The act of defecation depends on the coordinated function of the colon, rectum, pelvic floor muscles and anus.1 Anorectal dysfunction encompasses a group of bowel symptoms that result from impairment in the normal function of each of these structures. These symptoms include anal incontinence, defecatory difficulties and anorectal pain2 and can have a devastating effect on quality of life.3

Anal incontinence is defined as the involuntary loss of flatus or faeces4; Defecatory difficulties is the complaint of difficult evacuation, including symptoms of obstructive defecation, constipation5 and functional bowel disorders as per Rome IV criteria6; and anorectal pain as the complaint of pain, pressure or discomfort in the anus that occurs during defecation and/or straining to defecate.5 These symptoms can be due to acquired anatomical (e.g., rectocele, obstetric anal sphincter injury, lower anterior resection syndrome (LARS) or functional (e.g., levator ani syndrome, dyssynergic defecation) abnormalities.7

The mechanisms that control continence and allow defecation are complex and rely on the delicate interplay between an intact neurological function and integrity of the pelvic floor muscles and anal sphincter complex, stool consistency, bowel transit and rectal compliance and sensitivity.8 Physiotherapy aims to restore continence and a normal pattern of defecation by altering stool consistency, stool volume and transit time; correcting the dyssynergia or incoordination of the abdominal and pelvic floor musculature; strengthening and/or relaxing the pelvic floor muscles, including the external anal sphincter; keeping the rectum empty; improving rectal sensation; and empowering patients to self-manage symptoms of anorectal dysfunction.9,10

Physiotherapy management, which is considered conservative management, is often regarded as the first line approach of anorectal dysfunction and has been recommended by the National Institute of Clinical Excellence,11 the International Continence Society,3 The Royal College of Surgeons,12 The American Society of Colon and Rectal Surgeons13 and The American College of Gastroenterology.14