvic floor muscle training on bowel symptoms after low anterior resection for colorectal cancer

Colorectal cancer is a serious heath problem in industrialized countries. Worldwide it is the second most common cancer in women and the third in men. Approximately 35% of these tumors originated in the rectum. There are several treatment strategies for rectal cancer, depending on the location and the stage of the tumor. Since amny years, low anterior resection (LAR) of the rectum with total mesorectal excision (TME) is the gold standard for surgical treatment of mid and distal rectal cancer. This technique includes an excision of the tumor and the mesorectum with preservation of the autonomic nerves of the pelvis. Often, a TME is accompagnied by a temporary ileostomy and (neo-)adjuvant therapy is offered to most patients to respectively downstage and downsize the tumor, but also to reduce the risk of local recurrences. About 60-90 % of patients after radical surgery experience a wide range of bowel symptoms. The combination of these bowel symptoms is often referred to as Low Anterior Resection Syndrome (LARS) and is characterized by: frequent bowel movements, incontinence for flatus or feces, urgency and clustering of defecation. Additionally, urinary and sexual function can also be significantly impaired after low anterior resection. The current management for these bowel symptoms includes antidiarrheal medication, diatery instructions or a rather neglective advice to wait for improvement. Although, pelvic floor muscle training (PFMT) is highly recommended in the treatment of bowel symptoms in non-cancer populations, there is, until today, no evidence for the effect of PFMT in patients suffering from LARS. Therefore, the main objective of this research project entails examining the effect of PFMT on bowel symptoms after low anterior resection for rectal cancer. To investigate its effectiveness, all consecutive patients after LAR will be randomized into a treatment (12 weeks of PFMT) or a control group (information regarding bowel symptoms). Other objectives entail (i) the examination of the effect of PFMT on urinary and sexual symptoms, associated with the treatment (low anterior resection and (neo-)adjuvant therapy) for rectal cancer, (ii) the determination of the evolution in physical activity during the first year after low anterior resection and the detection of several predictors for a possible decrease in physical activity at different levels (sports, household, work and leisure time) and finally (iii) the analysis of the propulsive colonic contractions and the effect of hindgut denervation on the presence of coordinated proximal to distal contractions. Therefore high-resolution colon manometry (HRCM) can be valuable to get a greater insight of these changes in colonic motility. One month following surgery, or in case a temporary loop ileostomy was performed, one month after stoma closure, patients (n = 120) will be randomly assigned to the treatment group (N = 60) or the control group (N = 60). All patients will be evaluated 4 times (respectively 1,4,6 and 12 months after surgery or stoma closure), using different questionnaires concerning their bowel (LARS-score, CoReFo), urinary (ICIQ-FLUTS/ICIQ-MLUTS) and sexual function (FSFI / IIEF), but also regarding their physical activity (FPACQ) and quality of life (SF-12). The progress in recovery of bowel and bladder symptoms will be evaluated using a bladder and bowel diary. Muscle tone, strength, endurance and exhaustion of the pelvic floor muscles will be tested with digital palpation. The experimental group will receive 12 weeks of PFMT; including pelvic floor muscle exercises, biofeedback, rectal balloon training and relaxation. In addition, high resolution colon manometry will be performed in a subset of included patients (N = 20), 12 months after LAR or after closure of the ileostomy, to evaluate propulsive colonic contractions and to assess the effect of hindgut denervation on the presence of coordinated proximal to distal contractions.