Biofeedback defaecation training for anismus

Diagnostic value of the balloon expulsion test compared with anorectal manometry in Indian patients with dyssynergic defecation

INTRODUCTION

Digital rectal examination (DRE) and balloon expulsion test (BET) are simple tests to diagnose dyssynergic defecation (DD).

AIM

To determine differences in symptoms and manometry findings in patients with abnormal BET and normal BET. The secondary objective was to ascertain the sensitivity and specificity of BET and DRE + BET for the diagnosis of DD in an Indian setting using ARM findings as the gold standard.

MATERIAL AND METHODS

Retrospective analysis of patients with chronic constipation referred for anorectal manometry (ARM) between December 2012 and March 2019. DD was diagnosed using ARM. Findings on BET and, in a subset of cases, on DRE + BET were compared with ARM findings. The data were analyzed for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Agreement of BET and DRE + BET with ARM was calculated using Cohen's κ coefficient. A p-value of < 0.05 was considered significant.

RESULTS

A total of 1006 cases (734 males, 73%) formed the study cohort. Patients with abnormal BET more frequently reported digitation, bleeding per rectum, and straining (p < 0.00001). Moreover, they had a significantly higher median basal pressure compared to those with normal BET (80 vs. 67, p = 0.03). DD was significantly more common in those with abnormal BET. The sensitivity, specificity, PPV, and NPV of BET in detecting DD were 28.29%, 97.15%, 81.13%, and 75.78%, respectively. The percentage of agreement was 76.34%, and there was fair degree of correlation between the two tests. In a smaller subset of cases (166), DRE and BET findings were both available for analysis. We noted that the sensitivity, specificity, PPV, and NPV of combined DRE + BET were 57.63%, 88.79%, 73.91%, and 79.17%, respectively. The Cohen's κ correlation coefficient was 0.49, suggesting moderate agreement.

CONCLUSIONS

Patients with abnormal BET more frequently report digitation, straining, and bleeding per rectum, and have higher resting anal pressure. BET is a good screening test for DD in an Indian setting.

Digital Rectal Examination and Balloon Expulsion Test in the Study of Defecatory Disorders: Are They Suitable as Screening or Excluding Tests?

Background. Rome III criteria add physiological criteria to symptom-based criteria of chronic constipation (CC) for the diagnosis of defecatory disorders (DD). However, a gold-standard test is still lacking and physiological examination is expensive and time-consuming. Aim. Evaluate the usefulness of two low-cost tests-digital rectal examination (DRE) and balloon expulsion test (BET)-as screening or excluding tests of DD. Methods. We performed a systematic search in PUBMED and MEDLINE. We selected studies where constipated patients were evaluated by DRE or BET. Heterogeneity was assessed and random effect models were used to calculate the sensitivity, specificity, and negative predictive value (NPV) of the DRE and the BET. Results. Thirteen studies evaluating BET and four studies evaluating DRE (2329 patients) were selected. High heterogeneity (I2 > 80%) among studies was demonstrated. The studies evaluating the BET showed a sensitivity and specificity of 67% and 80%, respectively. Regarding the DRE, a sensitivity of 80% and specificity of 84% were calculated. NPV of 72% for the BET and NPV of 64% for the DRE were estimated. The sensitivity and specificity were similar when we restrict the analysis to studies using Rome criteria to define CC. The BET seems to perform better when a cut-off time of 2 minutes is used and when it is compared with a combination of physiological tests. Considering the DRE, strict criteria seem to improve the sensitivity but not the specificity of the test. Conclusion. Neither of the low-cost tests seems suitable for screening or excluding DD.

Biofeedback for treatment of chronic idiopathic constipation in adults

BACKGROUND

Biofeedback therapy has been used to treat the symptoms of people with chronic constipation referred to specialist services within secondary and tertiary care settings. However, different methods of biofeedback are used within different centres and the magnitude of suggested benefits and comparable effectiveness of different methods of biofeedback has yet to be established.

OBJECTIVES

To determine the efficacy and safety of biofeedback for the treatment of chronic idiopathic (functional) constipation in adults.

SEARCH METHODS

We searched the following databases from inception to 16 December 2013: CENTRAL, the Cochrane Complementary Medicine Field, the Cochrane IBD/FBD Review Group Specialized Register, MEDLINE, EMBASE, CINAHL, British Nursing Index, and PsychINFO. Hand searching of conference proceedings and the reference lists of relevant articles was also undertaken.

SELECTION CRITERIA

All randomised trials evaluating biofeedback in adults with chronic idiopathic constipation were considered for inclusion.

DATA COLLECTION AND ANALYSIS

The primary outcome was global or clinical improvement as defined by the included studies. Secondary outcomes included quality of life, and adverse events as defined by the included studies. Where possible, we calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes and the mean difference (MD) and 95% CI for continuous outcomes. We assessed the methodological quality of included studies using the Cochrane risk of bias tool. The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria.

MAIN RESULTS

Seventeen eligible studies were identified with a total of 931 participants. Most participants had chronic constipation and dyssynergic defecation. Sixteen of the trials were at high risk of bias for blinding. Attrition bias (4 trials) and other potential bias (5 trials) was also noted. Due to differences between study populations, the heterogeneity of the different samples and large range of different outcome measures, meta-analysis was not possible. Different effect sizes were reported ranging from 40 to 100% of patients who received biofeedback improving following the intervention. While electromyograph (EMG) biofeedback was the most commonly used, there is a lack of evidence as to whether any one method of biofeedback is more effective than any other method of biofeedback. We found low or very low quality evidence that biofeedback is superior to oral diazepam, sham biofeedback and laxatives. One study (n = 60) found EMG biofeedback to be superior to oral diazepam. Seventy per cent (21/30) of biofeedback patients had improved constipation at three month follow-up compared to 23% (7/30) of diazepam patients (RR 3.00, 95% CI 1.51 to 5.98). One study compared manometry biofeedback to sham biofeedback or standard therapy consisting of diet, exercise and laxatives. The mean number of complete spontaneous bowel movements (CSBM) per week at three months was 4.6 in the biofeedback group compared to 2.8 in the sham biofeedback group (MD 1.80, 95% CI 1.25 to 2.35; 52 patients). The mean number of CSBM per week at three months was 4.6 in the biofeedback group compared to 1.9 in the standard care group (MD 2.70, 95% CI 1.99 to 3.41; 49 patients). Another study (n = 109) compared EMG biofeedback to conventional treatment with laxatives and dietary and lifestyle advice. This study found that at both 6 and 12 months 80% (43/54) of biofeedback patients reported clinical improvement compared to 22% (12/55) laxative-treated patients (RR 3.65, 95% CI 2.17 to 6.13). Some surgical procedures (partial division of puborectalis and stapled transanal rectal resection (STARR)) were reported to be superior to biofeedback, although with a high risk of adverse events in the surgical groups (wound infection, faecal incontinence, pain, and bleeding that required further surgical intervention). Successful treatment, defined as a decrease in the obstructed defecation score of > 50% at one year was reported in 33% (3/39) of EMG biofeedback patients compared to 82% (44/54) of STARR patients (RR 0.41, 95% CI 0.26 to 0.65). For the other study the mean constipation score at one year was 16.1 in the balloon sensory biofeedback group compared to 10.5 in the partial division of puborectalis surgery group (MD 5.60, 95% CI 4.67 to 6.53; 40 patients). Another study (n = 60) found no significant difference in efficacy did not demonstrate the superiority of a surgical intervention (posterior myomectomy of internal anal sphincter and puborectalis) over biofeedback. Conflicting results were found regarding the comparative effectiveness of biofeedback and botulinum toxin-A. One small study (48 participants) suggested that botulinum toxin-A injection may have short term benefits over biofeedback, but the relative effects of treatments were uncertain at one year follow-up. No adverse events were reported for biofeedback, although this was not specifically reported in the majority of studies. The results of all of these studies need to be interpreted with caution as GRADE analyses rated the overall quality of the evidence for the primary outcomes (i.e. clinical or global improvement as defined by the studies) as low or very low due to high risk of bias (i.e. open label studies, self-selection bias, incomplete outcome data, and baseline imbalance) and imprecision (i.e. sparse data).

AUTHORS' CONCLUSIONS

Currently there is insufficient evidence to allow any firm conclusions regarding the efficacy and safety of biofeedback for the management of people with chronic constipation. We found low or very low quality evidence from single studies to support the effectiveness of biofeedback for the management of people with chronic constipation and dyssynergic defecation. However, the majority of trials are of poor methodological quality and subject to bias. Further well-designed randomised controlled trials with adequate sample sizes, validated outcome measures (especially patient reported outcome measures) and long-term follow-up are required to allow definitive conclusions to be drawn.

Primary Care Management of Chronic Constipation in Asia: The ANMA Chronic Constipation Tool

Chronic constipation (CC) may impact on quality of life. There is substantial patient dissatisfaction; possible reasons are failure to recognize underlying constipation, inappropriate dietary advice and inadequate treatment. The aim of these practical guidelines intended for primary care physicians, and which are based on Asian perspectives, is to provide an approach to CC that is relevant to the existing health-care infrastructure. Physicians should not rely on infrequent bowel movements to diagnose CC as many patients have one or more bowel movement a day. More commonly, patients present with hard stool, straining, incomplete feeling, bloating and other dyspeptic symptoms. Physicians should consider CC in these situations and when patients are found to use laxative containing supplements. In the absence of alarm features physicians may start with a 2-4 week therapeutic trial of available pharmacological agents including osmotic, stimulant and enterokinetic agents. Where safe to do so, physicians should consider regular (as opposed to on demand dosing), combination treatment and continuous treatment for at least 4 weeks. If patients do not achieve satisfactory response, they should be referred to tertiary centers for physiological evaluation of colonic transit and pelvic floor function. Surgical referral is a last resort, which should be considered only after a thorough physiological and psychological evaluation.

Excellent response rate of anismus to botulinum toxin if rectal prolapse misdiagnosed as anismus ('pseudoanismus') is excluded

AIM

Anismus causes obstructed defecation as a result of inappropriate contraction of the puborectalis/external sphincter. Proctographic failure to empty after 30 s is used as a simple surrogate for simultaneous electromyography/proctography. Botulinum toxin is theoretically attractive but efficacy is variable. We aimed to evaluate the efficacy of botulinum toxin to treat obstructed defecation caused by anismus.

METHOD

Botulinum toxin was administered, under local anaesthetic, into the puborectalis/external sphincter of patients with proctographic anismus. Responders (resolution followed by recurrence of obstructed defecation over a 1- to 2-month period) underwent repeat injection. Nonresponders underwent rectal examination under anaesthetic (EUA). EUA-diagnosed rectal prolapse was graded using the Oxford Prolapse Grade 1-5.

RESULTS

Fifty-six patients were treated with botulinum toxin. Twenty-two (39%) responded initially and 21/22 (95%) underwent repeat treatment. At a median follow up of 19.2 (range, 7.0-30.4) months, 20/21 (95%) had a sustained response and required no further treatment. Isolated obstructed defecation symptoms (OR = 7.8, P = 0.008), but not proctographic or physiological factors, predicted response on logistic regression analysis. In 33 (97%) of 34 nonresponders, significant abnormalities were demonstrated at EUA: 31 (94%) had a grade 3-5 rectal prolapse, one had internal anal sphincter myopathy and one had a fissure. Exclusion of these alternative diagnoses revised the initial response rate to 96%.

CONCLUSION

Simple proctographic criteria overdiagnose anismus and underdiagnose rectal prolapse. This explains the published variable response to botulinum toxin. Failure to respond should prompt EUA seeking undiagnosed rectal prolapse. A response to an initial dose of botulinum toxin might be considered a more reliable diagnosis of anismus than proctography.

Outcome of biofeedback therapy in dyssynergic defecation patients with and without irritable bowel syndrome

AIM

The Rome II and III diagnostic criteria for dyssynergic defecation require the exclusion of irritable bowel syndrome (IBS). To prospectively study whether the presence of IBS affects the outcome of biofeedback therapy in dyssynergic defecation patients.

METHODS

Consecutive patients with dyssynergic defecation underwent biofeedback therapy. Dyssynergic defecation was diagnosed based on symptoms, anorectal manometries, balloon expulsion tests, and colonic transit studies. The defecation dynamics and balloon expulsion time were evaluated at the end of the biofeedback therapy in all patients. IBS symptoms were graded before and 4 weeks after the biofeedback therapy using a 4-point Likert scale. Failure of the biofeedback therapy was defined as <50% improvement of constipation symptoms, which were evaluated using a 10 cm long visual analog scale before and 4 weeks after biofeedback therapy.

RESULTS

Fifty patients completed the study. The biofeedback therapy was successful in 30 patients. Twenty-nine patients fulfilled the Rome II criteria for IBS. Patients with or without IBS demonstrated similar responses to the biofeedback therapy (16 of 29 vs. 14 of 21, P>0.05). The disappearance of IBS symptoms was observed more frequently in patients with an improved defecation index compared with those with no improvement (8 of 12 vs 4 of 17, P<0.05). A high pretreatment constipation symptom score, a high rectal sensory threshold, and a delayed colonic transit time were associated with a poor treatment outcome.

CONCLUSIONS

The presence of IBS in dyssynergic defecation did not affect the outcome of biofeedback therapy. In addition, treating dyssynergic defecation patients with IBS by biofeedback therapy improved both constipation and IBS symptoms.

Pelvic floor dyssynergia: efficacy of biofeedback training

BACKGROUND AND STUDY AIMS

Paradoxical contraction of the pelvic floor during attempts to defaecate is described as pelvic floor dyssynergia (anismus). It is a behavioural disorder (no associated morphological or neurological abnormalities); consequently, biofeedback training has been recommended as a behavioural therapy for such a disorder. The aim of the present study was to evaluate long-term satisfaction of patients diagnosed with pelvic floor dyssynergia after biofeedback.

PATIENTS AND METHODS

Sixty patients (35 females and 25 males) with a mean age of 30±12years and a 4year duration of constipation were included. Forty-five patients had normal colonic transit and 15 patients had slow colonic transit. History, physical examination and barium enema were done to exclude constipation secondary to organic causes. Colonic and pelvic floor functions (colon-transit time, anorectal manometry, EMG and defaecography) were performed before and after biofeedback treatments. Patients were treated on a weekly basis with an average of (6±2) sessions.

RESULTS

At the end of sessions, 55 out of 60 patients (91.6%) reported a subjectively overall improvement. Symptoms of dyschezia were reported less frequently after biofeedback. Age and gender were not predictive factors of outcome. No symptoms at initial assessment were predictive for patient's satisfaction but the only factor of predictive value was the diagnosis of anismus and the motivated patient who wanted to continue the sessions.

CONCLUSION

Biofeedback remains a morbidity free, low-cost and effective outpatient therapy for well-motivated patients complaining of functional constipation and diagnosed as pelvic floor dyssynergia.

Measurements of pelvic floor dyssynergia: which test result matters?

PURPOSE

Failure to expel a 60-mL balloon on manometry and abnormal relaxation of anal sphincter on electromyographic testing are frequently used to diagnose pelvic floor dyssynergia. However, the relationship between these 2 test results and their relationship to defecography is poorly characterized. We aimed to describe this relationship and create a predictive model for pelvic floor dyssynergia on defecography.

METHODS

From March 2008 to April 2010 consecutive patients with symptoms suggestive of functional constipation were evaluated at our Pelvic Floor Disorders Center 125 and the results of their workups were collected prospectively. Sixty-three patients with pelvic floor dyssynergia on defecography were compared with 60 patients without dyssynergia in terms of manometry pressures, electromyographic text results, and balloon expulsion testing results (χ, t tests).

RESULTS

Of 125 patients meeting Rome II symptom criteria for constipation, 123 patients underwent defecography and, of these, 63 (51.2%) had evidence of pelvic floor dyssynergia. Patients with and without dyssynergia had a slight difference in mean resting pressures (62.8 mmHg vs 49.5 mmHg, P = .02) and no discernable differences in rectal sensitivity and compliance: first sensation (56.5 vs 62.5, P = .34) and maximum tolerated volume (164.2 vs 191.2, P = .09). It appeared that abnormalities in electromyographic relaxation and balloon expulsion occurred in the same patients: 84.1% of patients with abnormal electromyographic results also did not expel the balloon. However, the presence of these abnormalities, in isolation or together, did not predict the presence of dyssynergia on defecography.

CONCLUSION

Normal electromyographic results or the ability to expel a 60-mL balloon does not exclude the presence of pelvic floor dyssynergia on defecography. It is unclear which of these 3 tests should be used to guide the recommendation for (and to then measure response to) biofeedback.

Systematic review of randomized controlled trials of the effectiveness of biofeedback for pelvic floor dysfunction

BACKGROUND

Pelvic floor dysfunction (PFD) is a type of functional constipation. The effectiveness of biofeedback as a treatment remains unclear.

METHODS

A systematic review of all randomized controlled trials evaluating the effectiveness of biofeedback in adults with PFD was carried out. All online databases from 1950 to 2007 were searched. This was supplemented by hand searching references of retrieved articles.

RESULTS

Seven trials fulfilled the inclusion criteria. Three compared biofeedback with non-biofeedback treatments and four compared different biofeedback modalities. Electromyography feedback was most widely utilized. The trials were heterogeneous with varied inclusion criteria, treatment protocols and definitions of success. Most had methodological limitations. Quality of life and psychological morbidity were assessed rarely. Meta-analysis of the studies involving any form of biofeedback compared with any other treatment suggested that biofeedback conferred a sixfold increase in the odds of treatment success (odds ratio 5.861 (95 per cent confidence interval 2.175 to 15.794); random-effects model).

CONCLUSION

Although biofeedback is the recommended treatment for PFD, high-quality evidence of effectiveness is lacking. Meta-analysis of the available evidence suggests that biofeedback is the best option, but well designed trials that take into account quality of life and psychological morbidity are needed.

Evaluation of the paradoxical sphincter contraction by a strain/squeeze index in constipated patients

PURPOSE

One finding in patients with constipation is the paradoxical puborectalis contraction, i.e. , activation of the sphincter muscles during straining instead of relaxation. The aims of this study were to evaluate the importance of needle placement in sphincter-electromyography and to evaluate a strain/squeeze index in constipated patients and control subjects.

METHODS

We investigated consecutively 194 constipated patients and 16 control subjects with integrated electromyography during straining and squeezing and calculated a strain/squeeze index. The examination was performed in the puborectalis and in the external anal sphincter muscle through hook-electrodes.

RESULTS

There was a strong correlation between indices in the puborectalis muscle and in the external anal sphincter muscle (r = 0.70-0.80, P < 0.001). Forty-seven patients (24 percent) had a mean index of greater than 50 compared with none in the control group (P = 0.01). Mean overall index in patients was 24 (range, 0-306) vs. 18 (range, 0-45) in controls (P = 0.12). Patients with an index greater than 50 had impaired rectal evacuation (P < 0.001), increased threshold for urge (P < 0.05), and tended to have fewer stools (P = 0.06).

CONCLUSION

Quantification of paradoxical contraction in the puborectalis and external anal sphincter with a strain/squeeze index differentiates patients in whom paradoxical activity may be a cause of constipation. An index above 50 may be of pathologic significance. Correlations between activity in the puborectalis and external anal sphincter muscle were strong which suggests that investigation in one of them is sufficient.

Responses of anal constipation to biofeedback treatment

OBJECTIVE

Biofeedback is considered an effective treatment for anal constipation, but a substantial proportion of patients fail to improve. Our aim was to identify the key predictors of outcome using a comprehensive standardized evaluation of anorectal function.

MATERIAL AND METHODS

We retrospectively analysed the clinical and physiological data of 148 patients consecutively treated for constipation due to functional outlet obstruction by biofeedback. Clinical evaluation was performed by means of a structured questionnaire. Anorectal evaluation included anal pressure, neural reflexes, defecatory dynamics, rectal compliance, rectal sensitivity and balloon expulsion test. Biofeedback treatment was performed using a manometric technique. The clinical response to biofeedback treatment was evaluated as good (improvement of constipation) or poor (no improvement or worsening).

RESULTS

Of the 148 patients included, 112 (86 F, 26 M; age range 8-67 years) were followed-up for between 1 and 44 months, and 66% had a good response to treatment. The response depended on the severity of the defecatory dysfunction. Thus, lack of anal relaxation during straining and inability to evacuate a 1 ml intrarectal balloon were inversely related to physiological variables related to therapeutic success. Among the 49 patients with absent anal relaxation, 51% had a good response to treatment (versus 78% in patients with partial relaxation; p < 0.01), and among the 29 patients with failed balloon expulsion, 48% responded to treatment (versus 74% in patients able to evacuate > or = 1 ml intrarectal balloon; p < 0.05).

CONCLUSIONS

Even in the presence of negative predictors, biofeedback is a valuable treatment option in a substantial proportion of constipated patients.

Sacral magnetic stimulation in puborectalis paradoxical syndrome

BACKGROUND AND PURPOSE

Our earlier studies have demonstrated that sacral magnetic stimulation (MS) in the canine model, in healthy volunteers and in constipated subjects effected rectal pressure rise, decline of the rectal neck (anal canal) pressure as well as rectal evacuation. Based on these results, we studied the effect of sacral MS on defecation in patients with puborectalis paradoxical syndrome (PPS).

METHODS

Eleven subjects (8 women, 3 men; age 36-53 years) with PPS were enrolled in the study. The magnetic coil was placed on the back with its center located between L4 and L5. Stimulation parameters were set at 70% of maximum intensity, 40 Hz frequency and 2-second burst length with 2 seconds off. During MS, the rectal neck and gastric (intra-abdominal) pressures were measured. The procedure was performed in the empty and in the full rectum using the balloon expulsion test in the latter.

RESULTS

MS of the empty and balloon-filled rectum effected rise of the rectal pressure (p < 0.001), decline of the rectal neck pressure (p > 0.001) and no significant change of the intragastric pressure (p > 0.05). The balloon was expelled to the exterior in all the patients.

CONCLUSIONS

Sacral MS succeeded in dispelling to the exterior the water-filled rectal balloon. The method is simple, easy, non-invasive, non-radiologic and can be performed on an outpatient basis for the treatment of PPS.

Electromyography of the pelvic floor musculature in the assessment of obstructed defecation symptoms

PURPOSE

The purpose of this study was to use electromyography to examine the behavior of the external sphincter, puborectalis muscle, and pubococcygeus muscle during attempted defecation in patients with symptoms of obstructed defecation and in normal subjects to highlight differences of clinical significance.

METHODS

A total of 35 patients (31 females) aged 20 to 80 (mean, 53.7 +/- 13.3) years with unprepared bowel who had normal colon transit time and obstructed defecation symptoms and 12 voluntary control subjects (7 females) aged 23 to 68 (mean, 48 +/- 11.5) years underwent an electromyography evaluation of the activity of the external sphincter, puborectalis muscle, and pubococcygeus muscle during attempted defecation. The patients were also examined in separate sessions with defecography and anal manometry.

RESULTS

During attempted defecation, puborectalis muscle and external sphincter always reacted in the same manner. When evaluated with pubococcygeus muscle, three main patterns of activity were observed either in patients or in controls: 1) coordinated activation pattern; 2) coordinated inhibition pattern; and 3) uncoordinated or equivocal pattern: activation of pubococcygeus muscle with inhibition of puborectalis muscle/external sphincter, activation followed by inhibition of the three muscles, and activation followed by inhibition of pubococcygeus muscle and no change in the others. We never observed activation of puborectalis muscle/external sphincter concomitant with inhibition of pubococcygeus muscle. The inhibitory coordinated pattern occurred significantly (P = 0.01) more frequently in controls than in patients. These subjects also presented a significantly (P = 0.01) lower frequency of pubococcygeus muscle inhibition.

CONCLUSIONS

Either activation or inhibition appears as a physiological behavior, possibly adopted in different circumstances, of the pelvic floor muscles during attempted defecation. The higher prevalence of coordinated inhibitory patterns in normal subjects and the lower frequency of pubococcygeus muscle inhibition in patients with symptoms of obstructed defecation, however, suggests that a loss of inhibition capacity progressing from pubococcygeus muscle to puborectalis muscle/external sphincter muscles could determine the insurgence of obstructed defecation symptoms in some subjects, who should therefore benefit from biofeedback retraining aimed at reacquisition of the inhibition capacity of all muscles of the pelvic floor during defecation.

Clinical applications and techniques of cinedefecography

BACKGROUND

Cinedefecography is of value in routine examination of functional disorders of the pelvic floor. Interest in this technique has rapidly expanded owing to the increased availability of colorectal physiologic testing and better understanding of the multifactorial pathophysiology involving evacuation disorders.

METHODS

A summary of the available techniques, methodology, and indications for cinedefecography was undertaken. In addition, information was provided on interpretation of these images particularly in the context of anatomic abnormalities and clinical applications.

RESULTS

Cinedefecography can be rapidly and easily performed using standard radiographic equipment. Effective radiation dose is significantly lower than for other intestinal contrast studies. The technique has been found most useful for measurements of perineal descent, puborectalis length, and ascertaining the function of the puborectalis muscle and pelvic floor. Common diagnoses that can be made by this test include nonrelaxing puborectalis syndrome, perineal descent, rectocele, enterocele, sigmoidocele, and rectoanal intussusception.

CONCLUSION

Cinedefecography provides a wide range of information to assist the surgeon with the evaluation and management of patients with evacuatory and other associated pelvic floor disorders.

Prospective, randomized trial comparing four biofeedback techniques for patients with constipation

PURPOSE

The aim of this study was to compare four methods of biofeedback for patients with constipation.

METHODS

Thirty-six patients were prospectively, randomly assigned to one of four protocols: 1) outpatient intra-anal electromyographic biofeedback training; 2) electromyographic biofeedback training plus intrarectal balloon training; 3) electromyographic biofeedback training plus home training; or 4) electromyographic biofeedback training, balloon training, and home training. All 36 patients received weekly one-hour outpatient biofeedback training. Success was measured by increased unassisted bowel movements and reduction in cathartic use. In all instances patients maintained a daily log in which documentation was maintained regarding each bowel evacuation and the need for any cathartics. RESULTS; There was a statistically significant increase in unassisted bowel movements for Groups 1, 2, and 4 (P < 0.05) and a reduction in the use of cathartics in Groups 1, 2, and 3 (P < 0.05).

CONCLUSION

There was a significant improvement in outcome after all four treatment protocols for constipation; however, no significant difference was found among the treatments. Therefore, electromyographic biofeedback training alone is as effective as with the addition of balloon training, home training, or both.

Biofeedback for anismus: has placebo effect been overlooked?

OBJECTIVE

Multiple uncontrolled studies have concluded that biofeedback is successful in treating anismus. This study's objective was to assess the physiological effects of placebo and biofeedback treatment on patients with anismus and to correlate changes with clinical improvement.

PATIENTS AND METHODS

Twelve patients with symptoms and electrophysiological findings of anismus were studied. Initial assessment included a detailed history, symptom assessment by linear analogue scales, anorectal manometric and electrophysiological studies, colon transit scintigraphy, and scintigraphic proctography. Patients underwent 5 days of placebo treatment, followed 1 week later by re-assessment of symptoms and physiological studies. Five days of biofeedback was then given followed by another complete re-assessment 1 week later. A final interview was performed 2 months later. All assessments were by an independent observer who was not responsible for the treatments.

RESULTS

Seven patients reported an overall improvement in symptoms following placebo treatment. A total of seven patients reported improvement following biofeedback, three of whom had already reported an improvement with placebo. One patient who reported improvement following placebo had worsening of symptoms following biofeedback. The only symptoms or tests which changed more with biofeedback than placebo were anal pressure and electromyographic activity on attempted defaecation in the left lateral position. There was no demonstrable correlation between change in symptoms and change in physiological tests. The scintigraphic 'ejection fraction' of the rectum was unchanged by treatment.

CONCLUSION

Clinical improvement in previous studies may in part be due to placebo effect and observer bias. Improvement with biofeedback may be due to physiological changes which are not detected with conventional anorectal physiological tests.

Clinical significance and application of anorectal physiology

During the last decade, interest in anorectal disorders has increased continuously. This review presents the results of Hungarian authors' contributions to a better understanding of anorectal physiology over the last 10 years. It has been demonstrated that the surgical technique of pelvic floor reconstruction can be refined and surgical complication rates reduced through the analysis of anal basal pressure components and exploration of internal anal sphincter function. Objective assessment of anal continence (distinguishing continent from incontinent patients) is a consistent problem in clinical practice. The balloon-retaining test, a special application of manometry, facilitates evaluation of anorectal function in incontinent patients. Constipation is an extremely common symptom. Surgical treatment of these ailments should not be regarded as a first-choice therapy. Disordered defecation due to anismus can be identified by defecometry, and can eventually be treated by biofeedback training. The data presented here demonstrate the enormous impact of sophisticated diagnostic techniques on the therapeutic options in treatment of anorectal diseases.

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.

Results of biofeedback in constipated patients: a prospective study

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.

Biofeedback retraining in patients with functional constipation and paradoxical puborectalis contraction: comparison of anal manometry and sphincter electromyography for feedback

PURPOSE

This study was undertaken to assess the effect of biofeedback therapy in patients with constipation and paradoxical puborectalis contraction and to compare two different feedback modes.

METHODS

Twenty-six patients were randomly allocated to either of two feedback modes: anal pressure using a manometry probe or anal sphincter electromyography (EMG) using surface electrodes.

RESULTS

Six patients were unable to complete their training; ten patients were retrained using anal manometry and ten patients using EMG. The paradoxical puborectalis contraction disappeared after retraining with manometry feedback in eight of ten patients and with EMG feedback in ten of ten patients. A significant improvement in both bowel function and abdominal symptoms was found after training and a continued improvement at follow-up six months later. Six patients in the manometry group and nine in the EMG group experienced an overall improvement in symptoms. The two feedback methods did not differ in terms of efficacy.

CONCLUSIONS

Our results suggest that biofeedback, using either manometry or EMG, is effective in improving symptoms and anorectal function caused by paradoxical puborectalis contraction.

Biofeedback training in children with functional constipation. A critical review

Many uncontrolled studies suggest that biofeedback training is an effective adjunctive therapy in improving the outcome of functional constipation and/or encopresis in children. This could not be confirmed in controlled studies. Adding biofeedback training after conventional treatment had failed did not provide benefits. The results of biofeedback treatment in children with functional constipation and/or encopresis are disappointing.

Obstructed defecation: current status of pathophysiology and management

Obstructed defecation poses a challenging clinical problem and in many patients presenting with this syndrome the underlying pathophysiology cannot be determined. Up to now, attempts to diagnose and treat obstructed defecation (anismus) have focused on the function of the somatic pelvic floor musculature surrounding the anorectum, and concepts such as 'puborectalis paradox' and 'spastic pelvic floor' have gained widespread acceptance despite there being no objective data to support such concepts. New evidence showing that defecation is an integrated process of colonic and rectal emptying suggests that anismus may be much more complex than a simple disorder of the pelvic floor muscles. In a small number of patients obstructed defecation is caused by a more simple mechanism, such as internal sphincter hypertonia or a large rectocele, which is easily corrected surgically. Careful selection of patients for treatment, based on identifying the underlying pathophysiological disorder, is emphasized.

Continent colonic conduit for rectal evacuation in severe constipation

We describe a new operation for the treatment of rectal evacuatory disorders: a continent colonic conduit, incorporating an intussuscepted valve, was constructed from the sigmoid colon. Intubation of the conduit allowed irrigation and evacuation of the distal colon and rectum. Initially all 10 patients reported a reduction in time taken and the discomfort involved in completing evacuation. The number of stools passed per week increased in 9 out of 10 patients, from a median of 1.5 (range 0.25-7) to a median of 7 (range 3-7) postoperatively. Subsequently, 3 patients developed complications, 2 of whom required conversion to an ileostomy. Overall, the colonic conduit procedure was successful in treating the rectal evacuatory disorder in 7 patients, failed in 2, and 1 patient has a temporary defunctioning ileostomy. The procedure is a relatively simple surgical alternative for the treatment of a condition which is often resistant to conservative measures.

Biofeedback training in disordered defecation. A critical review

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.

Idiopathic slow-transit constipation

Until recently, the surgical management of idiopathic slow-transit constipation had remained unchanged since the condition was first described by Arbuthnot Lane in 1908. Although colectomy and ileorectal anastomosis is a successful treatment for the majority of patients, symptoms persist or are worse in some cases following such surgery. The previously inaccessible colon is now an area of interest in both health and disease; recent observations on aetiology, clinical investigation, neuropathology and surgical outcome lead us to question the rationale of colectomy for all patients with severe constipation.

Obstructed defecation

Obstructed defecation is one of the causes of chronic constipation. Clinical tests suggest that patients with obstructed defecation have impaired pelvic floor function. Appropriate management relies on proper identification of the underlying pathophysiology.

Cinedefecography and electromyography in the diagnosis of nonrelaxing puborectalis syndrome

A prospective study was undertaken to assess the correlation between electromyography (EMG) and cinedefecography (CD) for the diagnosis of nonrelaxing puborectalis syndrome (NRPR). Clinical criteria for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. EMG criteria included failure to achieve a significant decrease in electrical activity of the puborectalis (PR) during attempted evacuation. CD criteria included either paradoxical contraction or failure of relaxation of the PR along with incomplete evacuation. In addition, other etiologies for incomplete evacuation, such as rectoanal intussusception or nonemptying rectocele, were excluded by proctoscopy and defecography in all cases. One hundred twelve patients with constipation, 81 females and 31 males, with a mean age of 59 (range, 12-83) years were studied by routine office evaluation, CD, and EMG. Forty-two patients (37 percent) had evidence of NRPR on CD (rectal emptying: none, 24; incomplete, 18). Twenty-eight of these patients (67 percent) also had evidence of NRPR on EMG. EMG findings of NRPR were present in 12 of 70 patients (17 percent) with normal rectal emptying. Conversely, 14 of 72 patients (19 percent) with normal PR relaxation on EMG had an NRPR pattern on CD. The sensitivity and specificity for the EMG diagnosis of NRPR were 67 percent and 83 percent, and the positive and negative predictive values were 70 percent and 80 percent, respectively. Conversely, if EMG is considered as the ideal test for the diagnosis of NRPR, CD had a sensitivity of 70 percent, a specificity of 80 percent, and positive and negative predictive values of 66 percent and 82 percent, respectively. In summary, sensitivity, specificity, and predictive values of EMG and CD are suboptimal. Therefore, a combination of these two tests is suggested for the diagnosis of NRPR.

The internal anal sphincter: mechanisms of control and its role in maintaining anal continence

The human IAS has particular structural and functional characteristics. This smooth muscle constantly generates rhythmic electrical slow waves, but no action potentials. The slow waves are linked to calcium fluxes and both are essential for mechanical activity, i.e. the ASPW. The IAS is pharmacologically characterized by the presence of alpha excitatory and beta inhibitory adrenergic receptors. Cholinergic drugs have an indirect effect through the release of an inhibitory neurotransmitter, very probably VIP, from NANC nerves. The myogenic activity of the IAS is enhanced by its extrinsic sympathetic innervation. Thus, at rest, the IAS is in a state of partial tetanus and contributes approximately 55% of the MABP. Because the IAS ring cannot be completely closed, the anal mucosa and the haemorrhoidal plexuses fill the gap. By compressing these tissues, the IAS perfectly closes the anal canal to retain not only solids but also fluid stool and gas. Acute rectal distension and rectal activity, mainly through intramural pathways, induce reflex IAS relaxation, permitting the rectal contents to be sampled by receptors in the upper anal canal while continence is temporarily maintained by EAS activity and by expansion of the haemorrhoidal cushions. There is a correlation between the volume of rectal distension and the parameters of IAS relaxation. At maximal IAS relaxation, ASPW are absent, indicating the completeness of the inhibition. Although this RAIR is not essential for defecation, insufficient relaxation may be implicated in constipation. Hyperactivity of the IAS resulting in a high MABP and AUSPW has been considered both as a cause and as an effect in haemorrhoids and anal fissure. Continence for fluids and gas is impaired if IAS activity is decreased (i.e. a low MABP), either by direct trauma or by damage of its sympathetic innervation. Severe faecal incontinence will develop when the contractility of both the IAS and the EAS is affected.