Biofeedback therapy for dyssynergic defecation

INTRODUCTION Chronic constipation is a common self-reported bowel symptom that affects 2%-30% of people in Western countries and has considerable impact on health expenses and quality of life[1]. Most patients respond either to fiber- fluid supplementatio…     

Effectiveness of Biofeedback Therapy on Quality of Life in Patients with Dyssynergic Defecation Disorder

Background: The first option to be considered in the treatment of functional defecation disorder is to correct the dyssynergia. However, limited studies exist to show the effectiveness of biofeedback.Objective: We evaluated the effect of biofeedback on the severity of constipation, quality of life, and anorectal manometry in patients with dyssynergic defecation in which the biofeedback method was applied.Methods: Effectiveness of biofeedback method on the quality of life of 24 dyssynergic defecation patients according to Rome III criteria after clinical and balloon expulsion tests (BETs) and colonic transit time was measured. Data were collected with patient identification form, Bristol Stool Chart, Constipation Quality of Life Scale forms, Visual Analogue Scale, diaphragmatic breathing exercises form, constipation diary, and constipation biofeedback monitoring form. Dyssnergic defecation cases received 6-week biofeedback training. For the same timeframe, the control group had a catheter into the rectum without any intervention.Results: Constipation severity was reduced in both groups before biofeedback to post-biofeedback (P < .05). Anal canal pressure, BET, colonic transit time, and quality of life significantly improved in biofeedback patients compared with controls.Conclusions: Biofeedback has a favorable effect on therapy and quality of life in dyssynergic defecation cases.     

Functional anorectal disorders

This report defines criteria for diagnosing functional anorectal disorders (ie, fecal incontinence, anorectal pain, and disorders of defecation). Functional fecal incontinence is defined as the uncontrolled passage of fecal material recurring for > or =3 months in an individual with a developmental age of > or =4 years that is associated with: (1) abnormal functioning of normally innervated and structurally intact muscles, and/or (2) no or minor abnormalities of sphincter structure and/or innervation insufficient to explain fecal incontinence, and/or (3) normal or disordered bowel habits (ie, fecal retention or diarrhea), and/or (4) psychological causes. However, conditions wherein structural and/or neurogenic abnormalities explain the symptom, or are part of a generalized process (eg, diabetic neuropathy) are not included within functional fecal incontinence. Functional fecal incontinence is a common, but underrecognized symptom, which is equally prevalent in men and women, and can often cause considerable distress. The clinical features are useful for guiding diagnostic testing and therapy. Functional anorectal pain syndromes include proctalgia fugax (fleeting pain) and chronic proctalgia; chronic proctalgia may be subdivided into levator ani syndrome and unspecified anorectal pain, which are defined by arbitrary clinical criteria. Functional defecation disorders are characterized by 2 or more symptoms of constipation, with > or =2 of the following features during defecation: impaired evacuation, inappropriate contraction of the pelvic floor muscles, and inadequate propulsive forces. Functional disorders of defecation may be amenable to pelvic floor retraining by biofeedback therapy (such as dyssynergic defecation).     

Constipation: evaluation and treatment of colonic and anorectal motility disorders

This article focuses on the colonic and anorectal motility disturbances that are associated with chronic constipation and their management. Functional chronic constipation consists of three overlapping subtypes: slow transit constipation, dyssynergic defecation, and irritable bowel syndrome with constipation. The Rome criteria may serve as a useful guide for making a clinical diagnosis of functional constipation. Today, an evidence-based approach can be used to treat patients with chronic constipation. The availability of specific drugs for the treatment of chronic constipation, such as tegaserod and lubiprostone, has enhanced the therapeutic armamentarium for managing these patients. Randomized controlled trials have also established the efficacy of biofeedback therapy in the treatment of dyssynergic defecation.     

Functional disorders of defecation: Evaluation and treatment

Opinion statement Functional disorders of defecation are common and often overlap with slow-transit constipation. They are comprised of functional obstructive conditions such as dyssynergic defecation, as well as structural obstructive conditions such as rectal prolapse, excessive perineal descent, and rectocele. Evaluation includes detailed history and rectal and pelvic exam together with physiologic tests such as anorectal manometry, balloon expulsion test, defecography, and MRI. Treatment involves several medical, behavioral, and surgical approaches. Recently, randomized controlled trials have shown that biofeedback therapy is an effective treatment for dyssynergic defecation. Stapled transanal rectal resection appears to be a promising technique for treating defecation disorders associated with rectocele, excessive perineal descent, and mucosal intussusception, but controlled trials are lacking.     

Defecation disorders. Characteristics of manometric studies and rehabilitation

The authors review the literature and their personal experience about the systematic exploration of defecation disorders by anorectal manometry and colpocystodefecography. They stress the importance of combining functional and morphological evaluation, in order to avoid inappropriate surgery. Concerning anorectal manometry, the determination of the smallest volume of rectal distention inducing a complete relaxation of the internal anal sphincter was found more useful than the maximal tolerable volume in the exploration of defecation disorders. Finally, the authors report the results of biofeedback conditioning prescribed in 30 patients (27 women, 3 men, mean age: 55 years) with defecation disorders (terminal constipation in 21, fecal incontinence in 9 patients). Several characteristics of anorectal manometry and of defecography were significantly improved after biofeedback conditioning.     

Comparing the efficacy of biofeedback and balloon-assisted training in the treatment of dyssynergic defecation

BACKGROUND:

Dyssynergic defecation does not respond appropriately to routine treatments for constipation. Recently, research has shown that biofeedback therapy is useful in anorectal dyssynergia.

OBJECTIVE:

To compare two treatment modalities for patients experiencing dyssynergic defecation.

METHODS:

Sixty-five subjects with dyssynergic defecation were recruited and randomly allocated to one of two treatment groups: balloon defecation training and biofeedback therapy. In the first group, a balloon was inserted into the rectum and inflated by water injection so that the patient experienced the sensation of a full rectum and, thus, the need to defecate. The patient was subsequently asked to reject the balloon. In the biofeedback group, the pen electrode of an electromyographic biofeedback device was inserted into the rectum, with the patient subsequently being asked to increase abdominal pressure and relax the rectal muscles accordingly.

RESULTS:

The findings showed a reduction in constipation in both groups. The ability to reject the balloon (volume and time) was significantly better in postintervention measurements; however, better results were found in the biofeedback arm of the study. Patient satisfaction after treatment reached 52% with balloon training and 79% in the biofeedback group. Reports of incomplete evacuation and the need for digit use during defecation remained constant after treatment in balloon-trained patients.

CONCLUSION:

Biofeedback training appeared to be superior to balloon defecation training and resulted in measurable changes in subjective and objective variables of dyssynergia.     

Constipation: evaluation and treatment

Constipation is a common clinical problem that comprises a constellation of symptoms that include excessive straining, hard stools, feeling of incomplete evacuation, use of digital maneuvers, or infrequent defecation. Although many conditions, such as metabolic problems, fiber deficiency, anorectal problems, and drugs, can cause constipation, when excluded functional constipation consists of two subtypes: slow-transit constipation and dyssynergic defecation. Some patients with irritable bowel syndrome may exhibit features of both types of constipation. The Rome criteria for functional constipation together with modifications proposed here for dyssynergic defecation may serve as useful guidelines for making a diagnosis. Recent advances in technology, together with a better understanding of the underlying mechanisms, have led to real progress in the diagnosis of this condition. Management options are limited, however, and evidence to support these treatments is only modest. The treatment is primarily medical; surgical options should be reserved for refractory disease and after careful diagnostic work-up. Although laxatives remain the mainstay of therapy, prokinetics that are colon-selective are optimal for treating patients with slow-transit constipation, but they are not yet available for clinical use. Recent controlled trials, however, are promising. Biofeedback therapy is the preferred treatment for patients with dyssynergia, but is not widely available. In the near future, user-friendly biofeedback programs including home therapy may facilitate wider use of these methods for patients with dyssynergic defecation.     

Biofeedback treatment of fecal incontinence in geriatric patients

Eighteen fecally incontinent geriatric patients were first treated for constipation as a possible cause of incontinence, and the 13 who remained incontinent were provided sphincter biofeedback training. Half the patients were instructed to perform 50 sphincter exercises per day for a four-week period prior to the start of biofeedback training to determine whether such exercises would improve bowel control in the absence of biofeedback training. Sphincter exercises alone did not produce clinical improvements and did not significantly increase the strength of sphincter contractions. Biofeedback training did significantly augment sphincter strength and was associated with greater than 75 per cent decreases in incontinence for 10 (77 per cent) of the patients. Improvements were maintained in 60 per cent at six months and in 42 per cent at one year. Thus biofeedback training appears to be of specific value in the treatment of fecal incontinence in geriatric patients.     

Discriminative Value of Anorectal Manometry in Clinical Practice

Guidelines recommend anorectal manometry in patients with fecal incontinence and chronic constipation. However, limited evidence supports the utility of manometric testing. We retrospectively reviewed tracings obtained between November 2005 and May 2008. A total of 298 patients (86% women; average age 52 years) were included. The main indications were incontinence (51%) and constipation (42%). Patients suffering from incontinence were older and had lower resting and squeeze pressure compared to continent patients. However, the discriminative power of manometric pressure data was poor, with low sensitivity and specificity. An abnormal straining pattern suggesting dyssynergic defecation was seen in 43% of constipated patients compared to 13% of patients with fecal incontinence. A concordance between manometric patterns and the balloon expulsion test was seen in 72%. The low sensitivity and specificity of manometric parameters does not support the routine use of anorectal manometry in patients with defecation disorders.     

Biofeedback training in disordered defecation

Summary For 20 years now, biofeedback applications in the treatment of fecal incontinence and, more recently, chronic constipation in adults have proven that improvement of anorectal function can be achieved in a majority of patients. Despite this evidence, the definitive mode of action of biofeedback training remains obscure but may include improvement of both motor and sensory functions of the anorectum. In addition, behavioral modification of individual defecatory behavior in these patients may be effective as well. The long-term results of such treatment need to be tested in future research (64).Supported by a grant from the Deutsche Forschungsgemeinschaft, En 50/10.     

Treating pelvic floor disorders of defecation: Management or cure?

Pelvic floor disorders that affect defecation consist of structural disorders (eg, rectocele) and functional disorders (eg, dyssynergic defecation). Evaluation includes a thorough history and physical examination, a careful digital rectal examination, and physiologic tests such as anorectal manometry, colonic transit study, and balloon expulsion test. Defecography and dynamic MRI may facilitate detection of structural defects. Management consists of education and counseling regarding bowel function, diet, laxatives, and behavioral therapies. Recently, several randomized, clinical trials have shown that biofeedback therapy is effective in dyssynergic defecation. Dyssynergia may also coexist in structural disorders such as solitary rectal ulcer syndrome or rectocele. Hence, before proceeding with surgery, neuromuscular training or biofeedback should be considered. Several surgical approaches, including stapled transanal rectal resection, have been advocated, but well-controlled randomized studies are lacking and their efficacy is unproven.     

Electromyographic assessment of biofeedback training for fecal incontinence and chronic constipation

INTRODUCTION: Biofeedback training is an effective modality for the treatment of chronic constipation and fecal incontinence. In general, patients express satisfaction and perceive functional improvement following biofeedback therapy; however, quantifying these observations has been difficult. AIM: This study was undertaken to evaluate the physiologic benefits of biofeedback therapy as reflected by noninvasive electromyography parameters. METHODS: Fifty-five patients who underwent computerized electromyography-based biofeedback treatment at our institution between July 1993 and July 1995 were identified. Noninvasive electromyographic testing was performed before, during (weekly), and at completion of training. Mean number of weekly sessions was seven (range, 5–11). Short-term and ten-second contractions (amplitude/V), sustained contractions (endurance, in seconds), and net strength (V) of the external anal sphincter before and after biofeedback were compared for differences. RESULTS: There were 30 patients with chronic constipation, mean age, 65.3 (range, 33–86) years, composed of 24 women, and 25 patients with fecal incontinence, mean age 66 (range, 34–85) years, composed of 12 males. Statistically significant improvement in endurance and net strength following biofeedback training was noted in both the constipated and the fecal incontinence groups. Fifty-three of 55 (96.4 percent) patients expressed 50 to 100 percent subjective satisfaction after biofeedback therapy. Forty-six of 55 (83.6 percent) patients demonstrated individually improved endurance. CONCLUSIONS: Sphincter endurance and net strength, as measured by noninvasive electromyography, significantly improve following biofeedback therapy in both constipated and fecal incontinence patients. These data suggest that endurance and net strength may be useful tools in assessing a benefit from biofeedback training in these patients.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Defecation disorders: Neuromuscular aspects and treatment

Chronic constipation and fecal incontinence affect 20% of the population and are more prevalent in women, the elderly, those of lower socioeconomic status, and nursing home residents. These disorders pose a significant economic burden and affect quality of life. During the past decade, significant strides have been made in the understanding and treatment of defecation disorders, which have led to real advances in the management of these disorders. These treatments include biofeedback therapy, tegaserod, and lubiprostone for chronic constipation.     

Behavior therapy in gastrointestinal functional disorders]

Almost all functions of the gastrointestinal tract have been shown to be under central nervous control and to respond to environmental factors such as stress. It is, therefore, not surprising that disturbed gastrointestinal functions may be altered through psychological therapy approaches. For motor dysfunctions of the esophagus and functional dyspepsia, there is a lack of behavioral therapy studies, while controlled studies utilizing relaxation techniques, stress management strategies and anxiety treatment have been shown to improve symptoms and prevent recurrence in reflux esophagitis and peptic ulcer disease despite the wide use of effective medication. Most studies have treated patients with symptoms of the irritable bowel syndrome: This approach usually combined conventional medical treatment with psychotherapy. Psychological management usually consisted of relaxation training, stress management and patient information. Additional behavioral modification, e.g. of eating and defecation behavior, is superior to pharmacological and dietary management alone. The role of biofeedback therapy in these patients remains to be clarified in the future. It is, however, therapy of choice in some patients with constipation due to spastic pelvic floor syndrome and in fecal incontinence, if the external anal sphincter is insufficient to maintain continence. There ist a systematic lack of treatment opportunities as compared to the number of patients seeking health care for functional bowel disorders.     

Function and dysfunction of the colon and anorectum in adults: Working team report of the Swedish Motility Group (SMoG)

Symptoms of fecal incontinence and constipation are common in the general population. These can, however, be unreliably reported and are poorly discriminatory for underlying pathophysiology. Furthermore, both symptoms may coexist. In the elderly, fecal impaction always must be excluded. For patients with constipation, colon transit studies, anorectal manometry and defecography may help to identify patients with slow-transit constipation and/or pelvic floor dysfunction. The best documented medical treatments for constipation are the macrogols, lactulose and isphagula. Evolving drugs include lubiprostone, which enhances colonic secretion by activating chloride channels. Surgery is restricted for a highly selected group of patients with severe slow-transit constipation and for those with large rectoceles that demonstrably cause rectal evacuatory impairment. For patients with fecal incontinence that does not resolve on antidiarrheal treatment, functional and structural evaluation with anorectal manometry and endoanal ultrasound or magnetic resonance (MR) of the anal canal may help to guide management. Sacral nerve stimulation is a rapidly evolving alternative when other treatments such as biofeedback and direct sphincter repair have failed. Advances in understanding the pathophysiology as a guide to treatment of patients with constipation and fecal incontinence is a continuing important goal for translational research. The content of this article is a summary of presentations given by the authors at the Fourth Meeting of the Swedish Motility Group, held in Gothenburg in April 2007.     

Treatment of fecal incontinence in adults. Results as a function of clinical and manometric data and the importance of rehabilitation by biofeedback

Twenty-five females and 8 males, 20 to 83 year old, with fecal incontinence, normal rectal capacity and without evidence of active anorectal disease were studied in order to evaluate: a) the incidence of associated constipation; b) the anorectal motility pattern; c) the efficiency of treatment based on clinical data and anorectal motility disorders. Fifteen patients had constipation associated with fecal incontinence and 23 patients presented with at least one anorectal motility abnormality indicating biofeedback therapy. Compliance to therapy was poor since 9 patients did not accept the treatment; among the 24 subjects who accepted the treatment, 18 became continent and 5 were improved. These results were observed after treatment of constipation alone (6 cases) or associated with biofeedback therapy (5 cases), after biofeedback therapy (7 cases), and after surgery alone (3 cases) or followed by biofeedback therapy (2 cases). These results show that: a) constipation is frequently associated with incontinence in the adult; b) treatment of constipation, biofeedback therapy and surgery, used alone or combined according to clinical and anorectal motility data lead to good results in 75 p. 100 of patients.     

Defecation disorders: An important subgroup of functional constipation, its pathophysiology, evaluation and treatment with biofeedback.

Functional defecation disorders are common and affect approximately 50% of patients with chronic constipation. The etiology of functional defecation disorders is not well known, but several pathophysiologic mechanisms have been described, including failure of rectoanal coordination, paradoxical anal contraction or insufficient relaxation of anal sphincter during defecation and impairment of rectal sensation as well as secondary slowing of colonic transit. Symptoms alone are inadequate to distinguish patients with defecation disorders from those with other types of constipation. Detailed clinical evaluation and anorectal physiologic tests are required for definitive diagnosis. There is also a pathophysiological association between functional defecation disorders and other anorectal conditions such as solitary rectal ulcer syndrome. Among the various treatment modalities, biofeedback therapy has emerged as an effective and specific treatment method for functional defecation disorders. The main goals of biofeedback therapy are to relax the pelvic floor and anal sphincter muscles during defecation and to improve rectoanal coordination and sensory perception. Today, it is possible to diagnose most functional disorders of defecation and either effectively treat or ameliorate symptoms in a majority of these patients.     

Biofeedback treatment of chronic constipation: myths and misconceptions

Chronic constipation is a prevalent disorder with considerable impact on healthcare costs and quality of life. Most patients would respond to conservative measures in primary care. Patients with refractory constipation are commonly referred to dedicated centers for appropriate investigations and management. After testing, three main subtypes of constipation are commonly identified: normal colon transit, slow transit, and functional defecation disorders. The etiology of functional defecation disorders is consistent with maladaptive behavior, and biofeedback therapy has been considered a valuable treatment option. Being safe and only marginally invasive, retraining has been historically employed to manage all types of refractory constipation. There are a number of strongly held beliefs about biofeedback therapy that are not evidence-based. The aim of this review was to address these beliefs concerning protocols, efficacy, indications, and safety, with a special focus on the relevance of identifying patients with a functional defecation disorder who are ideal candidates for retraining. Randomized controlled trials support the effectiveness of biofeedback therapy for severe, refractory constipation due to functional defecation disorders. Limitations of the treatment are discussed, but biofeedback remains the safest option to successfully manage this hard-to-treat subtype of constipation.     

Dyssynergic defecation

Dyssynergic defecation is a common clinical problem that affects half of patients with chronic constipation. In many patients, there is a significant overlap with slow transit constipation. The chief underlying pathophysiologic mechanism is a failure of rectoanal coordination. By using a combination of history, prospective stool diaries, detailed clinical evaluation, and anorectal physiologic tests, it is possible to diagnose this problem. Controlled trials are under way to evaluate the efficacy of biofeedback therapy. Meanwhile, it is possible to treat most patients by using neuromuscular conditioning and biofeedback therapy. Further refinements in diagnostic criteria and in rehabilitation therapy programs should facilitate better diagnosis and treatment of patients with dyssynergic defecation.