Pelvic floor rehabilitation improves anorectal function after sphincter-preserving surgery for low rectal cancer

Abstract

BACKGROUND

Sphincter-preserving surgery with prophylactic colostomy is the benchmark treatment for low rectal cancer, although postoperative anorectal dysfunction significantly reduces quality of life. Although pelvic floor muscle training seems effective in functional recovery, there is currently little systematic evidence regarding the efficacy of this therapy in this specific population.

AIM

To investigate whether structured pelvic floor muscle rehabilitation training provides better anorectal functioning than standard postoperative care in patients with temporary colostomy following sphincter-preserving surgery for low rectal cancer.

METHODS

This was a retrospective study involving 100 patients with low rectal cancer who underwent sphincter-preserving surgery combined with prophylactic colostomy from January 2020 to December 2023. Patients were randomly assigned to receive structured pelvic floor muscle rehabilitative training (observation group, n = 52) or routine postoperative care without specific pelvic floor training (control group, n = 48). Group characteristics at baseline were similar. The primary end points were anorectal function parameters measured by anorectal manometry (resting anal pressure, maximum squeeze pressure, and thresholds of rectal sensation) and Wexner incontinence score. Secondary outcomes included various measures of defecation function, patient quality of life, and satisfaction.

RESULTS

Both parameters were found to be notably more superior in outcomes of the observation group over other groups. At 3 months after colostomy closure, resting anal pressure (65.3 ± 8.7 mmHg vs 52.4 ± 9.2 mmHg, P < 0.001) and maximum squeeze pressure (128.5 ± 15.3 mmHg vs 98.7 ± 16.8 mmHg, P < 0.001) were significantly higher in the observation group when compared with those in the surgical procedure group. The Wexner incontinence scores improved more (4.2 ± 1.8 vs 8.5 ± 2.3, P < 0.001), with good continence achieved by 73.1% of observation group patients versus 41.7% of controls (P = 0.001). Compared with the control group, the observation group recovered of normal defecation patterns (68.5 ± 12.3 days vs 95.8 ± 18.5 days, P < 0.001), bowel boom frequency (3.8 ± 1.2 times/day vs 6.5 ± 2.1 times/day, P < 0.001), and quality of life score (82.5 ± 8.3 vs 68.2 ± 10.5, P < 0.001). Multivariate analysis identified pelvic floor rehabilitation as an independent predictor of favorable anorectal function recovery (adjusted odds ratio = 8.73, 95% confidence interval: 3.15-24.18, P < 0.001).

CONCLUSION

Structured pelvic floor muscle rehabilitation training is associated with significant improvement of anorectal function recovery, fecal continence, bowel pattern normalization and quality of life in low rectal cancer patients post-sphincter-preserving surgery accompanied by temporary colostomy, which is a safe and practical postoperative functional rehabilitation method. All of these results require confirmation, ideally in prospectively randomised controlled trials.

Key Words: Anal sphincter-preserving surgery; Low rectal cancer; Anorectal function; Fecal incontinence workload rehabilitation; Prophylactic colostomy; Pelvic floor muscle

Core Tip: Postoperative anorectal dysfunction is one of the most difficult problems associated with sphincter-preserving surgery for low rectal cancer after temporary fecal diversion. In this retrospective study we demonstrate that a preoperative and postoperative structured pelvic floor muscle rehabilitation program enhances anorectal manometric parameters in addition to fecal continence and bowel function recovery as well as quality of life. These results reinforce the routine integration of pelvic floor rehabilitation in postoperative care in order to optimize functional outcomes for these patients.

INTRODUCTION

Rather, in the low-rectal cancer area, it is important to distinguish between low-rectal cancer area and middle- or high- rectal cancer because of its unique anatomical proximity with the anal sphincter complex, which raises troubles for therapeutic options as long as far. The large-pore subtypes are associated with poor prognosis and play a prominent role in the clinical spectrum of rectal cancer, a major global health problem, which is still increasing in incidence. Low rectal tumors (i.e., within 5 cm of the anal verge), characterised by their location low-down into the pelvis, account for 30%-40% of all malignant lesions that develop along the length of the rectum. These tumours also lead to a substantial reduction in quality of life due to anorectal impairment, and surgical intricacies[1].

A promising targeted strategy for treating tumours in this region of the rectum is sphincter-preserving surgery, which can produce favourable oncological outcomes while supporting preservation of anal continence. Abdominoperineal resection has equivalent survival and depths of mesorectum compared with total mesorectal excision with sphincter preservation but sacrifices anorectal function. Prophylactic colostomy has been commonly performed to avoid anastomotic complications and closure is usually scheduled 3-6 months after operation when anastomosis functionality has already been confirmed by a surgeon[2,3].

Postoperative anorectal dysfunction is a well-known clinical challenge after colostomy closure, which can occur in 40%-80% of patients despite the considerable advancement and refinement of sphincter-preserving surgical techniques. Functional impairments. Common functional complications are fecal incontinence and urgency (involuntary bowel movements), high frequency in bowels (diarrhea), incomplete evacuation, low anterior resection syndrome. These complications can be explained also due to pelvic floor anatomy disruption surgery, sphincter muscles denervation, decrease anorectal compliance and numerous years of disuse atrophy time during the colostomy. These disorders can have a major detrimental impact on quality of life and social functioning, as well as psychological health[4,5].

Several recent studies have examined pelvic floor muscle rehabilitation as an intervention to enhance postoperative anorectal function. Pelvic floor training may involve biofeedback therapy, electrical stimulation of pelvic muscle and exercise regimens to promote optimal strength and coordination of the muscles involved in maintaining continence. Speculative so far, interventions are likely to change sphincter pressures as evidenced in colorectal surgery populations with endoluminal therapies improving continence and promoting functional recovery. At the same time, few systemic investigations focused on patients with low rectal cancer who suffered from sphincter preservation under temp colostomy[6,7].

The rationale behind each component of this rehabilitation protocol is grounded in the rudiments of physiology. Progressive resistance overload may explain the hypertrophy of external anal sphincter and puborectalis muscle fibers, torsional deformation in vasculature, and improvement in neuromuscular recruitment patterns in targeted pelvic floor muscle exercises (Kegel training). Lay summary what is biofeedback therapy utilizes the principles of cortical neuroplasticity and delivers incentive visual feedback regarding sphincter contraction, which facilitates sensory re-education of the anorectal canal and enhances volitional coordination that is required for continence. The electrical current mimics the effect of muscle contraction and provides it an adrenaline rush to counteract disuse atrophy acquired by fecal diversion on the volitional pathways, while in addition modulating pudendal nerve pathway sensory thresholds[7,8]. The exact timing of such treatment, beginning 2-4 weeks prior to stoma closure, is strategic: Patients will be given the chance to recognize which muscles are engaged and the proper technique at low levels of demand then get ready automatically for their first testing antagonistically on restoring anastomotic continuity when bowel habit resumes.

Evaluation of clinical efficacy and safety colon strength-facilitating colostomy-program train with patients low rectal cancer limited by through sphincter-preserving but adjunctive-implication-pelvic floor muscle rehabilitation training. We hypothesised that systematic pelvic floor rehabilitation preceding and following colostomy closure would lead to superior values of anorectal manometry parameters, benefit time-free of bowel movement, restore normal defecation and improve quality-of-life outcomes compared to a standard approach based on conservative postoperative management in the absence of specific pelvic floor training.

MATERIALS AND METHODS

Study design

In this study, clinical efficacy and safety were retrospectively investigated for pelvic floor muscle rehabilitation training in patients with low rectal cancer after sphincter-preserving surgery combined with prophylactic colostomy. This paper was a retrospective study of de-identified data, and informed consent was waived (approval No. HEYLL2025126), which was approved by the Institutional Review Board of participating institutions.

Patient selection and enrollment

We reviewed 3-year outcome for 246 patients who underwent prophylactic colostomy during sphincter-preserving procedures for low rectal cancer at two tertiary care hospitals from January 2020 to December 2023. Revisions were: (1) Patients aged 18 years to 75 years; (2) Histologically proven rectal adenocarcinoma ≤ 5 cm from the anal verge; (3) A history of sphincter-preserving surgery with prophylactic loop ileostomy or colostomy; (4) Eastern Cooperative Oncology Group performance status 0-1; and (5) Over six months elapsed between colostomy closure surgery and last available anorectal function assessment. Exclusion criteria included: (1) History of anorectal disorders (inflammatory bowel disease, chronic anal fissures, prior anorectal surgery); (2) Serious comorbidities preventing participation in the rehabilitation programme (decompensated heart failure, invasive malignancies or severe chronic obstructive pulmonary disease); (3) Neurological diseases affecting pelvic floor function (spinal cord injury, multiple sclerosis and extensive diabetic neuropathy); (4) Anastomotic complications requiring surgical reoperation; and (5) Incomplete compliance with protocol of charge to drop-fallout.

In a retrospective cohort study, 100 patients fulfilled the inclusion criteria and were placed in two groups according to the postoperative rehabilitation protocol. They were divided in two groups: Observation group (n = 52) that underwent standard postoperative care post-op plus structured pelvic floor muscle rehabilitation training or control group (n = 48) that received only standard postoperative care alone. By which the sequential evolution of institutional clinical practice assigned patients to group assignment: Before June 2021, standard postoperative care without structured pelvic floor training was the routine procedure at participating centers; from June 2021 onward, a standardized rehabilitation program was systematically implemented when certified pelvic floor physical therapists became available and evidence suggesting its implementation began accumulating. The time-based allocation diminishes the potential for individual-level selection bias due to patient preference, or physician discretion; however, it reflects a historical comparison and cannot control for contemporaneous changes in patient case-mix, surgical technique, or perioperative management practices (regarded as limitations discussed).

Surgical procedures

All patients were treated by mainly laparoscopic sphincter-preserving surgery in experienced centres. Surgical approach comprised total mesorectal excision with high ligation of inferior mesenteric artery. Tumor resection was performed according to oncological principles with appropriate distal margin (≥ 1 cm for well-differentiated tumors and ≥ 2 cm when possible). Depending on location, colorectal or coloanal anastomosis was performed using circular stapler technique or hand sewn methods. Of all patients, a prophylactic diverting stoma (loop ileostomy or loop colostomy) was made from the very beginning to protect the sutured anastomosis. An enterostomal therapist performed stoma site selection and marking preoperatively. Colostomy closure was performed 3-6 months after confirmation of anastomotic integrity via contrast enema or endoscopy, completion of adjuvant therapy when indicated and assurance of optimal nutritional status. The closure was carried out under general anesthesia by common methods with primary anastomosis.

Pelvic floor muscle rehabilitation protocol

A retrospective cohort study was made, including 100 patients in whom applied criteria were met and divided into two groups according to postoperative rehabilitation protocol. The data were collected in a training group (observation group, n = 52) that underwent standard postoperative care post-op + structured pelvic floor muscle rehabilitation training vs control group (n = 48) receiving only standard postoperative care alone up to October 2023.

Phase 1: Training leading up to closure (2-4 weeks before stoma closure). Baseline anorectal manometry and digital rectal examination for tone and coordination of the anal sphincters. Individualized pelvic floor muscle exercises (Kegel exercise) training with behavioral focus on the correct recognition of muscles and contraction technique. You were trained three times a week (30 minutes each session) to perform: (1) Pelvic floor muscle contractions plantfully isolated (i.e. 3 × 10 seconds hold, 5-10 seconds contraction with a 10-seconds rest interval); (2) Fast contractions at short intervals of time commonly called quick flicks (3 × 10 rapid contractions); and (3) Functional training contraction performed during daily life activity. Patients performed home exercises twice daily.

Phase 2: Early post-closure training (0-3 months post-closure). Following closure, rehabilitative efforts were increased with twice-weekly supervised training comprised of the following: (1) Biofeedback using anorectal manometry equipment to provide visual feedback on sphincter pressures to aid patients in optimizing contraction patterns (20 minutes per session, 10 contraction cycles); (2) Electrical stimulation therapy administered via anal probe electrodes at an appropriate frequency (35-50 Hz), pulse width (200-300 microseconds), and intensity comfortable for each patient at sensory threshold elevated during initial session for 20 minutes, per session; and (3) Finally progressive resistance training to increase strength with graduate anal dilators when appropriate. Home exercise schedules were continued but with increased intensity (3 times/day, 15 minutes per time).

Phase 3: Maintenance exercise (3-6 months after closure). Supervised sessions at a reduced frequency of once/week with an ongoing focus on techniques and functional integration. Patients continued at-home exercises with an emphasis on long-term patient engagement. At 3 and 6 months, anorectal manometry was repeated to assess progress and guide training adaptations. Also, the control group was treated with usual postoperative management, including wound care, diet instructions and standardised follow-up without specific pelvic floor muscle training. Advises were to resume normal activities gradually, they received no structured instruction in pelvic floor exercise therapy biofeedback or electrical stimulation.

Outcome measures

Primary outcomes: Anorectal function parameters were assessed using high-resolution anorectal manometry at baseline (before colostomy closure), 3 months, and 6 months post-closure. Measurements included: (1) Resting anal pressure: Reflecting internal anal sphincter function, normal range 60-80 mmHg; (2) Maximum squeeze pressure: Reflecting external anal sphincter and puborectalis muscle function, normal range 120-150 mmHg; and (3) Rectal sensation thresholds: First sensation, urge to defecate, and maximum tolerable volume assessed using balloon distension. Fecal continence was evaluated using the Wexner incontinence score (Cleveland Clinic Florida Fecal Incontinence Score), ranging from 0 (perfect continence) to 20 (complete incontinence), with scores categorized as: 0 (perfect), 1-7 (good), 8-14 (moderate), 15-20 (severe incontinence).

Secondary outcomes: Defecation function endpoints included: (1) Time to return of normal bowel pattern (defined as formed stool/Lacked urgency and incontinence); (2) Daily frequency of bowel movements; (3) Bristol Stool Scale for stool consistency; and (4) Presence any urgency, incomplete evacuation or manual assistance needed. The Fecal Incontinence Quality of Life Scale (FIQL), which includes 4 domains of quality of life measurement: Lifestyle, coping/behavior, depression/self-perception; embarrassment (scores; range 1-5 higher = improved quality of life). Satisfaction of patients was assessed using 10-point graphic analogue scale (0 = total dissatisfaction, 10 = total satisfaction). All assessments were performed at baseline, and 3-6 months following colostomy closure.

Data collection

Data were retrospectively extracted from electronic medical records including demographics, tumor pathology, surgical details, perioperative outcomes, rehabilitation participation and functional assessment results. All anorectal manometry studies were performed by experienced gastrointestinal physiologists according to standardized protocols. Functional assessments and questionnaires were conducted by trained research coordinators who were blinded to group assignment, when possible.

Statistical analysis

Sample size parameter for designing the study utilized published literature with a mean difference of approximately 20 mmHg and standard deviation of 15 mmHg in maximum squeeze pressure. A sample size of 44 patients per group was required for α = 0.05 (2-tailed) and power = 0.80. To mitigate data sparsity we elected to include all eligible patients with 1 + follow-up time in the study period, resulting in a total of 52 observation and 48 control group patients. Continuous variables were expressed as mean ± SD and analyzed by independent samples t-test for normally distributed data or Mann-Whitney U test in case of non-normally distributed data. Using either χ² testing or Fisher’s exact test where appropriate, categorical variables were compared and reported as n (%). Repeated measures analysis of variance was used to evaluate change within groups over time. We sought independent predictors of good functional outcome (Wexner score ≤ 7 at 6 months) using multivariate logistic regression analysis controlling for age, sex, tumor distance from anal verge neoadjuvant therapy and baseline function as confounders. Statistical significance was set at P < 0.05 (two-tailed). All analyses were performed using SPSS version 26.0 (IBM Corporation, Armonk, NY, United States).

RESULTS

Patient characteristics

The randomization achieved a balanced distribution of baseline demographic, clinical, and tumour characteristics between arms (Table 1). The average age with 58.3 ± 10.5 years in the observation group and the control group 59.7 ± 11.2 years (P = 0.523). Additionally, compared with patients in the control group, more patients in the observation group received intravenous fluid (63.5% vs 60.4%, P = 0.754; Table 1). There were similar tumor locations, tumor-node-metastasis staging, and neoadjuvant chemoradiotherapy between groups. The mean time from the initial surgery to colostomy closure for the observation group was 4.2 ± 1.1 months vs 4.5 ± 1.3 months in control (P = 0.213) and there were no significant differences between groups for baseline anorectal function parameters.

Table 1 Baseline characteristics of study participants, n (%)/mean ± SD.

Characteristic	Observation group (n = 52)	Control group (n = 48)
Age (years)	58.3 ± 10.5	59.7 ± 11.2
Male sex	33 (63.5)	29 (60.4)
BMI (kg/m2)	23.8 ± 3.2	24.1 ± 3.5
Tumor distance from anal verge (cm)	3.8 ± 1.2	3.6 ± 1.3
TNM stage
I	12 (23.1)	10 (20.8)
II	21 (40.4)	19 (39.6)
III	19 (36.5)	19 (39.6)
Neoadjuvant therapy	35 (67.3)	31 (64.6)
Time to stoma closure (months)	4.2 ± 1.1	4.5 ± 1.3

No significant differences were observed between groups for any baseline characteristic (all P > 0.05). BMI: Body mass index; TNM: Tumor-node-metastasis.

Primary outcomes: Anorectal function parameters

Anorectal manometry showed improvement in anorectal pressures from baseline to 6 months post-closure in both groups, but with significantly greater improvements in the observation group (Table 2). At 3 months following closure, resting anal pressure was significantly higher in the observation group compared with controls (65.3 ± 8.7 mmHg vs 52.4 ± 9.2 mmHg, P < 0.001). Eight hundred patients underwent radiofrequency ablation, and 124 thyrotropin-releasing hormone at randomisation with organisation to anti-hypertensive treatment depending on response: This difference remained significant at 6 months (72.5 ± 7.8 mmHg vs 58.3 ± 8.5 mmHg; P < 0.001). The effect was especially marked in maximum squeeze pressure, which was significantly higher in cases than the observation group at 3 months (128.5 ± 15.3 mmHg vs 98.7 ± 16.8 mmHg, P < 0.001) and also at 6 months (145.2 ± 14.5 mmHg vs 112.3 ± 17.2 mmHg, P < 0.00) (Table 2).

Table 2 Anorectal manometry parameters over time, mean ± SD.

Parameter	Time point	Observation (n = 52)	Control (n = 48)
RAP (mmHg)	Baseline	48.5 ± 10.3	47.2 ± 11.1
	3 months	65.3 ± 8.7c	52.4 ± 9.2
	6 months	72.5 ± 7.8c	58.3 ± 8.5
MSP (mmHg)	Baseline	85.3 ± 18.5	83.7 ± 19.2
	3 months	128.5 ± 15.3c	98.7 ± 16.8
	6 months	145.2 ± 14.5c	112.3 ± 17.2

^cP < 0.001 vs control group at same time point.

RAP: Resting anal pressure; MSP: Maximum squeeze pressure.

Fecal continence outcomes: The observation group demonstrated significantly lower Wexner incontinence scores at all post-closure time points (Table 3). At 6 months, the observation group achieved a mean score of 4.2 ± 1.8 compared to 8.5 ± 2.3 in controls (P < 0.001). When categorizing continence status at 6 months, 73.1% (38/52) of observation group patients achieved good continence (Wexner score ≤ 7) vs only 41.7% (20/48) in the control group (P = 0.001). Perfect continence (Wexner score = 0) was achieved by 23.1% (12/52) of observation group patients compared to 8.3% (4/48) of controls (P = 0.047, Figure 1).

Figure 1 Fecal continence outcomes at 6 months post-colostomy closure. A: Wexner incontinence score: Bar graph comparing mean Wexner incontinence scores between the observation group (n = 52, purple) receiving pelvic floor muscle rehabilitation training and control group (n = 48, yellow) receiving standard postoperative care. Error bars represent SD. The observation group demonstrated significantly lower incontinence scores (4.2 ± 1.8 vs 8.5 ± 2.3, P < 0.001); B: Continence achievement rates: Bar graph showing the percentage of patients achieving good continence (Wexner score ≤ 7) and perfect continence (Wexner score = 0) in each group. Numbers within bars indicate patient counts. The observation group achieved significantly higher rates of both good continence (73.1% vs 41.7%, P = 0.001) and perfect continence (23.1% vs 8.3%, P = 0.047) compared to controls.

Table 3 Functional outcomes and quality of life measures at 6 months, n (%)/mean ± SD.

Outcome measure	Observation (n = 52)	Control (n = 48)
Wexner incontinence score	4.2 ± 1.8c	8.5 ± 2.3
Good continence (score ≤ 7)	38 (73.1)b	20 (41.7)
Time to normal defecation (days)	68.5 ± 12.3c	95.8 ± 18.5
Daily bowel frequency (times/day)	3.8 ± 1.2c	6.5 ± 2.1
Urgency	10 (19.2)c	25 (52.1)
FIQL total score (range 1-5)	4.1 ± 0.6c	3.2 ± 0.8
Patient satisfaction score (0-10)	8.3 ± 1.1c	6.1 ± 1.6

^bP < 0.01.

^cP < 0.001 vs control group.

FIQL: Fecal Incontinence Quality of Life Scale.

Secondary outcomes

Defecation function recovery: The observation group experienced significantly earlier restoration of normal bowel function (Table 3). Time to normal defecation pattern was substantially shorter in the observation group (68.5 ± 12.3 days vs 95.8 ± 18.5 days, P < 0.001). At 6 months post-closure, daily bowel movement frequency was significantly lower in the observation group (3.8 ± 1.2 times/day vs 6.5 ± 2.1 times/day, P < 0.001). The observation group also reported lower rates of urgency (19.2% vs 52.1%, P < 0.001), incomplete evacuation (15.4% vs 41.7%, P = 0.004), and need for manual assistance with defecation (7.7% vs 27.1%, P = 0.011).

Quality of life and patient satisfaction: Quality of life assessment using the FIQL scale demonstrated significantly higher scores in the observation group across all four domains. At 6 months, the total FIQL score was 4.1 ± 0.6 in the observation group vs 3.2 ± 0.8 in controls (P < 0.001). Patient satisfaction scores were notably higher in the observation group (8.3 ± 1.1 vs 6.1 ± 1.6, P < 0.001), with 86.5% (45/52) of observation group patients reporting satisfaction scores ≥ 7 compared to 54.2% (26/48) in the control group (Figure 2).

Figure 2 Quality of life and patient satisfaction at 6 months. A: Fecal Incontinence Quality of Life Scale total scores and patient satisfaction scores with standard deviation error bars; B: Percentage of patients achieving high satisfaction (score ≥ 7). Purple bars: Observation group (n = 52, pelvic floor rehabilitation); yellow bars: Control group (n = 48, standard care). Numbers in bars represent patient counts. Green arrow indicates improvement magnitude. P values from independent t-test (A) and χ² test (B).

Multivariate analysis

Multivariate logistic regression analysis identified several independent predictors of achieving good continence (Wexner score ≤ 7) at 6 months (Table 4). After adjusting for age, sex, tumor distance from anal verge, neoadjuvant therapy, baseline manometry values, and time to stoma closure, pelvic floor rehabilitation training emerged as the strongest independent predictor [adjusted odds ratio (OR) = 8.73, 95% confidence interval (CI): 3.15-24.18, P < 0.001]. Higher baseline maximum squeeze pressure (OR = 1.05 per mmHg increase, 95%CI: 1.02-1.08, P = 0.002) and greater tumor distance from anal verge (OR = 1.42 per cm increase, 95%CI: 1.08-1.87, P = 0.012) were also significant independent predictors of favorable outcomes. Good continence defined as Wexner incontinence score ≤ 7 at 6 months.

Table 4 Multivariate analysis of predictors for good continence at 6 months.

Variable	Adjusted OR	95%CI	P value
Pelvic floor rehabilitation	8.73	3.15-24.18	< 0.001
Baseline MSP (per mmHg)	1.05	1.02-1.08	0.002
Tumor distance from anal verge (per cm)	1.42	1.08-1.87	0.012
Age (per year)	0.97	0.93-1.01	0.156
Male sex	1.23	0.48-3.15	0.665
Neoadjuvant therapy	0.78	0.29-2.08	0.619

Good continence defined as Wexner incontinence score ≤ 7 at 6 months. OR: Odds ratio; CI: Confidence interval; MSP: Maximum squeeze pressure.

Safety and adverse events

The pelvic floor rehabilitation program was well tolerated with no serious adverse events reported. Minor discomfort during electrical stimulation sessions was reported by 5 patients (9.6%) in the observation group, which resolved with intensity adjustment. No participants discontinued rehabilitation due to adverse effects. There were no significant differences between groups in wound healing complications, anastomotic leakage, or readmission rates within 30 days post-colostomy closure (Figure 3).

Figure 3 Safety outcomes. A: Postoperative complication rates showing no significant differences between groups; B: Rehabilitation adverse events in observation group: 90.4% no discomfort, 9.6% minor discomfort (resolved), 0% serious events. Purple: Observation group (n = 52); yellow: Control group (n = 48).

DISCUSSION

This retrospective observational study structured pelvic floor muscle rehabilitation training was associated with a significant improvement in post-operative anorectal function recovery compared to controls after sphincter-preserving resection and temporary colostomy for low rectal cancer. Comprehensive rehabilitative therapy in the observation group resulted in significantly better outcomes on all assessed endpoints, including improved anorectal pressures, fecal continence as well as return to normal bowel function by day 7 and overall quality of life. These data indicate that pelvic floor rehabilitation may be an important adjunct to standard postoperative care in this population and could reduce the functional morbidity associated with low rectal malignancy management.

The results of observation group in resting and maximum squeeze pressures were significantly improved, the difference of maximum squeeze pressure was particularly obvious. These results are consistent with known mechanisms of pelvic floor exercises: Muscle strength improvement by exercising the external anal sphincter and puborectalis muscle, neuromuscular coordination improvement by biofeedback therapy, and possible neural plasticity increase by electrical stimulation[8,9]. The observed magnitude of improvement in resting (30% at 6 months) and squeeze pressure (40% at 6 months) exceed the values previously reported by general colorectal populations in some studies, which may reflect the benefits of protocolized early and intensive rehabilitation[10,11].

Greater increases in fecal continence observed by Wexner scores is arguably the most clinically relevant outcome. Also, a number needed to treat of approximately 3.2 (73.1% vs 41.7% good continence achievement in the rehabilitation group vs controls) demonstrates strong clinical efficacy with reasonable translation to practice. These outcomes compare very closely to those reported in existing literature regarding continence problems after closure of stomas, which appear to be present in only 40%-80% however are largely without particular interventions[12,13].

This portrayal probably reflects an amalgamation of better sphincter strength, enhanced awareness of rectal sensation through biofeedback and the functional ability to more effectively round out muscle function which patently ends up in a better continence result. That one in four patients entering rehabilitation achieves perfect continence and can anticipate further improvement (search) is a truly impressive statistic which fuels hope regarding the possibilities for intervention.

The primary composite endpoint was time to normal bowel and recovery of bowel function, the most important issue concerning their which was achieved faster in the observation group. Functional recovery is often quicker (68.5 days as opposed to 95.8 days) with less chance of unpredictable bowel habits so that people can return to social and work life almost a month sooner. A study comparing 107 patients undergoing anterior resection reported more objective improvements in daily bowel frequency (3.8 times/day vs 6.5 times/day) and also regarding urgency and incomplete evacuation, which are the most prominent features of low anterior resection syndrome[14,15]. These improvements probably stem from a combination of factors: The rectum learns to accommodating larger stool volumes through graduated training; sensory awareness advances, allowing children to better recognize when they need a bowel movement; and sphincter control evolves, enabling pooping only under socially acceptable circumstances.

This relationship was strong and persisted despite adjustment for baseline differences and then confounders, suggesting a minor independent continued functional small gain from the intervention in good continence (odds ratio = 8.73), but the observational nature of this analysis limits causal implication. The association of higher baseline maximum squeeze pressure with better outcomes is consistent with the idea that retained post-operative sphincter function may dictate recovery potential, and further supports the notion that the efficacy of rehabilitation at least partially depends on a functional muscle ‘reserve’[16]. The previous observations that distant location of the tumor from the anal verge is an independent predictor of improved continence probably reflect a difference in extensiveness of sphincter surgery combined with exarticulation of neurovascular structures between proximal and distal tumors[17].

Our multi-phase rehabilitation protocol works: It is feasible and safe. In addition, patients are given pre-closure training days to actively contraction their pelvic floor muscles while maintaining a colostomy diversion with the goal of ultimately improving their readiness for functional reconstruction. The integration of biofeedback, and electrical stimulation in this initial post-closure stage is key to capitalise on the neuroplasticity and muscle strengthening that occur during this early window. The maintenance stage facilitates continued adherence and continued benefit. The described approach can be designed as per different healthcare context (demand for expertise, specialized equipment may vary). The low number of adverse events and patients’ satisfaction[18,19] also indicate a good acceptability which is an important feature to long-terms deliveries with programs.

Our results confirm and add to available evidence for pelvic floor rehabilitation in colorectal surgery cohorts. Although previous studies found benefits in the general post-colectomy population or in those with idiopathic fecal incontinence[20,21], data specifically directed towards patients following low rectal cancer resection with a temporary colostomy has been lacking. However, the beneficial associations demonstrated in our cohort may simply be due to optimal treatment timing (pre-closure initiation allows time for preparation while post-closure intensification occurs during a critical recovery period), integrated multimodal-treatment approaches (exercise-biofeedback-electrical stimulation) and patient population characteristics.

There are a couple of limitations that should be kept in mind when interpreting these results. At the heart of this study is the limitation that using a non-randomized, retrospective design constitutes and remains critical to what can be drawn from our findings. As group allocation for the two cohorts was determined by a temporal change in routine care and not randomization, differences between the groups may exist beyond what was measured through the baseline characteristics. Concomitant systematic differences between the two cohorts pre-June 2021 and post-June 2021 which could include enhancements to surgical technique, further optimisations of perioperative care pathways, updates in adjuvant therapy protocols or secular trends in reported outcomes may not be excluded as a source of confounding which multivariate adjustment is unable to mitigate fully. Thus, selection bias is a fundamental limitation of the current analytic approach that can not be remedied. Lastly, the control group was not specifically receiving pelvic floor instruction representing the state of practice at that time but what would provide a stronger comparison would be an attention control or placebo interventions[22,23]. Future studies should focus on randomized control trials using sufficiently powered samples, objectively assessed adherence monitoring and standardized long-term follow up so that efficacy can be more conclusively established. Optimized protocols could also have fewer resource requirements through comparative effectiveness studies of chosen rehabilitation components (exercise alone vs biofeedback vs electrical stimulation vs combinations). Research into predictive biomarkers or baseline characteristics that identify patients most likely to benefit could facilitate targeted rehabilitation strategies. Limitations of the study include its single-care setting and a fairly homogeneous patient population. The economic evaluation would guide health care policy based on direct costs, indirect costs (productivity loss), and quality-adjusted life-years. Lastly, innovative devices (home biofeedback sensors, mobile health apps, virtual reality training) could make treatment more affordable and sustainable while increasing accessibility[24,25].

Structured pelvic floor muscle rehabilitation training, commencing pre-surgically (during colostomy formation) and followed by systematic care post-operatively, can markedly improve the recovery of anorectal function in patients with low rectal cancer after sphincter-preserving surgery. Conclusion The intervention is associated with objective manometry parameters, a significantly lower rate of fecal incontinence, faster return to normal bowel activity, and clinically worthwhile health-related quality-of-life improvement model without significant adverse side effects. The findings indicate that standard postoperative care in this population should also include comprehensive pelvic floor rehabilitation, ensuring that patients can return to their previous level of function and quality of life after cancer treatment. It is safe, feasible, and shows significant efficacy across more than one clinically important outcome domain.