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.     

Long-term efficacy of biofeedback training for fecal incontinence

PURPOSE: Biofeedback therapy in fecal incontinence has been reported to improve continence in more than 70 percent of patients, but most studies have followed patients for less than two years. METHODS: Patients treated by biofeedback training between 1985 and 1986 were given a questionnaire in 1991, as were incontinent patients who had not entered this treatment program. All were asked for the occurrence, frequency, and severity of incontinence events in the past two weeks. Anamnestic and anorectal manometry data from the initial visit were also compared. RESULTS: Eighteen of 24 treated patients and 40 of 71 untreated patients responded. Of those treated by biofeed-back, 78 percent reported episodes of fecal incontinence as compared with 77.5 percent of those not treated by biofeedback. Severity of incontinence, however, was significantly less (P <0.02) in the treatment group (mean number of events, 0.2/day) than in those without treatment (1/day). In biofeedback-treated patients, it was identical with the frequency and severity reported immediately after therapy. No differences were found with respect to initial clinical data and anorectal manometry between both groups. CONCLUSION: Biofeedback training improves continence in patients not only during treatment and within the first two years but also for several years after therapy.Supported by a grant from the Deutsche Forschungsgemeinschaft, En 50/10.Presented in part at the European Gastrointestinal Motility Symposium, Barcelona, Spain, November 19 to 21, 1992. Published abstract form in the Journal of Gastrointestinal Motility 1992;4:218.     

Are pelvic floor movements abnormal in disordered defecation?

Pelvic floor movements were assessed by videoproctography in 126 subjects: neuropathic fecal incontinence patients (n=44), chronic constipation patients (n =52), and controls (n=30). A significantly lower pelvic floor position at rest and a more obtuse anorectal angle were found in incontinent patients than in controls (P <0.01). constipated patients showed no significant difference from controls at rest. There was less pelvic floor movement during contraction in incontinent patients than in controls, indicating a flaccid, noncontractile pelvic floor in neuropathic incontinence. Movement during contraction in constipated subjects was also less than in controls. Changes in the pelvic floor position during straining were the same as in controls. These data indicate that the pelvic floor is flaccid and noncontractile in neuropathic fecal incontinence, which supports the concept of a progressive neuropathy involving the sacral outflow. Similar changes are not seen at rest in patients with constipation even though they have a long history of straining.     

Biofeedback training is useful in fecal incontinence but disappointing in constipation

BACKGROUND: Successful biofeedback therapy has been reported in the treatment of fecal incontinence and constipation. It is uncertain which groups of incontinent patients benefit from biofeedback, and our impression has been that biofeedback is more successful for incontinence than for constipation. PURPOSE: This study was designed to review the results of biofeedback therapy at the Lahey Clinic. METHODS: Biofeedback was performed using an eightchannel, water-perfused manometry system. Patients saw anal canal pressures as a color bar graph on a computer screen. Assessment after biofeedback was by manometry and by telephone interview with an independent researcher. RESULTS: Fifteen patients (13 women and 2 men) with incontinence underwent a mean of three (range, 1–7) biofeedback sessions. The cause was obstetric (four patients), postsurgical (five patients), and idiopathic (six patients). Complete resolution of symptoms was reported in four patients, considerable improvement in four patients, and some improvement in three patients. Manometry showed a mean increase of 15.3 (range, ?3–30) mmHg in resting pressure and 35.7 (range, 13–57) mmHg in squeezing pressure after biofeedback. A successful outcome could not be predicted on the basis of cause, severity of incontinence, or initial manometry. Twelve patients (10 women and 2 men) with constipation underwent a mean of three (range, 1–14) biofeedback sessions. Each had manometric evidence of paradoxic nonrelaxing external sphincter or puborectalis muscle confirmed by defography or electromyography. All patients could be taught to relax their sphincter in response to bearing down. Despite this, only one patient reported resolution of symptoms, three patients had reduced straining, and three patients had some gain in insight. CONCLUSIONS: Biofeedback helped 73 percent of patients with fecal incontinence, and its use should be considered regardless of the cause or severity of incontinence or of results on initial manometry. In contrast, biofeedback directed at correcting paradoxic external sphincter contraction has been disappointing.     

Biofeedback for the treatment of fecal incontinence

Biofeedback therapy has been proposed as a treatment for fecal incontinence with good, short-term results. PURPOSE: This study was designed to assess long-term clinical results of biofeedback therapy compared with medical therapy alone and to assess manometric results in patients treated with biofeedback. METHODS: Two groups of incontinent patients were studied. Group 1 consisted of 16 patients (3 males and 13 females; mean age, 59.9 years). Etiologies treated by biofeedback included descending perineum syndrome (7), postfistula or hemorroidectomy (4), and miscellaneous (5). Group 2 consisted of eight patients (two males, six females; mean age, 62.2 years). Etiologies treated with medical treatment alone (including enema and antidiarrheal therapy) included descending perineum syndrome (3), postfistula or hemorroidectomy (2), and miscellaneous (3). The incontinence score was initially 17.81±3.27 (standard deviation) in Group 1 and 17.0±2.77 in Group 2. Resting pressure of the upper and lower anal sphincter, maximum squeezing pressure, and duration of contraction were not initially different in Groups 1 and 2 but were significantly lower than in the control group of patients without incontinence (n=12; 8 males, 4 females; mean age, 66.4 years) (P<0.05). Follow-up duration was 30 months, with intermediate clinical score at 6 months for Group 1. RESULTS: After biofeedback therapy, the incontinence score at 30 months was lower in Group 1 (14.43±6.35 vs.17.81 ±3.27;P<0.035) and unchanged in Group 2 (18.0±2.72 vs.17.0±2.77). However, in Group 1 the score at 6 months was much lower than at 30 months (6.31±7.81 vs.14.43±6.35;P<0.001). Only the amplitude of voluntary contraction and upper anal pressure (51.1 (range, 27–90) vs 36.7 (range, 20–80) mmHg) were significantly increased (81.5 (range, 55–120) vs.62.1 (range, 30–90) mmHg;P<0.05). CONCLUSION: Biofeedback improved continence at 6 months and at 30 months. However, the score at 6 months was much better, suggesting that the initial good results may deteriorate over a long time. These data suggest that it could be useful to reinitiate biofeedback therapy in some patients.     

Anorectal dysfunction in patients with urologic disturbance due to multiple sclerosis

Anorectal function was evaluated in 11 patients with voiding dysfunction due to multiple sclerosis. In six patients with constipation, three also had symptoms of obstructed defecation and one patient was incontinent due to stercoral diarrhea. One patient was only fecal incontinent and one patient had obstructed defecation as the only symptom. Three patients had no anorectal symptoms. Anal manometry in the women compared with a control group revealed significant lower anal resting and squeeze pressures, although no significant difference of rectal sensation to distention with air was found. Pudendal nerve terminal latencies were obtained in seven patients and were all normal. In four patients latency could not be demonstrated due to poor contraction of the sphincter on stimulation of the pudendal nerve. Two of these patients were incontinent and two had both constipation and obstructed defecation. It is concluded that patients with voiding symptoms due to multiple sclerosis often reveal anorectal symptoms or motility disorders. Although anal sphincter function is reduced, fecal incontinence is not prevalent in this group. The reason for this lies probably in the fact that many of the patients are constipated, thus securing fecal continence.     

A new probe for measuring electromyographic activity from multiple sites in the anal canal

A new multiple electrode probe (MEP) designed to measure surface electromyographic activity from the subcutaneous and deep portions of the external anal sphincter is described. Using the MEP, electromyographic activity was sampled in an asymptomatic subject and in three incontinent patients. Comparisons of electromyographic data between and within subjects, and across sessions, indicate that the MEP discriminates muscle activity from different sites along the anal canal. The recording method described is capable of identifying patterns of muscle recruitment which have not been reported before using surface electromyography. After a defecation maneuver, the distal and proximal portions of external and sphincter were observed to contract in what would seem to be a closing reflex. Moreover, the absence of this pattern may indicate abnormality. Accordingly, the MEP promises to be useful in the diagnosis, evaluation, and treatment of fecal and urinary incontinence and, particularly, in the biofeedback treatment of these and related disorders.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Prospective assessment of biofeedback for the treatment of paradoxical puborectalis contraction

Eighteen patients with chronic constipation were diagnosed as having paradoxical puborectalis contraction (PPC) as the cause for their constipation. The diagnosis of PPC was made after office evaluation, colonic transit study, manometry, cinedefecography, and electromyography (EMG). These 18 patients had a mean duration of symptoms of 26.9 years; none of these patients had unassisted bowel movements. Fourteen patients had a mean of 4.6 laxative-induced bowel evacuations per week, and 11 patients had a mean of 4.4 enema-induced bowel evacuations per week. Patients underwent a mean of 8.9 one-hour EMG-based biofeedback sessions. At a mean follow-up of 9.1 (range, 0.5–12) months, these 18 patients had a mean of 7.3 unassisted bowel actions per week ( P <0.0001). In addition, persistent laxative use was reported by only two patients, and, in both cases, this was once a week or less ( P <0.001). Similarly, enema use was reported by only three patients, one once weekly and the other two thrice weekly ( P <0.002). No biofeedback-related complications were identified. EMG-based biofeedback is a valuable technique associated with an 89 percent success rate in the treatment of PPC.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Biofeedback therapy in rectal prolapse patients

PURPOSE: The aim of the study was to evaluate the effect of perioperative biofeedback training on postoperative continence in patients with rectal prolapse. METHODS: Thirtysix consecutive patients were operated on between 1987 and 1993. Twenty-nine could be traced for reexamination. Four were excluded because of a recurring prolapse. Anal manometry, assessment of rectoanal sensation, and surface electromyography were performed during the reexamination. From 1987 to 1991, no perioperative biofeedback training was given (Group 1, n=14). Since the beginning of 1992, incontinent patients were given biofeedback training (Group 2, n=11). RESULTS: Continence scores improved in both study groups. Both study groups had equally low resting pressures compared with Group 3 (controls) (30.6±1 4.9 vs.53.0±11.9 mmHg;P <0.001). Anal resting pressure correlated with postoperative continence score, whereas contractile pressures did not ( r =–0.5,P < 0.05, and r =–0.3,P =not significant, respectively). CONCLUSION: Biofeedback therapy can improve the function of external sphincter; however, the most important reason for postoperative incontinence in rectal prolapse patients is low resting pressure that cannot be corrected by biofeedback therapy.Supported by grants from the Central Finland Health Care District.     

Results of biofeedback in constipated patients

PURPOSE: The aims of this study were to assess the results of biofeedback treatment in constipated patients and to identify variables that might be used to predict the outcome. METHOD: Twenty-eight patients (5 men; median age, 46 (range, 22–72) years) with any degree of paradoxical activation measured with thin hook needle electromyography in the external sphincter or puborectalis muscle were included. The symptom duration varied between 1 and 30 (median, 9) years. The patients had eight outpatient training sessions with electromyography-based audiovisual feedback. All patients were followed up prospectively with a validated bowel function questionnaire from which a symptom index was created. RESULTS: At three months, nine patients had no improvement and underwent other treatments. The remaining 19 patients were followed up for a median of 14 (range, 12–34) months. Twelve patients (43 percent) stated they had improved rectal emptying. A good result was associated with increased stool frequency ( P < 0.05), improved symptom index (P <0.01), and reduction of laxative use ( P <0.05). A long symptom duration, a high pretreatment symptom index, and laxative use were related to a poor result ( P <0.01–0.05). The improved group had less perineal descent ( P <0.05), and a prominent puborectalis impression on defecography tended to be more common ( P =0.06). CONCLUSION: With the use of wide inclusion criteria, biofeedback was successful in 43 percent of patients, with a treatment effect lasting at least one year. The results suggest that biofeedback should be used as the initial treatment of constipated patients with a paradoxical puborectalis contraction.     

Defecographic findings in patients with anal incontinence and constipation and their relation to rectal emptying

PURPOSE: The aim of this study was to examine defecographic findings in patients with anal incontinence and constipation and to compare these findings with rectal emptying. METHODS: One hundred seventy-five preoperative defecographies documented on videotape in patients with either anal incontinence or constipation were retrospectively reviewed. The examinations were evaluated with respect to anatomic abnormalities of the rectum or anal canal. The results were compared with a semiquantitative assessment of rectal emptying as it appeared on the video sequence after one minute of strain. RESULTS: Anatomic abnormalities were found equally in incontinent and constipated patients, except for failure to open the anal canal, which was found only in constipated patients. Rectal intussusception was the most frequent finding. Abnormal defecograms were found in both sexes. Enteroceles, sigmoidoceles, and large rectoceles were found only in women. The presence of intussusception, lacking relaxation of the puborectalis muscle, and rectocele did not correlate with poor rectal emptying. Poor rectal emptying was also found in 19 of 58 patients with normal defecograms. CONCLUSIONS: Anatomic abnormalities of the rectum may be demonstrated independently of the clinical symptoms and are not always correlated to impaired rectal emptying. Since they may also be found in healthy controls, surgical correction of these abnormalities should be considered only with great caution.     

Biofeedback improves functional outcome after sphincteroplasty

The primary treatment for obstetric sphincter injury is overlapping sphincteroplasty. However, despite restoration of the anatomy, only 65 percent of patients are fully continent. PURPOSE: This study was undertaken to determine if postoperative biofeedback improved continence in patients with poor functional outcomes after sphincteroplasty. METHOD: Outcomes of 28 patients who underwent electromyographic biofeedback training after sphincteroplasty for obstetric sphincter injury were reviewed. Nine patients had an accompanying levatorplasty. Average age was 34 (range, 23–57) years. Patients began biofeedback a mean of 32 (range, 2–192) months postoperatively. Before beginning biofeedback, patients completed an incontinence questionnaire, bowel diary, and scored their incontinence. At the end of treatment, they were again asked to score their incontinence and rate their improvement. Using an incontinence scale with a maximum score of 30, the average incontinence score before biofeedback was 20 (range, 13–30). Incontinent episodes per week ranged from one to nine. Sixteen patients were incontinent to solid stool. RESULTS: Overall, the average posttreatment incontinence score decreased from 20 to 3 (P < 0.0001). Average number of incontinent episodes per week decreased from 5.4 to 1.4 (P < 0.0001) Twenty-five patients (89 percent) reported improvement in their continence. All had a posttreatment incontinent score of less than three. Three patients noted no improvement. Of those, one subsequently had a colostomy, one is waiting the implant of an artificial anal sphincter, and one has sought no further treatment. There were no complications reported. CONCLUSION: Biofeedback improves functional outcome after sphincteroplasty and is a reasonable option for patients with less than optimum outcome after sphincteroplasty.     

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.     

Endosonographic assessment of the anal sphincter after surgical reconstruction

PURPOSE: Patients with anal incontinence attributable to trauma are usually treated by sphincter reconstruction. Failures because of incomplete reconstruction may possibly be detected by anal endosonography which gives detailed information on the anal sphincter muscles. The aim of this study was to describe the endosonographic findings in patients after sphincter reconstruction. MATERIALS AND METHODS: Ten female patients who had undergone surgical sphincter reconstruction using an overlapping technique because of anal incontinence were studied with anal endosonography a median of six months after surgery. Five patients were fully continent, three were incontinent for flatus, and two patients were still incontinent for solid stool at the time of this study. Eight patients had also been studied with endosonography before surgery, and, in these patients, we compared the initial sonograms with the follow-up sonograms. The angular extent of the endosonographic defects in the external sphincter before and after reconstruction was measured in degrees and compared with the outcome of surgery. RESULTS: After reconstruction, continuity of the external anal sphincter was completely restored at all levels in four patients, one of whom still had anal incontinence. Continuity was partially restored in three patients: two were fully continent, while one patient, previously incontinent for stool, was incontinent for flatus. In three patients the continuity was restored at one level but a persisting defect was found at a different level. In two of these patients the grade of incontinence was unchanged. Three patients also had defects in the internal anal sphincter. CONCLUSION: After surgical sphincter reconstruction for anal incontinence, we found sphincteric defects in six patients, including four of five patients who still had some degree of incontinence. Thus, endosonography may be used for postoperative assessment and may explain the unsatisfactory results of surgery in some patients. We recommend that endosonography be also performed preoperatively, whereby the effect of the operation on the size of the sphincteric defect can be assessed.     

Etiology and management of fecal incontinence

Fecal incontinence is a challenging condition of diverse etiology and devastating psychosocial impact. Multiple mechanisms may be involved in its pathophysiology, such as altered stool consistency and delivery of contents to the rectum, abnormal rectal capacity or compliance, decreased anorectal sensation, and pelvic floor or anal sphincter dysfunction. A detailed clinical history and physical examination are essential. Anorectal manometry, pudendal nerve latency studies, and electromyography are part of the standard primary evaluation. The evaluation of idiopathic fecal incontinence may require tests such as cinedefecography, spinal latencies, and anal mucosal electrosensitivity. These tests permit both objective assessment and focused therapy. Appropriate treatment options include biofeedback and sphincteroplasty. Biofeedback has resulted in 90 percent reduction in episodes of incontinence in over 60 percent of patients. Overlapping anterior sphincteroplasty has been associated with good to excellent results in 70 to 90 percent of patients. The common denominator between the medical and surgical treatment groups is the necessity of pretreatment physiologic assessment. It is the results of these tests that permit optimal therapeutic assignment. For example, pudendal nerve terminal motor latencies (PNTML) are the most important predictor factor of functional outcome. However, even the most experienced examiner's digit cannot assess PNTML. In the absence of pudendal neuropathy, sphincteroplasty is an excellent option. If neuropathy exists, however, then postanal or total pelvic floor repair remain viable surgical options for the treatment of idiopathic fecal incontinence. In the absence of an adequate sphincter muscle, encirclement procedures using synthetic materials or muscle transfer techniques might be considered. Implantation of a stimulating electrode into the gracilis neosphincter and artificial sphincter implantation are other valid alternatives. The final therapeutic option is fecal diversion. This article reviews the current status of the etiology and incidence of incontinence as well as the evaluation and treatment of this disabling condition.     

Abnormal internal anal sphincter fibrosis and elasticity in fecal incontinence

PURPOSE: We aimed to investigate the changes in the proportion of collagen and in the elasticity of the internal anal sphincter in patients with neurogenic fecal incontinence. METHODS: Collagen content was studied in ten patients with neurogenic fecal incontinence (mean age, 51.5 years) and ten controls (age, 58.6 years) using histologic techniques to determine differences between incontinence and health and to determine the effect of aging. Changes in elasticity were also measured in 8 controls (mean age, 63 years) and 13 patients with neurogenic incontinence (mean age, 60 years) by recording the in vitro length-tension relationship of the freshly excised internal anal sphincter. RESULTS: Incontinent patients had a significantly higher collagen content than controls (55 percent vs.33 percent;P=0.013). In incontinent patients the amount of collagen and the patients' ages correlated significantly (P=0.001). There was a greater increase in stable tension per increase in muscle length in the strips from incontinent patients compared with controls. CONCLUSIONS: Changes in fibrous tissue content are likely to influence muscle tone and responsiveness of the sphincter in fecal incontinence.C. T. M. Speakman was supported by the Sir Alan Parks Research Foundation, The Royal College of Surgeons, and M. A. Kamm was supported by the St. Mark's Research Foundation.     

Prospective study of biofeedback for treatment of constipation

PURPOSE: This study was designed to evaluate prospectively the results of pelvic floor physiotherapy with the aid of biofeedback in a heterogeneous group of patients with intractable constipation. METHODS: Biofeedback was used to treat 19 patients (age range, 16–78 (median, 63) years) with intractable constipation. Assessment, using visual linear analog scales of symptoms, was performed prospectively by an independent researcher. Biofeedback was performed by a physiotherapist, and patients were required to attend six sessions on an outpatient basis. The cause of constipation was heterogeneous, with no specific disorder being implicated on testing with anal manometry, defecating proctography, and colonic transit time. RESULTS: At six weeks, there was a median 27 percent (range, –8–93 percent) improvement in symptom scores. At six months, there was a median 23 percent (range, –54–64 percent) improvement in symptom scores. These were statistically significant compared with the scores at outset, six weeks ( P =0.0006), and six months ( P =0.012). However, only two (12.5 percent) patients at the six-month follow-up had an improvement of greater than 50 percent in their symptoms. CONCLUSION: Biofeedback is not recommended in the management of constipation.Presented at the Royal Australasian College of Surgeons Annual Scientific Congress, Melbourne, Australia, May 5 to 10, 1996.No reprints are available.     

Sensory retraining is key to biofeedback therapy for formed stool fecal incontinence

OBJECTIVES: Biofeedback is a nonsurgical treatment that reportedly produces good results in 65-75% of fecally incontinent patients. However, previous studies have not ruled out nonspecific treatment effects. It is also unknown whether biofeedback works primarily by improving the strength of the striated pelvic floor muscles or by improving the rectal perception. We aimed to 1) evaluate the efficacy of biofeedback in formed-stool fecal incontinence, 2) assess the relative contribution of sensory and strength retraining to biofeedback outcomes, and 3) identify patient characteristics that predict a good response to treatment. METHODS: Twenty-four patients with frequent (at least once a week) solid-stool incontinence were provided with three to four biofeedback sessions. They were taught to squeeze in response to progressively weaker rectal distentions. Patients were re-evaluated by anorectal manometry and symptom diary 3 months after completing training and by diary and interview 6-12 months after training. RESULTS: Seventeen (71%) were classified responders; 13 became continent and four reduced incontinence frequency by at least 75%. Clinical improvements were maintained at 12-month follow-up. At 3-month follow-up, responders had significantly lower thresholds for perception of rectal distention and for sphincter contraction, but squeeze pressures did not significantly differ from those of nonresponders. Baseline measures that predicted a favorable response were sensory threshold (50 ml or less), urge threshold (100 ml or less), lower threshold for sphincter contraction, and lower threshold for the rectoanal inhibitory reflex; neither anal squeeze pressure nor severity of incontinence predicted treatment outcome. CONCLUSIONS: In solid-stool fecal incontinence biofeedback training effects are robust and seem not to be explained by expectancy or nonspecific treatment effect. Sensory retraining appears to be more relevant than strength training to the success of biofeedback.     

Biofeedback therapy for excessive stool frequency and incontinence following anterior resection or total colectomy

PURPOSE: Excessive stool frequency and incontinence after anterior resection (AR) or total colectomy (TC) can be refractory to expectancy and antidiarrheal agents. We prospectively assessed efficacy of anorectal biofeedback therapy (BF) in this clinical situation. METHODS: Thirteen patients (10 men and 3 women; mean age, 62.1 (standard error of the mean (SEM), 4.6) years) had more than six bowel movements per day and/or episodes of incontinence, which did not abate after antidiarrheal agents were given for at least six (mean, 27.9 (SEM, 6.3)) months after surgery. All underwent four sessions of outpatient BF. Assessment was by continence questionnaire and anorectal physiology tests, which were administered before and after BF. RESULTS: In seven AR patients, daily stool frequency was decreased (8.7 (SEM, 2.1) before and 4.6 (SEM, 1.2) after; P <0.05), and daily incontinence episodes were reduced (2.7 (SEM, 0.9) before and 0.4 (SEM, 0.2) after; P <0.05) after BF. Six TC patients also had decreased daily stool frequency (6.2 (SEM, 2.1) before, 3.3 (SEM, 1.6) after; P <0.05) and incontinence episodes (2.4 (SEM, 0.9) before, 0.5 (SEM, 1) after; P <0.05) after BF. There were no significant changes in anorectal physiology parameters after BF. At a mean follow-up of 10.6 (SEM, 2.5) months after BF, there were no regressions or complications. CONCLUSIONS: BF is a safe and effective option for refractory excessive stool frequency and/or incontinence following AR or TC.     

Manometric and radiologic investigations and biofeedback treatment of chronic idiopathic anal pain

In 12 patients suffering from chronic idiopathic anal pain, the rectosphincteric function was studied using manometric and x-ray techniques. The results of manometric investigations were compared with those obtained in 12 healthy volunteers. In all patients, the resting pressure in the anal canal was significantly higher than in control subjects. In 10 patients, defecography revealed abnormalities of the pelvic muscles. We treated the patients by using biofeedback techniques, consisting of voluntary modifications of the state of contraction of the external sphincter. In all cases, pain disappeared after a mean of eight biofeedback training sessions. When noxious manifestations had disappeared, manometry showed a significant decrease in the anal canal resting pressure. Our results indicate 1) that chronic idiopathic anal pain is associated with abnormal anorectal manometric profiles, probably resulting from a dysfunctioning of the striated external anal sphincter, and 2) that biofeedback training is an effective treatment for chronic idiopathic anal pain.This work was supported by INSERM Grant No. 89/3h58/BCR/ CR/BD and by Fondation pour la Recherche Médicale.