Biofeedback training in chronic constipation.

Twenty nine patients, aged 5-16 years, were studied to evaluate whether biofeedback training is effective in treating children with chronic constipation and encopresis; the clinical outcome at six weeks and 12 months was also evaluated. Patients received on average five biofeedback training sessions. The existence of external anal contraction or decreased rectal sensation in 16 (55%) and eight (27%) of the children, respectively was identified on manometry. After biofeedback training, 26 (90%) of the patients learned to relax the external anal sphincter; 18 (63%) normalised rectal sensation. The training resulted in a significant increase in defecation frequency and a significant decrease in encopresis. At six weeks, 16 (55%) of the patients were clinically symptom free. At follow up after 12 months the results were sustained. Only three patients showed a relapse within six months, of whom two were successfully treated with one extra training session. Biofeedback training might be a useful therapeutical approach in children with chronic constipation and encopresis.     

Randomised controlled trial of biofeedback training in persistent encopresis with anismus

BACKGROUND: Paradoxical external anal sphincter contraction during attempted defecation (anismus) is thought to be an important contributor to chronic faecal retention and encopresis in children. Biofeedback training can be used to teach children to abolish this abnormal contraction. METHODS: A randomised controlled trial in medical treatment resistant and/or treatment dependent children with anismus using surface electromyographic (EMG) biofeedback training to determine whether such training produces sustained faecal continence. Up to four sessions of biofeedback training were conducted at weekly intervals for each patient. Anorectal manometry was performed before randomisation and six months later. Parents of patients completed the "child behaviour checklist" (CBCL) before randomisation and at follow up. RESULTS: Sixty eight children underwent anorectal manometry and EMG. Of these, 29 had anismus (ages 4-14 years) and were randomised to either EMG biofeedback training and conventional medical treatment (BFT) (n = 14) or to conventional medical treatment alone (n = 15). All but one child were able to learn relaxation of the external anal sphincter on attempted defecation. At six months' follow up, laxative free remission had been sustained in two of 14 patients in the BFT group and in two of 15 controls (95% confidence interval (CI) on difference, -24% to 26%). Remission or improvement occurred in four of 14 patients in the BFT group and six of 15 controls (95% CI on difference, -46% to 23%). Of subjects available for repeat anorectal manometry and EMG at six months, six of 13 in the BFT group still demonstrated anismus v 11 of 13 controls (95% CI on difference, -75% to -1%). Of the four patients in full remission at six months, only one (in the BFT group) did not exhibit anismus. Rectal hyposensitivity was not associated with remission or improvement in either of the groups. Mean CBCL total behaviour problem scores were not significantly different between the BFT and control groups, but there was a significant improvement in CBCL school scale scores in the BFT group, and this improvement was significantly greater than that seen in the control group. CONCLUSIONS: The result of this study, together with those reported in other controlled trials, argues against using biofeedback training in children with encopresis.     

Abnormal defecation dynamics in chronically constipated children with encopresis

We studied the ability to defecate water-filled balloons in 16 healthy and 37 chronically constipated children with encopresis. The act of bearing down for defecation was evaluated by measuring intra-abdominal pressure, rectal pressure, anal pressure, external anal sphincter EMG activity, and rectal sensation and rectal volume necessary to inhibit the anal sphincters. Fifteen control children and 20 constipated children were able to defecate rectal balloons. External sphincter activity decreased during the act of bearing down for defecation in 100% of controls, in 58% of constipated children able to defecate balloons, and in only 7% of patients unable to defecate balloons. Constipated children unable to defecate balloons were significantly less likely to recover after conventional laxative treatment than constipated children able to defecate balloons (P less than 0.02). Increased external sphincter activity during defecation appears to be the factor that prevents balloon expulsion in constipated children and could be the cause of their chronic fecal retention.     

Randomised controlled trial of biofeedback training in persistent encopresis with anismus

BACKGROUND—Paradoxical external anal sphincter contraction during attempted defecation (anismus) is thought to be an important contributor to chronic faecal retention and encopresis in children. Biofeedback training can be used to teach children to abolish this abnormal contraction.
METHODS—A randomised controlled trial in medical treatment resistant and/or treatment dependent children with anismus using surface electromyographic (EMG) biofeedback training to determine whether such training produces sustained faecal continence. Up to four sessions of biofeedback training were conducted at weekly intervals for each patient. Anorectal manometry was performed before randomisation and six months later. Parents of patients completed the "child behaviour checklist" (CBCL) before randomisation and at follow up.
RESULTS—Sixty eight children underwent anorectal manometry and EMG. Of these, 29 had anismus (ages 4-14 years) and were randomised to either EMG biofeedback training and conventional medical treatment (BFT) (n = 14) or to conventional medical treatment alone (n = 15). All but one child were able to learn relaxation of the external anal sphincter on attempted defecation. At six months'' follow up, laxative free remission had been sustained in two of 14 patients in the BFT group and in two of 15 controls (95% confidence interval (CI) on difference, −24% to 26%). Remission or improvement occurred in four of 14 patients in the BFT group and six of 15 controls (95% CI on difference, −46% to 23%). Of subjects available for repeat anorectal manometry and EMG at six months, six of 13 in the BFT group still demonstrated anismus v 11 of 13 controls (95% CI on difference, −75% to −1%). Of the four patients in full remission at six months, only one (in the BFT group) did not exhibit anismus. Rectal hyposensitivity was not associated with remission or improvement in either of the groups. Mean CBCL total behaviour problem scores were not significantly different between the BFT and control groups, but there was a significant improvement in CBCL school scale scores in the BFT group, and this improvement was significantly greater than that seen in the control group.
CONCLUSIONS—The result of this study, together with those reported in other controlled trials, argues against using biofeedback training in children with encopresis.

     

Randomised trial of biofeedback training for encopresis

AIMS: To evaluate biofeedback training in children with encopresis and the effect on psychosocial function. DESIGN: Prospective controlled randomised study. PATIENT INTERVENTIONS: A multimodal treatment of six weeks. Children were randomised into two groups. Each group received dietary and toilet advice, enemas, oral laxatives, and anorectal manometry. One group also received five biofeedback training sessions. MAIN OUTCOME MEASURES: Successful treatment was defined as less than two episodes of encopresis, regular bowel movements, and no laxatives. Psychosocial function after treatment was assessed using the Child Behaviour Checklist. RESULTS: Children given laxatives and biofeedback training had higher success rates than those who received laxatives alone (39% v 19%) at the end of the intervention period. At 12 and 18 months, however, approximately 50% of children in each group were successfully treated. Abnormal behaviour scores were initially observed in 35% of children. Most children had improved behaviour scores six months after treatment. Children with an initial abnormal behaviour score who were successfully treated had a significant improvement in their behavioural profiles. CONCLUSIONS: Biofeedback training had no additional effect on the success rate or behaviour scores. Psychosocial problems are present in a subgroup of children with encopresis. The relation between successful treatment and improvement in behavioural function supports the idea that encopresis has an aetiological role in the occurrence and maintenance of behavioural problems in children with encopresis.     

Randomised trial of biofeedback training for encopresis.

AIMS: To evaluate biofeedback training in children with encopresis and the effect on psychosocial function. DESIGN: Prospective controlled randomised study. PATIENT INTERVENTIONS: A multimodal treatment of six weeks. Children were randomised into two groups. Each group received dietary and toilet advice, enemas, oral laxatives, and anorectal manometry. One group also received five biofeedback training sessions. MAIN OUTCOME MEASURES: Successful treatment was defined as less than two episodes of encopresis, regular bowel movements, and no laxatives. Psychosocial function after treatment was assessed using the Child Behaviour Checklist. RESULTS: Children given laxatives and biofeedback training had higher success rates than those who received laxatives alone (39% v 19%) at the end of the intervention period. At 12 and 18 months, however, approximately 50% of children in each group were successfully treated. Abnormal behaviour scores were initially observed in 35% of children. Most children had improved behaviour scores six months after treatment. Children with an initial abnormal behaviour score who were successfully treated had a significant improvement in their behavioural profiles. CONCLUSIONS: Biofeedback training had no additional effect on the success rate or behaviour scores. Psychosocial problems are present in a subgroup of children with encopresis. The relation between successful treatment and improvement in behavioural function supports the idea that encopresis has an aetiological role in the occurrence and maintenance of behavioural problems in children with encopresis.     

Is encopresis always the result of constipation?

Encopresis is often the result of chronic constipation in the majority of paediatric patients. In clinical practice, however, encopresis is also seen without constipation and it is unknown whether these two clinical variants are based on similar or different pathophysiological mechanisms, requiring different therapeutic approaches. We analysed clinical symptoms, colonic transit time (CTT), orocaecal transit time (OCTT), anorectal manometric profiles, and behavioural scores. Patients were divided into two groups, one consisted of 111 children with paediatric constipation, and another group of 50 children with encopresis and/or soiling without constipation. Significant clinical differences in children with encopresis/soiling existed compared with children with paediatric constipation regarding: bowel movements per week, the number of daytime soiling episodes, the presence of night time soiling, the presence and number of encopresis episodes, normal stools, pain during defecation, abdominal pain, and good appetite. Total and segmental CTT were significantly prolonged in paediatric constipation compared with encopresis/soiling, 62.4 (3.6-384) and 40.2 (10.8-104.4) hours, respectively. No significant differences were found in OCTT. Among the two groups, all manometric parameters were comparable, except for a significantly higher threshold of sensation in children with paediatric constipation. The defecation dynamics were abnormal in 59% and 46% in paediatric constipation and encopresis/soiling, respectively, and were significantly different from controls. Using the child behaviour checklist no significant differences were found when comparing children with paediatric constipation and encopresis/soiling, while both patient groups differed significantly from controls. In conclusion, our findings support the concept of the existence of encopresis as a distinct entity in children with defecation disorders. Identification of such children is based on clinical symptoms, that is, normal defecation frequency, absence of abdominal or rectal palpable mass, in combination with normal marker studies and normal anal manometric threshold of sensation, Thus, encopresis is not always the result of constipation and can be the only clinical presentation of a defecation disorder.     

Anorectal function and continence mechanisms in childhood encopresis

We compared anorectal sensory and motor functions, expulsion dynamics, and continence mechanisms in 50 children with encopresis and 21 healthy control children. When expulsion dynamics were studied, 43% of boys with encopresis inappropriately contracted the muscles near the anal canal compared with 10% of girls with encopresis (p greater than 0.05) and 10% of control children of both sexes (p less than 0.05). In contrast to previous studies we demonstrated no abnormalities of thresholds of conscious rectal sensation or internal anal sphincter relaxation. In addition, children with encopresis had no demonstrable abnormalities of rectosphincteric continence mechanisms or strength of external anal sphincter contraction. We conclude that a significant number of boys with encopresis have abnormal anorectal expulsion dynamics, which may contribute to chronic fecal retention and incontinence. Abnormalities of anorectal sensory and motor function and of rectosphincteric continence mechanisms do not seem to be important in the pathogenesis of childhood encopresis.     

Faecal incontinence in childhood: A multidisciplinary approach including biofeedback

Abstract One hundred and seven children with faecal incontinence were evaluated and managed over a 3 year period by a multidisciplinary team. After initial clinical assessment, evaluation of defaecatory mechanisms (using a balloon model) and assessment of personal-social development and self-concept were undertaken. Management was based on initial bowel evacuation, short-term laxatives, and habit training involving systematic use of positive reinforcement; 69 children received biofeedback conditioning. Idiopathic megacolon with constipation and soiling was the most common finding (98 cases). Other diagnoses included previously undiagnosed neurogenic bowel (three cases), post-surgical anal anomalies (four cases), and psychogenic encopresis (two cases). Idiopathic megacolon was characterized by decreased rectal sensation, increased threshold for external sphincter relaxation and an inability to evacuate. Faecal incontinence was associated with an undesirably low social self-concept (70% of the 40 evaluated), but was not related to a delay in development (mean general developmental quotient = 105 ± 8, for the 35 tested). Family psychopathology warranting referral for family therapy was found in 14 children (13%). The management programme yielded a short-term (3 months) cure rate of 68% and a long-term (12 months) cure rate of 90%, with 10% having continued soiling which varied from occasional to several incidents/week. No significant improvement in self-concept was observed overall, although marked improvements were observed in some children. We conclude that disordered defaecatory dynamics are a major determinant of faecal incontinence in children. Undesirably low social self-concepts but normal developmental ability accompany this condition. Management is facilitated by a multidisciplinary approach, acknowledging the role of both behavioural and physiological components of the problem. This approach is effective in eradicating soiling in the majority of cases, comparing favourably with other published data.     

生物反馈治疗小儿功能性便秘的疗效研究

目的 评价生物反馈治疗盆底肌协调障碍引起的小儿功能性便秘的疗效.方法 对47例肛门直肠动力检查提示盆底肌协调障碍的功能性便秘患儿进行生物反馈治疗,每周2次,对完成3次及以上生物反馈治疗者进行了疗效分析.结果 共有27例患儿完成至少3次生物反馈治疗,其中男20例,女7例,年龄4～12岁[(6.7±2.2)岁],病程6个月～8年[(3.0±2.3)年].共完成5次生物反馈治疗者有16例,完成7次生物反馈治疗者8例.随着生物反馈治疗次数增加,直肠最大排便压力(mm Hg,1 mm Hg=0.133 kPa)增高,治疗前和治疗3、5、7次后依次为36.2±10.4,45.1±9.5,47.6±9.1,47.8±8.8(P<0.01),而肛门外括约肌肌电值逐渐下降,但差异无统计学意义.治疗后通过电话随访3个月至1年,根据排便症状改善情况进行疗效评定.27例患儿中治愈13例,显效8例,有效3例,无效2例,失访1例,总有效率88.9%(24/27).结论 生物反馈疗法可提高最大排便压力,能有效地治疗盆底肌协调障碍引起的儿童功能性便秘.     

Treatment of childhood encopresis: a randomized trial comparing three treatment protocols

OBJECTIVES: To compare short- and long-term effectiveness of three additive treatment protocols in children experiencing chronic encopresis. METHODS: Children, 6 to 15 years of age, who experienced at least weekly fecal soiling for 6 months or longer were eligible for the study. Children were randomly assigned to a group that received intensive medical therapy (IMT), a group that received intensive medical therapy plus a behavior management program called enhanced toilet training (ETT), or a group that received intensive medical therapy with enhanced toilet training and external anal sphincter electromyographic biofeedback (BF). Data concerning toileting habits were collected for 14 consecutive days before an initial visit, and at 3, 6, and 12 months after initiation of therapy. All data were collected using a computerized voice-mail system that telephoned the families each day. At 12 months, children were classified as significantly improved (reduction in soiling, P < 0.001) or cured ( 0.90, P < 0.001 in each case). Response to treatment during the first 2 weeks of therapy was highly predictive of outcome at 3, 6, and 12 months (P < 0.0001). Children in the ETT group used less laxative medication (P < 0.04) and required fewer treatment contacts (P = 0.08) than children in the IMM group. All three treatments resulted in significant increases in daily bowel movements passed in the toilet and self-initiated toileting, and resulted in decreases in average daily soiling at 3, 6, and 12 months (P < 0.05). CONCLUSIONS: Enhanced toilet training is somewhat more effective in treating childhood encopresis than either intensive medical therapy or anal sphincter biofeedback therapy. Although similar total cure rates at 1 year can be expected with these three forms of therapy, enhanced toilet training results in statistically significant decreases in the daily frequency of soiling for the greatest number of children.     

Long-term efficacy of polyethylene glycol 3350 for the treatment of chronic constipation in children with and without encopresis

Seventy-four children (43 with chronic constipation, 31 with constipation and encopresis) treated with polyethylene glycol 3350 (PEG) for longer than 3 months were studied to assess long-term efficacy. The mean duration of PEG therapy was 8.4 months (range, 3-30). Weekly stool frequency, stool consistency, and symptoms associated with constipation improved significantly with PEG therapy in all 74 patients. In 31 children with encopresis, soiling ceased completely in 16 patients and frequency of soiling decreased significantly in all others. The average effective long-term dose of PEG was 0.7 g/kg/day. Long-term PEG therapy is effective for the treatment of chronic constipation with and without encopresis in children.     

Factors responsible for persistence of childhood constipation

In this study 56% of children with chronic constipation and encopresis were unable to defecate rectal balloons. Most of them had an abnormal contraction of the external and sphincter during defecation trials. Eighty-six percent were still unable to defecate balloons 1 year later after having complied with a conventional treatment program. Only 14% of patients unable to defecate balloons had recovered by 1 year, whereas 64% of patients able to had recovered (p less than 0.02). Only 13% of patients unable to relax the external sphincter had recovered by 1 year, whereas 70% of those able to do so had recovered (p less than 0.01). In addition, none of the patients with an abdominal fecal mass present during the initial examination independent of ability or inability to defecate balloons had recovered (p less than 0.001). This study shows that abnormal defecation dynamics and the severity of constipation are predictors for persistence of chronic constipation and encopresis.     

Modulation of abnormal defecation dynamics by biofeedback treatment in chronically constipated children with encopresis

To determine whether outcome in chronically constipated and encopretic children with abnormal defecation dynamics could be improved with biofeedback training, we randomly assigned patients, 5 to 16 years of age, to receive conventional treatment alone (n = 19) or conventional plus biofeedback treatment (n = 22) and evaluated physiologic outcome at 7 months and clinical outcome at 7 and 12 months. Eighty-six percent of patients learned normal defecation dynamics with up to six biofeedback sessions. At 7 months, 13% of conventionally treated and 77% of biofeedback-treated patients had normal defecation dynamics (p less than 0.01); one conventionally treated (5%) and 12 biofeedback-treated patients (55%) had recovered (p less than 0.01). Learning normal defecation dynamics was correlated with clinical recovery (p less than 0.01). At 7 months, 11% of patients with normal defecation dynamics after biofeedback treatment had abnormal defecation dynamics, and 71% of the biofeedback-treated patients with normal defecation dynamics recovered. At 12 months, 16% of conventionally treated and 50% of biofeedback-treated patients had recovered (p less than 0.05). Balloon defecation did not improve significantly in those who learned normal defecation dynamics. Therefore the ability to defecate balloons is apparently not dependent on the normal function of the external and sphincter and pelvic floor muscles alone. Biofeedback treatment is complementary to a good conventional therapeutic regimen in patients with abnormal defecation dynamics.     

Early constipation and toilet training in children with encopresis

OBJECTIVE: To evaluate the frequency of predisposing factors for encopresis before and during toilet training, comparing children with primary and secondary encopresis. METHODS: In this retrospective study, questionnaires from the initial evaluation at an encopresis clinic at a tertiary care pediatric hospital were reviewed for the presence or absence of factors in the first 2 years of life, for toilet training practices, and for disruptive events during the training process. Children younger than 48 months or those with organic defecation disorders were excluded. RESULTS: In 411 children with encopresis, the reported frequency of predisposing factors included constipation in 35%, and previous treatment for constipation in 24%. Toilet training was initiated before age 2 years in 26% and after age 3 years in 14%. Interruption of toilet training and punishment were seen more in primary encopresis than in secondary encopresis (50% versus 23%; P < 0.05) and (52% versus 26%; P < 0.05) respectively. Constipation (30% versus 18%; P < 0.05) and abdominal pain (23% versus 9%; P <0.0:5) during toilet training were more common in primary encopresis as was fear of the toilet (47% versus 10%; P < 0.05). CONCLUSIONS: In children with encopresis, early difficult defecation, previous treatment for constipation, and early initiation of toilet training were less common than expected. Children with primary encopresis did not have an increased incidence of early constipation or invasive treatments compared with those with secondary encopresis. However, children with primary encopresis did have more difficult and disruptive toilet training experiences.     

Faecal incontinence in childhood: a multidisciplinary approach including biofeedback

One hundred and seven children with faecal incontinence were evaluated and managed over a 3 year period by a multidisciplinary team. After initial clinical assessment, evaluation of defaecatory mechanisms (using a balloon model) and assessment of personal-social development and self-concept were undertaken. Management was based on initial bowel evacuation, short-term laxatives, and habit training involving systematic use of positive reinforcement; 69 children received biofeedback conditioning. Idiopathic megacolon with constipation and soiling was the most common finding (98 cases). Other diagnoses included previously undiagnosed neurogenic bowel (three cases), post-surgical and anomalies (four cases), and psychogenic encopresis (two cases). Idiopathic megacolon was characterized by decreased rectal sensation, increased threshold for external sphincter relaxation and an inability to evacuate. Faecal incontinence was associated with an undesirably low social self-concept (70% of the 40 evaluated), but was not related to a delay in development (mean general developmental quotient = 105 +/- 8, for the 35 tested). Family psychopathology warranting referral for family therapy was found in 14 children (13%). The management programme yielded a short-term (3 months) cure rate of 68% and a long-term (12 months) cure rate of 90%, with 10% having continued soiling which varied from occasional to several incidents/week. No significant improvement in self-concept was observed overall, although marked improvements were observed in some children. We conclude that disordered defaecatory dynamics are a major determinant of faecal incontinence in children. Undesirably low social self-concepts but normal developmental ability accompany this condition. Management is facilitated by a multidisciplinary approach, acknowledging the role of both behavioural and physiological components of the problem.(ABSTRACT TRUNCATED AT 250 WORDS)     

针对性生物反馈训练方法治疗合并隐性脊柱裂的便秘和便失禁的疗效

目的 探讨针对性生物反馈训练方法对合并隐性脊椎裂的功能性便秘(FC)和非潴留性便失禁(NRFI)患儿治疗效果.方法 2003～2006年对34例FC患儿和21例NRFI患儿进行常规保守治疗,在保守治疗无效的患儿中有15例FC患儿和9例NRFI患儿接受针对性生物反馈训练和神经电刺激治疗,并进行客观功能检查,评价治疗效果.结果 经过保守治疗有22例(40%)患儿治愈,5例明显好转.保守治疗无效的24例患儿经过针对性生物反馈训练和神经电刺激治疗有19例(79.2%)患儿治愈,其余5例明显好转.保守治疗无效患儿组的平均病程为(3.1±2.9)年,明显长于保守治疗有效的患儿组(2.0±1.2)年(P<0.05),客观检查结果也显示保守治疗无效患儿组的反映肛门直肠功能的指标改变明显严重于保守治疗有效的患儿组,经过针对性生物反馈训练和神经电刺激治疗各项指标均明显恢复(P<0.05).结论 针对性生物反馈训练和神经电刺激治疗是治疗合并隐性脊椎裂的FC和NRFI患儿的有效方法.     

Safety of polyethylene glycol 3350 for the treatment of chronic constipation in children

OBJECTIVES: To assess the clinical and biochemical safety profile of long-term polyethylene glycol 3350 (PEG) therapy in children with chronic constipation and to assess pediatric patient acceptance of PEG therapy. DESIGN: Prospective observational study. SETTING: Pediatric clinics at a referral center.Patients Eighty-three children (44 with chronic constipation, 39 with constipation and encopresis) receiving PEG therapy for more than 3 months. MAIN OUTCOME MEASURES: Clinical adverse effects related to PEG therapy and acceptance and compliance with PEG therapy. Serum electrolyte levels, osmolality, albumin levels, and liver and renal function test results were measured. RESULTS: At the time of evaluation, the mean duration of PEG therapy was 8.7 months, and the mean PEG dose was 0.75 g/kg daily. There were no major clinical adverse effects. All blood test results were normal, except for transient minimal alanine aminotransferase elevation unrelated to therapy in 9 patients. All children preferred PEG to previously used laxatives, and daily compliance was measured as good in 90% of children. CONCLUSIONS: Long-term PEG therapy is safe and is well accepted by children with chronic constipation with and without encopresis.     

Assessment of the effectiveness of biofeedback in children with dyssynergic defecation and recalcitrant constipation/encopresis: does home biofeedback improve long-term outcomes

The purpose of this study was to determine whether biofeedback benefits children with dyssynergic defecation and constipation/encopresis, and whether home biofeedback improves long-term outcomes. Thirty-six patients with chronic constipation who had failed at least 6 months of conventional treatment and demonstrated dyssynergic defecation at anorectal manometry were randomized to biofeedback in the laboratory alone (group 1, n=24) or in the laboratory and at home (group 2, n=12) and followed up at 2, 4, and a mean of 44 months. Thirty patients were available for long-term follow-up. Bowel movements increased in all from a mean of 1.4/week to 5.1, 5.8, and 5.1 per week at 2 months, 4 months, and long-term, respectively (p < or = 0.001). Soiling decreased in all from a mean of 5.5/week to 0.6, 0.1, and 1 per week at 2 months, 4 months, and long-term, respectively (p < or = 0.001). Laxative use decreased from a mean of 4.1 days/week to 0.6, 0.3, and 0.7 per week at 2 months, 4 months, and long-term, respectively (p < or = 0.001). Twenty-seven of 30 parents ranked their satisfaction a mean of 2.2 (range 1-excellent to 3-good). There were no significant differences in outcomes between the laboratory alone group and the laboratory plus home group. Biofeedback is beneficial for some children with chronic constipation and dyssynergic defecation. Supplemental home biofeedback does not improve long-term outcomes.     

Neurogenic faecal incontinence in children with spina bifida: rectosphincteric responses and evaluation of a physiological rationale for management, including biofeedback conditioning

ABSTRACT. The rectosphincteric responses of 22 spina bifida (SB) children, aged 3.0 to 11.0 years, with frequent neurogenic faecal incontinence were investigated by clinical and anomanometric techniques and a bowel habilitation programme based on the physiological rationale of timed regular and complete evacuations, regulation of bowel habit and faecal consistency by diet and biofeedback conditioning of rectosphincteric responses. Eighteen patients had perianal anaesthesia, flail anus and absent anorectal reflex, but some degree of (reduced) rectal sensation. Four had reduced perianal sensation and normal to high pressure external sphincter and a megarectum apparently causing an absence of rectal sensation. Twenty were unable to expel the rectal balloon voluntarily. After biofeedback exercises (2--5 sessions) and a home programme of evacuation and diet, 21 of the 22 achieved satisfactory continence over 2--6 months with improved rectal sensation and ability to evacuate voluntarily. This experience suggests that early anorectal evaluation and a comprehensive bowel habilitation programme may be an effective approach to the prevention of disability due to faecal incontinence in SB children.