Biofeedback training is useful in fecal incontinence but disappointing in constipation

Cellular signaling pathways as plastic, proto-cognitive systems: Implications for biomedicine

Many aspects of health and disease are modeled using the abstraction of a "pathway"-a set of protein or other subcellular activities with specified functional linkages between them. This metaphor is a paradigmatic case of a deterministic, mechanistic framework that focuses biomedical intervention strategies on altering the members of this network or the up-/down-regulation links between them-rewiring the molecular hardware. However, protein pathways and transcriptional networks exhibit interesting and unexpected capabilities such as trainability (memory) and information processing in a context-sensitive manner. Specifically, they may be amenable to manipulation via their history of stimuli (equivalent to experiences in behavioral science). If true, this would enable a new class of biomedical interventions that target aspects of the dynamic physiological "software" implemented by pathways and gene-regulatory networks. Here, we briefly review clinical and laboratory data that show how high-level cognitive inputs and mechanistic pathway modulation interact to determine outcomes in vivo. Further, we propose an expanded view of pathways from the perspective of basal cognition and argue that a broader understanding of pathways and how they process contextual information across scales will catalyze progress in many areas of physiology and neurobiology. We argue that this fuller understanding of the functionality and tractability of pathways must go beyond a focus on the mechanistic details of protein and drug structure to encompass their physiological history as well as their embedding within higher levels of organization in the organism, with numerous implications for data science addressing health and disease. Exploiting tools and concepts from behavioral and cognitive sciences to explore a proto-cognitive metaphor for the pathways underlying health and disease is more than a philosophical stance on biochemical processes; at stake is a new roadmap for overcoming the limitations of today's pharmacological strategies and for inferring future therapeutic interventions for a wide range of disease states.

Factors Associated With Response to Anorectal Biofeedback Therapy in Patients With Fecal Incontinence

BACKGROUND & AIMS

Anorectal biofeedback (BF) is commonly used to treat patients with fecal incontinence (FI), but demand usually exceeds availability. It is therefore important to identify patients most likely to respond to BF treatment. We aimed to identify pre-treatment clinical or physiologic factors that might be used to predict completion and success of BF in women with FI.

METHODS

We analyzed data from 400 women with FI (mean age, 61 ± 14 y) undergoing instrumental BF in a tertiary care setting from 2003 through 2016. All patients completed questionnaires before BF, including Rome and the hospital anxiety and depression scale questionnaires. Histories of medication use, surgery, medical conditions, and bowel pattern were recorded, urge was assessed, and patients kept stool diaries. Before and after treatment (6 weekly sessions with a gastroenterologist-supervised nurse specialist, 4 involving instrumented anorectal biofeedback), patients were examined by a physician and fecal incontinence severity index and visual analogue scale scores were recorded. The main outcome measure was response to therapy, defined as improvement of 50% or more in weekly FI episodes at the end of BF compared with before BF.

RESULTS

The BF treatment was completed by 363 women (91%); of these, 62 had low baseline symptom frequency (no FI episodes in the 2 weeks before BF). Younger age was associated with failure to complete treatment. Of the 301 patients remaining, 202 patients (67%) had a response to therapy; among these women, urge FI was associated with response at end of BF, but not at follow up (6 months after therapy). Baseline severity of symptom scores and quality of life measures were associated with greater improvement in the same variable at the end of BF and after 6 months. Patients with low baseline symptom frequency improved in all secondary outcome measures, similar to patients with higher baseline symptom frequency.

CONCLUSIONS

In an analysis of 363 women with FI, approximately two-thirds had a response to BF treatment. Urge FI was the only baseline variable associated with response. Baseline severity of symptoms and quality of life measures were associated with greater improvement in the same variable, but not overall response. It is therefore a challenge to select treatment for patients with FI.

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.

Current management of fecal incontinence: Choosing amongst treatment options to optimize outcomes

The severity of fecal incontinence widely varies and can have dramatic devastating impacts on a person’s life. Fecal incontinence is common, though it is often under-reported by patients. In addition to standard treatment options, new treatments have been developed during the past decade to attempt to effectively treat fecal incontinence with minimal morbidity. Non-operative treatments include dietary modifications, medications, and biofeedback therapy. Currently used surgical treatments include repair (sphincteroplasty), stimulation (sacral nerve stimulation or posterior tibial nerve stimulation), replacement (artificial bowel sphincter or muscle transposition) and diversion (stoma formation). Newer augmentation treatments such as radiofrequency energy delivery and injectable materials, are minimally invasive tools that may be good options before proceeding to surgery in some patients with mild fecal incontinence. In general, more invasive surgical treatments are now reserved for moderate to severe fecal incontinence. Functional and quality of life related outcomes, as well as potential complications of the treatment must be considered and the treatment of fecal incontinence must be individualized to the patient. General indications, techniques, and outcomes profiles for the various treatments of fecal incontinence are discussed in detail. Choosing the most effective treatment for the individual patient is essential to achieve optimal outcomes in the treatment of fecal incontinence.

The role of anorectal investigations in predicting the outcome of biofeedback in the treatment of faecal incontinence

OBJECTIVE

The current literature does not provide unequivocal evidence on prognostic factors of patients' response to biofeedback for management of faecal incontinence. The aim of this study was to identify independent predictors of patient response to biofeedback.

MATERIAL AND METHODS

Baseline demographic characteristics, symptomatology and anorectal investigation reports of 137 patients who completed biofeedback therapy were analysed retrospectively. Short-term response (<3 months) to biofeedback was assessed using subjective criteria (improvement/ no improvement). P Values < 0.05 were considered to be statistically significant.

RESULTS

At univariate analysis, age, duration of symptoms, severity of faecal incontinence, mean maximum squeeze and resting pressure differed significantly (p < 0.05) were associated with patients' response. However, after performing logistic regression analysis age, duration and severity of symptoms were the only variables associated with the outcome (p Values were 0.041, 0.022 and 0.025, respectively).

CONCLUSION

Three independent factors (younger age, shorter duration and lower severity of faecal incontinence) were associated with patient outcome after completing our unit's biofeedback protocol. Anorectal investigations are of questionable value in patient selection for biofeedback therapy.

Long-term results of biofeedback treatment for faecal incontinence: a comparative study with untreated controls

AIM

Long-term results of biofeedback for faecal incontinence are controversial. Moreover, its value compared with standard care has been recently questioned. The study aimed to analyse the long-term efficacy of biofeedback therapy for faecal incontinence to formed stool and to compare it with no treatment.

METHOD

Seventy-nine patients with faecal incontinence to solid stool were evaluated at baseline and 1, 6, 36 and 60 months after treatment. To compare the long-term results with no treatment, 40 patients initially evaluated but not referred for therapy were used as controls.

RESULTS

More than 80% of patients recovered continence or had a reduction in the number of episodes of incontinence greater than 75% at 1, 6, 36 and 60 months, indicating that the success rate of biofeedback was maintained over time. At 60 months, 86% of patients treated with biofeedback were fully continent or had a > 75% reduction in the number of incontinent episodes compared to 26% of the untreated patients (P < 0.001).

CONCLUSION

Biofeedback therapy is effective in patients with faecal incontinence to formed stool compared with no treatment. Overall, clinical improvement is maintained in the long term.

Biofeedback therapy plus anal electrostimulation for fecal incontinence: prognostic factors and effects on anorectal physiology

BACKGROUND

The current literature does not provide unequivocal data on prognostic factors in conservative management of fecal incontinence. Moreover, the physiopathologic effects of pelvic floor rehabilitation on anorectal function are not well understood. Our aim is to identify some prognostic parameters and assess their effects on anorectal physiology of biofeedback therapy plus anal electrostimulation for fecal incontinence.

METHODS

We studied prospectively 45 consecutive adult patients with fecal incontinence treated at our institution with biofeedback plus electrostimulation. The outcome parameter was modification of the Wexner Incontinence Score (WIS) at the end of treatment. In addition, we studied the modifications of anorectal manometry and the rectal sensitivity threshold after treatment.

RESULTS

At univariate analysis, age, the pretreatment WIS, and the pretreatment resting and maximum squeeze pressures were correlated with the clinical outcome. Patients showed a significant reduction in the rectal sensitivity threshold but no significant change in manometric parameters after treatment.

CONCLUSIONS

We identify good sphincter function and mild to moderate symptomatology as favorable prognostic factors in biofeedback and anal electrostimulation therapy. Improvement in rectal sensitivity can be implicated in symptomatic improvement. The impossibility of correlating the clinical results with the effects on anorectal physiology suggests a nonspecific effect of conservative treatment.

The role of biofeedback in the treatment of gastrointestinal disorders

Biofeedback is a form of treatment that has no adverse effects and can be provided by physician extenders. The therapy relies on patients' ability to learn how to influence their bodily functions through dedicated machinery and teaching. This Review provides a comprehensive overview of all potential therapeutic applications of biofeedback for functional constipation, fecal incontinence, functional anorectal pain, IBS, functional dyspepsia, and aerophagia. Practical clinical applications of biofeedback therapy supported by randomized, controlled trials (RCTs) are limited to fecal incontinence and dyssynergic defecation. For fecal incontinence, RCTs suggest that biofeedback combining strength training and sensory discrimination training is effective in approximately 75% of patients and is more effective than placebo. However, verbal feedback provided by a therapist during extended digital examination may be equally effective, and children whose fecal incontinence is associated with constipation plus fecal impaction do no better with biofeedback than medical management. For dyssynergic defecation, RCTs show that biofeedback combining pelvic floor muscle relaxation training, practice in defecating a water-filled balloon, and instruction in effective straining is effective in approximately 70% of patients who have failed to respond to laxative treatment. For both incontinence and dyssynergic defecation, the benefits of biofeedback last at least 12 months.

Biofeedback therapy for dyssynergic defecation

Dyssynergic defecation is one of the most common forms of functional constipation both in children and adults; it is defined by incomplete evacuation of fecal material from the rectum due to paradoxical contraction or failure to relax pelvic floor muscles when straining to defecate. This is believed to be a behavioral disorder because there are no associated morphological or neurological abnormalities, and consequently biofeedback training has been recommended for treatment. Biofeedback involves the use of pressure measurements or averaged electromyographic activity within the anal canal to teach patients how to relax pelvic floor muscles when straining to defecate. This is often combined with teaching the patient more appropriate techniques for straining (increasing intra-abdominal pressure) and having the patient practice defecating a water filled balloon. In adults, randomized controlled trials show that this form of biofeedback is more effective than laxatives, general muscle relaxation exercises (described as sham biofeedback), and drugs to relax skeletal muscles. Moreover, its effectiveness is specific to patients who have dyssynergic defecation and not slow transit constipation. However, in children, no clear superiority for biofeedback compared to laxatives has been demonstrated. Based on three randomized controlled studies in the last two years, biofeedback appears to be the preferred treatment for dyssynergic defecation in adults.

Electrical stimulation and pelvic floor muscle training with biofeedback in patients with fecal incontinence: a cohort study of 281 patients

PURPOSE

Pelvic floor rehabilitation is an appealing treatment for patients with fecal incontinence but reported results vary. This study was designed to assess the outcome of pelvic floor rehabilitation in a large series of consecutive patients with fecal incontinence caused by different etiologies.

METHODS

A total of 281 patients (252 females) were included. Data about medical history, anal manometry, rectal capacity measurement, and endoanal sonography were collected. Subgroups of patients were defined by anal sphincter complex integrity, and nature and possible underlying causes of fecal incontinence. Subsequently patients were referred for pelvic floor rehabilitation, comprising nine sessions of electric stimulation and pelvic floor muscle training with biofeedback. Pelvic floor rehabilitation outcome was documented with Vaizey score, anal manometry, and rectal capacity measurement findings.

RESULTS

Vaizey score improved from baseline in 143 of 239 patients (60 percent), remained unchanged in 56 patients (23 percent), and deteriorated in 40 patients (17 percent). Mean Vaizey score reduced with 3.2 points (P < 0.001). A Vaizey score reduction of >or= 50 percent was observed in 32 patients (13 percent). Mean squeeze pressure (+5.1 mmHg; P = 0.04) and maximal tolerated volume (+11 ml; P = 0.01) improved from baseline. Resting pressure (P = 0.22), sensory threshold (P = 0.52), and urge sensation (P = 0.06) remained unchanged. Subgroup analyses did not show substantial differences in effects of pelvic floor rehabilitation between subgroups.

CONCLUSIONS

Pelvic floor rehabilitation leads overall to a modest improvement in severity of fecal incontinence, squeeze pressure, and maximal tolerated volume. Only in a few patients, a substantial improvement of the baseline Vaizey score was observed. Further studies are needed to identify patients who most likely will benefit from pelvic floor rehabilitation.

Prospective comparison of short- and long-term effects of pelvic floor exercise/biofeedback training in patients with fecal incontinence after surgery plus irradiation versus surgery alone for colorectal cancer: clinical, functional and endoscopic/endosonographic findings

OBJECTIVE

The influence of irradiation on the clinical severity of incontinence, sphincter function, morphologic features and short/long-term treatment effects of sphincter training therapy is still insufficiently understood in irradiated patients with fecal incontinence after surgery for colorectal cancer. These parameters were compared in irradiated and non-irradiated patients and followed prospectively with regard to short- and long-term training effects.

MATERIAL AND METHODS

Forty-one patients having been irradiated after surgery (50.0+/-5.0 Gy) and 54 non-irradiated patients with fecal incontinence participated in this prospective, non-randomized trial. Baseline evaluation included a semiquantitative severity assessment score of fecal incontinence (modified Cleveland Incontinence Score (MCIS)), rectal manometry and endoscopy. After 3 weeks (short term) of intensive in-hospital pelvic floor exercise combined with biofeedback training, a second evaluation was made. In addition, anal endosonography (EUS) was performed in cases of treatment failure. After one year (long term) a third evaluation was made clinically (MCIS score).

RESULTS

Irradiated patients presented with a significantly higher degree of fecal incontinence (lower MCIS) compared to non-irradiated patients: 7.4+/-2.2 versus 8.7+/-2.7 points (p<0.001). Rectosigmoidal inflammation was more frequent in irradiated than non-irradiated patients (26.9% versus 9.3%) (p<0.03). Sphincter pressure, sensation/pain threshold and the rectoanal inhibitory reflex were similar in both groups. A significant short-term training effect was observed in both groups following sphincter training therapy in terms of an increase in MCIS from 7.4+/-2.2 to 9.4+/-2.7 points in the irradiated group and from 8.7+/-2.7 to 11.4+/-2.5 points in the non-irradiated group (p<0.0001). After one year the scores were 8.2+/-3.8 and 10.7+/-4.4 points, respectively (p<0.0001). There was a significant correlation (p<0.001) between baseline MCIS and the short- and long-term MCIS. In patients with short-term treatment failure (16.6%) anal EUS revealed structural defects of the external sphincter in four patients. There was no association of sphincter diameter with sphincter pressure, sensation/pain threshold and short/long-term MCIS.

CONCLUSIONS

The main result of this study is that irradiated patients show short- and long-term training effects comparable with those of non-irradiated patients despite the higher degree of incontinence at baseline. The correlation between the initial MCIS and short- and long-term treatment effects may be regarded as an important clinical predictor for treatment outcome. Functional and morphologic features are less suitable for this purpose.

Bio-feedback treatment of fecal incontinence: Where are we, and where are we going?

Fecal incontinence is a disabling disease, often observed in young subjects, that may have devastating psycho-social consequences. In the last years, numerous evidences have been reported on the efficacy of bio-feedback techniques for the treatment of this disorder. Overall, the literature data claim a success rate in more than 70% of cases in the short term. However, recent controlled trials have not confirmed this optimistic view, thus emphasizing the role of standard care. Nonetheless, many authors believe that this should be the first therapeutic approach for fecal incontinence due to the efficacy, lack of side-effects, and scarce invasiveness. Well-designed randomized, controlled trial are eagerly awaited to solve this therapeutic dilemma.

Geriatric fecal incontinence

Fecal incontinence is a common problem in the elderly population,particularly in nursing homes, and is one of the common reasons for nursing home placement. In addition to the inconvenience of the incontinence for the patient and caregiver, it is associated with increased mortality. Identifiable physiologic changes in the anorectal region may contribute to the development of fecal incontinence.Fecal incontinence is a disorder of men and women, with an equal or greater prevalence in men in advancing years. All patients who have fecal incontinence warrant an initial medical evaluation,including the exclusion of fecal impaction. Cognitively impaired patients benefit most from habit training. Selected elderly patients who have fecal incontinence may benefit from biofeedback and surgical intervention.

Customized biofeedback therapy improves results in fecal incontinence

BACKGROUND AND AIMS

Biofeedback therapy has been extensively used and accepted in fecal incontinence, but reports of its efficiency vary. We evaluated feedback therapy efficiency when (a) selecting the patient's subject of the therapy, and (b) customizing the therapy protocol used for each patient.

PATIENTS AND METHODS

Fifty-three patients with fecal incontinence were selected for biofeedback training. The treatment program was customized for each patient depending on the underlying dysfunction, the patient's cooperative and learning attitude, and the patient's progress. Biofeedback efficiency was measured using clinical scores, subjective satisfaction of the patient, and manometry.

RESULTS

Incontinent scores showed improvement in 66% of patients and good improvement in 11% and 15%, respectively, indicating an overall excellent effect of the therapy. Subjective satisfaction was strongly correlated with the previous incontinent scores. Comparison of manometry parameters before and after biofeedback therapy, including maximum anal resting, maximum anal squeeze pressure, and maximum duration of the squeeze, all showed significant differences. In addition, the sensory threshold significantly decreased after biofeedback therapy. Clinical improvements were maintained during the following 12 months.

CONCLUSION

Biofeedback improves objective and subjective parameters of anorectal function. Selection of patients and customization of the therapy program increased biofeedback efficiency for the treatment of fecal incontinence.

Review article: Recent trends in diagnosis and treatment of faecal incontinence

The inability to control bowel discharge is not only common but extremely distressing. It has a negative impact on a patient's lifestyle, leads to a loss of self-esteem, social isolation and a diminished quality of life. Faecal incontinence is often due to multiple pathogenic mechanisms and rarely due to a single factor. Normal continence to stool is maintained by the structural and functional integrity of the anorectal unit. Consequently, disruption of the normal anatomy or physiology of the anorectal unit leads to faecal incontinence. Currently, several diagnostic tests are available that can provide an insight regarding the pathophysiology of faecal incontinence and thereby guide management. The treatment of faecal incontinence includes medical, surgical or behavioural approaches. Today, by using logical approach to management, it is possible to improve symptoms and bowel function in many of these patients.

Outcome measures for fecal incontinence: anorectal structure and function

Fecal incontinence is a symptom attributable to a variety of disorders affecting one or more factors that maintain continence. Objective assessments should complement symptom assessments as outcome measures in therapeutic trials; conceivably, these assessments may also predict the response to therapy. Consistent with existing trends, most therapeutic trials should incorporate anal sphincter pressures and rectal sensation as outcome variables, paying meticulous attention to techniques. Rectal sensation is increased after pelvic floor retraining by biofeedback therapy in fecal incontinence; however, the predictive value of improved anal pressures after biofeedback has not been clearly established. Other factors maintaining continence can be assessed by newer approaches. In addition to assessing rectal sensation, a barostat also measures rectal compliance; alterations in rectal compliance modulate rectal perception. Particularly appropriate end points for trials involving surgical repair are sphincter integrity, assessed by endoanal ultrasound or magnetic resonance imaging (MRI), and puborectalis and pelvic floor motion, assessed by dynamic MRI. Despite disagreement about which technique is superior for evaluating the internal sphincter, MRI performs the same or better than ultrasound for assessing the external sphincter. The utility of measuring pudendal nerve latencies as a marker of pudendal nerve injury is limited; needle electromyography provides a sensitive measure of denervation and can usually identify myopathic damage, neurogenic damage, or mixed injury. These standardized, reproducible assessments of the multifaceted mechanisms maintaining fecal incontinence should be incorporated as outcome variables in therapeutic trials of fecal incontinence.

Significance of pelvic floor muscles in anal incontinence

BACKGROUND & AIMS

The pathophysiology of anal incontinence may be elusive using current parameters. Our aim was to establish the role of the levator ani in anal continence.

METHODS

In 53 patients with anal incontinence, 30 with constipation as disease controls, and 15 healthy controls, we evaluated incontinence severity by a 0-12 scale, anorectal function by standard manometric tests, and levator ani contraction by a perineal dynamometer.

RESULTS

Patients with incontinence exhibited various physiologic abnormalities (3.2 +/- 0.3 per patient), but multiple regression analysis showed that levator ani contraction was the independent variable with strongest relation to the severity of incontinence (R = -0.84; P < 0.0001), as well as a predictive factor of the response to treatment (R = 0.53; P < 0.01). Furthermore, in contrast to other physiologic parameters, clinical improvement in response to treatment (4.4 +/- 0.5 score vs. 7.9 +/- 0.5 score pre; P < 0.001) was associated with a marked and significant strengthening of levator ani contraction (448 +/- 47 g vs. 351 +/- 35 g pre; P < 0.05).

CONCLUSIONS

We have shown the importance of levator ani failure in understanding the etiology of anal incontinence and in predicting response to treatment.

Patient's perceptions of biofeedback therapy for obstructive defaecation

OBJECTIVE: The aim of this study is to assess the long-term outcomes of a biofeedback treatment programme for obstructive defaecation up to five years after completion of treatment, reporting from the patients' perspective the subsequent progression of defaecation difficulties and the perceived usefulness of the biofeedback training and its components. METHODS: A biofeedback program for obstructive defaecation at a major hospital in Sydney provided 37 patients with reading material, taught defaecation techniques, and prescribed simulated defaecation and anal relaxation exercises to practice between their monthly biofeedback sessions. Twenty-nine of these patients were contacted by telephone an average of 23 months after last attending and asked to rate the present severity of their condition, changes since last attending biofeedback, and which aspects of the program they found most helpful. RESULTS: Of patients who completed the program, 70% achieved at least a 15% improvement in perceived symptom severity. Those who completed the program and achieved benefit were more likely to name the exercises as the most helpful program component. At the time of follow-up, however, there was no difference in perceived symptom severity between program completers and noncompleters. Program completers, and those followed up more than two years after last attending biofeedback, were more likely to report a worsening in symptom severity subsequent to their final treatment session. CONCLUSIONS: This study confirms the favourable short-term outcomes achieved by some patients completing biofeedback treatment for obstructive defaecation. The findings suggest that biofeedback equipment may be economically used in an educative and corrective role, and that other factors such as education, exercises and counselling alone play an important role. Finally, the benefits of biofeedback may not be maintained through long-term follow-up, raising questions as to the natural history of the disorder and the long-term effectiveness of biofeedback treatment.

General geriatrics and gastroenterology: constipation and faecal incontinence

The incidence of constipation increases with age but no consistent changes of colonic or anorectal motility have been shown in elderly people. Instead, neurological diseases, constipating drugs, bedriddenness and weak straining ability may explain this increased prevalence of constipation. The amount of dietary fibre in the diet may be reduced because of poor chewing ability. Parkinson's disease is accompanied by both slow colonic transit and impaired relaxation of the anal sphincter. Drug-induced constipation is particularly likely with anti-parkinsonism drugs (either anti-cholinergic or dopaminergic) and also with tricyclic anti-depressants, opiates, iron, anti-convulsants and aluminium- or calcium-containing antacids. The prevalence of faecal incontinence is also increased in elderly people. About half of frail bedridden institutionalized patients are incontinent. Anal sphincter pressures tend to be lower, but variables of sensitivity are not. In bedridden people faecal impaction may occur. The ensuing rectal distension leads to relaxation of the internal sphincter and hence to faecal soiling. The condition is often overlooked though correct diagnosis is rather simple, being made with a digital rectal examination.

Anal sphincter biofeedback and pelvic floor exercises for faecal incontinence in adults--a systematic review

BACKGROUND

Faecal incontinence is a common health care problem. Biofeedback is extensively used in clinical practice to treat faecal incontinence.

AIM

To systematically review and evaluate the evidence from clinical studies on the effectiveness of biofeedback as a treatment for faecal incontinence in adults.

METHODS

A systematic literature search was undertaken using electronic databases, with review of the retrieved references.

RESULTS

The search identified 46 studies published in English using biofeedback to treat adults complaining of faecal incontinence. Those studies included a total of 1364 patients. Of those studies with adequate data, 275 out of 566 patients (49%) were said to be cured of symptoms of faecal incontinence following biofeedback therapy and 617 out of 861 (72%) patients were reported to be cured or improved. Studies varied in the method of biofeedback used, criteria for success and the outcome measures used. Only eight of the 46 studies employed any form of control group.

CONCLUSIONS

The data suggest that biofeedback and exercises help a majority of patients with faecal incontinence. However, methodological variation, lack of controls and a lack of validated outcome measures are problems in evaluating these results.

Review article: the therapy of constipation

Constipation is a common symptom that may be idiopathic or due to various identifiable disease processes. Laxatives are agents that add bulk to intestinal contents, that retain water within the bowel lumen by virtue of osmotic effects, or that stimulate intestinal secretion or motility, thereby increasing the frequency and ease of defecation. Drugs which improve constipation by stimulating gastrointestinal motility by direct actions on the enteric nervous system are under development. Other modalities used to treat constipation include biofeedback and surgery. Laxatives and lavage solutions are also used for colon preparation and evacuation of the bowels after toxic ingestions.

Biofeedback treatment of fecal incontinence: a critical review

PURPOSE

The aims of this review are 1) to critically evaluate the literature on the efficacy of biofeedback treatment for fecal incontinence, 2) to compare different types of biofeedback, and 3) to identify patient characteristics which predict a successful outcome.

METHODS

The MEDLINE database was searched for articles published between 1973 and 1999 which included the terms "biofeedback" and "fecal incontinence." Pediatric and adult articles in any language were screened. Inclusion for review required that the study be prospective, have five or more subjects, and have a description of the treatment protocol.

RESULTS

Thirty-five studies were reviewed. Only six studies used a parallel treatment design and just three of those randomized subjects to treatment groups. A meta-analysis (weighted by subjects) was performed to compare the results of two treatment protocols that dominate the literature. The mean success rate of studies using Coordination training (i.e., coordinating pelvic floor muscle contraction with the sensation of rectal filling) was 67 percent, while the mean success rate for studies using Strength training (i.e., pelvic floor muscle contraction) was 70 percent. Furthermore, the mean success rate for those Strength training studies using electromyographic biofeedback was 74 percent, while the mean success rate for studies using anal canal pressure biofeedback Strength training was 64 percent. However, these conclusions are limited by the absence of clearly identified criteria for determining success. There are also inconsistencies in the literature regarding the patient selection criteria, severity and cause of symptoms, amount of treatment, as well as the type of biofeedback protocols and instrumentation used. Finally, no patient characteristics were identified that would assist in predicting successful outcome.

CONCLUSION

Although most studies report positive results using biofeedback to treat fecal incontinence, quality research is lacking. Recommendations are made for future investigations to 1) improve experimental design, 2) include long term follow-up data, and 3) to use an adequate sample size that allows for meaningful analysis.

Long-term results of electromyographic biofeedback training for fecal incontinence

PURPOSE

The aim of this study was to examine the long-term results of electromyographic biofeedback training in fecal incontinence.

METHODS

Thirty-seven patients (1 male) received a customised program of 2 to 11 (median, 3) biofeedback training sessions with an anal plug electromyometer. Nine patients had persistent incontinence after anal sphincter repair, a further 8 patients had postsurgical or partial obstetric damage of the sphincter but no sphincter repair, 9 patients had neurogenic sphincter damage, and 11 patients were classified as having idiopathic fecal incontinence. Duration of voluntary sphincter contraction was measured by anal electromyography (endurance score) before and after treatment. A postal questionnaire was used to investigate the following variables: 1) subjective rating on a four-grade Likert-scale of the overall result of the biofeedback training; 2) incontinence score (maximum score is 18, and 0 indicates no incontinence); and 3) rating of bowel dissatisfaction using a visual analog scale (0 to 10).

RESULTS

Twenty-two patients (60 percent) rated the result as very good (n = 8) or good (n = 14) immediately after the treatment period. Median endurance score improved from 1 to 2 minutes (P < 0.0001). Median incontinence score improved from 11 to 7, and bowel dissatisfaction rating improved from 5 to 2.8 (both P < 0.0001). After a median follow-up of 44 (range, 12-59) months, 15 patients (41 percent) still rated the overall result as very good (n = 3) or good (n = 12). The incontinence score did not change during follow-up. Median bowel dissatisfaction rating deteriorated from 2.8 to 4.2 but remained better than before treatment. Poor early subjective rating and the need for more than three biofeedback sessions were predictive of worsening during follow-up.

CONCLUSION

We think it is encouraging that in this study biofeedback treatment for fecal incontinence with an intra-anal plug electrode resulted in a long-term success rate in nearly one-half of the patients.

Biofeedback for fecal incontinence using transanal ultrasonography: novel approach

PURPOSE

Neosphincter procedures may prove to be the treatment of choice for patients with neuropathic fecal incontinence but are rarely proposed for milder forms of the disease. Biofeedback may prove beneficial to these patients but is yet unproven. The objectives of this study were to develop a method of performing biofeedback using transanal ultrasound to teach the patient to contract repetitively and to determine biologic measures of sphincter function using transanal ultrasound in healthy and incontinent patients.

METHODS

Initial uncontrolled studies were performed to determine the compliance, normal values, biologic measures of external sphincter strength (isotonic and isometric fatigue times), and early efficacy data using continence scores and visual analog scale scores.

RESULTS

Forty-four patients were assessed during three months, with relative improvements in continence scores (St. Mark's Hospital, 40 percent; Pescatori, 20 percent) and patient and investigator visual analog scale scores (38 percent for both) and measurable increase in biologic fatigue times measured by transanal ultrasound.

CONCLUSIONS

Transanal ultrasound seems to be a method of teaching external sphincter contraction and measuring sphincter strength with good initial compliance. Clinically and statistically significant improvements in incontinence scores, visual analog scale scores, and biologic strength of the external sphincter were detected in the short-term follow-up with uncontrolled data. The randomized, controlled trial that we have begun will either confirm or refute these results.

Effect of delivery on anal sphincter morphology and function

PURPOSE

Anal sphincter injury is a serious complication of childbirth, which may result in persistent anal incontinence. Occult injuries, visualized with endoanal ultrasonography, have previously been reported in up to 35 percent of females in a British study. The aim of the present study was to study anal sphincter morphology and function before and after delivery in primiparous females in the United States.

METHODS

Thirty-eight primiparous patients (mean age, 31 years) were evaluated with endoanal ultrasonography, anal manometry, and pudendal nerve terminal motor latency during pregnancy and after delivery. Bowel function before and after delivery was recorded according to set questionnaires. Cesarean section was performed in three patients.

RESULTS

Clinical sphincter tears, requiring primary repair, occurred in 15 percent of the patients. After delivery endoanal ultrasonography revealed disruptions in the external anal sphincter in six patients, but no patient had disruption in the internal anal sphincter. One patient had slight scarring in the external sphincter. Of the seven patients with pathologic findings at endoanal ultrasonography, the left pudendal latency increased after delivery (P < 0.05), and manometric results were reduced. Three of these seven patients had a third-degree or fourth-degree tear during delivery. All investigations were normal in the three patients who underwent cesarean section.

CONCLUSIONS

The present study demonstrates a significant frequency of sphincter injuries (20 percent) after vaginal delivery. Obstetricians should be aware of this risk and explicitly inquire about incontinence symptoms at follow-up after delivery.

Long-term cost of fecal incontinence secondary to obstetric injuries

INTRODUCTION

Anal incontinence is eight times more frequent in females than in males because of injuries sustained at childbirth. The aim of the present study was to determine the long-term costs associated with anal incontinence related to obstetric injuries.

METHODS

Sixty-three patients with anal incontinence caused by obstetric sphincter injuries answered questionnaires regarding previous treatments, symptoms, and use of protective products. Of the patients, 31 were treated surgically, 11 with biofeedback, 6 with a combination of surgery and biofeedback, and 15 conservatively. Treatments and their respective costs were obtained from patient records, patient questionnaires, billing database, and Health Care Financing Administration's 1996 inpatient database. Costs were expressed in 1996 dollars.

RESULTS

The mean incontinence score changed from 26 at evaluation to 16 at follow-up (P < 0.001). The average cost per patient was $17,166. Evaluation and follow-up charges totaled $65,412, and physiologic assessment accounted for 64 percent of these costs. Treatment charges totaled $559,341, and physician charges accounted for 18 percent of these charges.

CONCLUSIONS

Fecal incontinence after childbirth results in substantial economic costs, and treatment is not always successful. New treatment modalities, such as artificial bowel sphincter or dynamic graciloplasty, should be assessed to determine their cost-effectiveness.

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.

Is electrostimulation of the pelvic floor an effective treatment for neurogenic faecal incontinence?

BACKGROUND

This study was designed to evaluate the results of electrostimulation of the pelvic floor for faecal incontinence.

METHODS

Twenty-four patients with neurogenic (n = 20) or idiopathic (n = 4) incontinence were treated on 12 occasions. Twenty were women, and the mean age was 63 years (range, 26-85 years). The result was evaluated at 3 and 12 months with a validated questionnaire and anorectal manometry.

RESULTS

Eleven patients (46%) reported improvement after 3 months, and the Miller's incontinence score was reduced (P < 0.01). Resting pressures, rectal compliance, and the length of the high-pressure zone were unchanged, but squeeze pressures tended to decrease. A lower threshold was seen for the rectoanal inhibitory reflex (RAIR) (P < 0.01), and the saline infusion test tended to show improved retention (P = 0.07). Nine of 13 patients followed up for 1 year claimed improvement. The most pronounced subjective improvement was seen in patients with moderate incontinence.

CONCLUSIONS

Electrostimulation was successful in a substantial proportion of the patients. The threshold for RAIR was lowered, and the saline infusion test tended to improve, but variables reflecting sphincter competence did not improve. Moderate incontinence was prognostically favourable, and electrostimulation might therefore be an alternative to surgery in this group.

Fecal incontinence in women

Pelvic floor disorders are common in women. Most gynecologists are well versed in the management of urinary incontinence and uterovaginal prolapse; however, knowledge of disorders involving the anorectum is often lacking. This review will discuss the issue of anorectal incontinence in women, attempt to provide a logical outline for evaluation and treatment, and offer potential methods of prevention.

Should patients with combined colonic inertia and nonrelaxing pelvic floor undergo subtotal colectomy?

PURPOSE

Treatment of severe constipation caused by combined colonic inertia and nonrelaxing pelvic floor is controversial. This study is designed to evaluate the outcome of preoperative biofeedback and subtotal colectomy for patients with combined colonic inertia and nonrelaxing pelvic floor.

METHODS

One hundred six patients who underwent subtotal colectomy for intractable constipation from 1982 through 1995 answered a detailed questionnaire regarding postoperative bowel function, symptoms of abdominal pain and bloating, and degree of satisfaction after the operation. Sixteen of these patients had a combination of colonic inertia and nonrelaxing pelvic floor diagnosed by transit marker study, electromyography, and defecography. These patients completed preoperative biofeedback training.

RESULTS

Electromyographic relaxation of pelvic floor musculature was demonstrated after the biofeedback treatment in all patients, but symptoms of difficult evacuation persisted. Postoperatively, seven patients (43 percent) had complete resolution of symptoms of constipation or difficult evacuation. Six patients still complained of incomplete evacuation that was severe in two and unresponsive to postoperative biofeedback. Three patients (18 percent) complained of diarrhea (>5 bowel movements per day) and incontinence of liquid stools (at least one episode a week). Nine patients (56 percent) were satisfied despite persistent symptoms.

CONCLUSIONS

Subtotal colectomy can improve some symptoms in patients with slow transit constipation and nonrelaxing pelvic floor. However, incomplete evacuation persists in a significant number of patients and almost one-half of patients are dissatisfied with their surgery.

Paradoxical sphincter reaction is influenced by rectal filling volume

PURPOSE

Paradoxical sphincter reaction is frequently found in constipated patients but sometimes also in incontinent patients and in asymptomatic subjects. Its significance in defecation disorders has, therefore, been debated. The aim of the present study was to investigate whether paradoxical sphincter reaction is influenced by rectal filling volume.

PATIENTS AND METHODS

Eighteen patients with defecation disorders and paradoxical sphincter reaction shown by electromyography were reinvestigated with an extended electromyographic investigation while in the lying position and while in the sitting position, with 50-ml, 100-ml, and 150-ml water-filled rectal balloons.

RESULTS

All 18 patients showing paradoxical sphincter reaction in the first investigation also showed the reaction at the second investigation in the lying position with a 0-ml volume of rectal contents. In the sitting position, with a volume of 150 ml of rectal contents, the increase in electromyographic activity disappeared in seven patients (39 percent) and no longer showed paradoxical sphincter reaction. Electromyography showed decreased activity in one patient and unchanged activity in six patients during straining. A closing reflex was seen after completed straining in all of these seven patients.

CONCLUSIONS

The present study demonstrates that paradoxical sphincter reaction diagnosed by electromyography is influenced by the rectal filling volume and might diminish when the rectum is filled with contents. The conventional electrophysiologic technique in the diagnosis of paradoxical sphincter reaction might, therefore, overdiagnose this condition.

Fatigue rate index as a new measurement of external sphincter function

PURPOSE

Assessment of sustained voluntary contraction of the external sphincter is helpful in evaluating the patient who has a defecation disorder on presentation. A new index of external sphincter function is described.

METHOD

A prospective registry of patients referred for computerized anal manometry using standard protocols was reviewed. Patients were grouped by primary symptoms; those with overlapping complaints were excluded. The rate of fatigue, defined as the change in stationary squeeze over a 40-second period of voluntary contraction, was calculated by linear regression analysis. Fatigue rate index, a calculated measure of time necessary for the external sphincter to become completely fatigued, was determined to permit comparison of external sphincter fatigue in patients with different complaints.

RESULTS

Twenty-six healthy volunteers (15 women; mean age, 45 years), 33 patients with a primary complaint of anal seepage (13 women; mean age, 53 years), 75 patients with gross incontinence (61 women; mean age, 53 years), and 49 patients with severe constipation (41 women; mean age, 45 years) were evaluated. Mean resting and squeeze pressures were 55 mmHg and 107 mmHg for volunteers, 37 mmHg and 97 mmHg for patients with seepage, 30 mmHg and 49 mmHg for incontinent patients, and 56 mmHg and 93 mmHg for constipated patients. Pudendal neuropathy, as evidenced by a prolonged pudendal nerve terminal motor latency (> 2.4 ms), was identified in 13 percent of volunteers, 32 percent of patients with seepage, 54 percent of incontinent patients, and 38 percent of constipated patients. Mean fatigue rate index was 3.3 minutes for volunteers, 2.3 minutes for seepage patients, 1.5 minutes for incontinent patients, and 2.8 minutes for constipated patients. Compared with volunteers and patients with seepage, the incontinent patients had a significantly shorter fatigue rate index (P < 0.05; Student's t-test), which was independent of the variations in resting pressure (P < 0.05; two-way analysis of variance).

CONCLUSION

The external anal sphincter is normally subject to fatigue. Patients with worsening degrees of incontinence have a predictably lower fatigue rate index. Fatigue rate index is a simple measure of external sphincter integrity, which may be used in assessment of sphincter function and future treatment protocols.

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.

Outcome and predictors of success of biofeedback for constipation

BACKGROUND

A study was undertaken to determine outcome and to identify predictors of success for biofeedback for constipation.

METHODS

Patients who had at least one biofeedback session were evaluated whether or not they completed a treatment course. Parameters assessed included use of cathartics, number of spontaneous bowel movements per week, presence of rectal pain, number of biofeedback sessions and results of anorectal physiology.

RESULTS

A total of 194 patients (59 male, 135 female) of median age 71 (range 11-96) years, including 30 with concomitant rectal pain, were treated. The median number of spontaneous bowel movements per week before treatment was 0. Some 35 per cent of patients had complete success (three or more spontaneous bowel movements per week with discontinuation of cathartics), 13 per cent had partial success (fewer than three spontaneous bowel movements per week with continued use of cathartics) and 51 per cent had no improvement. Neither patient age, sex nor duration of symptoms significantly affected outcome. Only 18 per cent of patients who had between two and four sessions had complete success, compared with 44 per cent of those who had five or more (P < 0.001). A total of 63 per cent of patients who completed the treatment protocol experienced complete success, compared with 25 per cent of those who self-discharged (P < 0.0001).

CONCLUSIONS

This large study indicates that the success rate of biofeedback for patients with constipation is less than previously reported. However, the success rate improves significantly after five or more sessions and is significantly related to the patient's willingness to complete treatment.

Anismus: fact or fiction?

PURPOSE

Although anismus has been considered to be the principal cause of anorectal outlet obstruction, it is doubtful whether contraction of the puborectalis muscle during straining is paradoxical. The present study was conducted to answer this question.

METHODS

During the first part of the study, we retrospectively reviewed 121 patients with constipation and/or obstructed defecation (male:female, 10/111; median age, 51 years). All of these patients underwent electromyography (EMG) of the pelvic floor and the balloon expulsion test (BET) in the left lateral position. Evacuation proctography was performed in all of these patients in the sitting position. Both the posterior anorectal angle and the central anorectal angle were measured. EMG and BET were also performed in ten controls (male:female, 4/6; median age, 47). In 147 patients with fecal incontinence (male:female, 24/123; median age, 58) only EMG activity was recorded. Criteria for anismus during straining were increase or insufficient (<20 percent) decrease of EMG activity, failure to expel an air-filled balloon on BET, and decrease or insufficient (<5 percent) increase of anorectal angle on evacuation proctography. Between June 1994 and March 1995, we conducted a second prospective study in a consecutive series of 49 patients with constipation and/or obstructed defecation and 28 patients with fecal incontinence. Both groups were compared with 19 control subjects. In this study, all three tests were performed. EMG and BET were performed both in the left lateral position and in the sitting position.

RESULTS

The retrospective study was undertaken by comparing the constipated patients with the incontinent patients and the controls, and the anismus detected by EMG was found in, respectively, 60, 46, and 60 percent. Failure to expel the air-filled balloon was observed in 80 constipated patients (66 percent) and in 9 control subjects (90 percent). Based on posterior anorectal angle and central anorectal angle measurements, anismus was diagnosed in, respectively, 21 and 35 percent of constipated patients. In the prospective study, none of the tests showed significant differences regarding the prevalence of anismus between the two subgroups of patients and the control subjects. The prevalence of anismus only differed between constipated and incontinent patients when the diagnosis was based on BET in the sitting position (67 vs. 32 percent; P < 0.005). Our study shows that contraction of the puborectalis muscle during straining is not exclusively found in patients with constipation and/or obstructed defecation. The three tests most commonly used for the diagnosis of anismus showed an extremely poor agreement.

CONCLUSION

Based on these findings, we doubt the clinical significance of anismus.

Prospective trial of pelvic floor retraining in patients with fecal incontinence

PURPOSE

Our aim was to prospectively evaluate pelvic floor retraining (PFR) in improving symptomatic fecal incontinence.

METHODS

PFR was used to treat 30 patients with fecal incontinence (28 women; age range, 29-85 (median, 68) years). PFR was performed by a physiotherapist in the outpatient department according to a strict protocol and included biofeedback using an anal plug electromyometer. Manometry (24 patients), pudendal nerve terminal motor latency (PNTML, 16 patients), and anal ultrasound (14 patients) were done before commencing therapy. Independent assessment of symptoms was done at the commencement of therapy, at 6 weeks, and at 6 and 12 months posttherapy.

RESULTS

Twenty patients (67 percent) had improved incontinence scores, with eight patients (27 percent) being completely or nearly free of symptoms. Of 28 patients followed up longer than six months, 14 achieved a 25 percent or greater improvement at six weeks, which was sustained in all cases. Fourteen had an initial improvement of less than 25 percent, with only four (29 percent) showing later improvement (P < 0.0001). There was no relationship between results of the therapy and patient age, initial severity of symptoms, etiology of incontinence, and results of anal manometry, PNTML, and anal ultrasound.

CONCLUSIONS

PFR is a physical therapy that should be considered as the initial treatment in patients with fecal incontinence. An improvement can be expected in up to 67 percent of patients. Initial good results can predict overall outcome.

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.

Clinical and physiologic effects of biofeedback in outlet obstruction constipation

PURPOSE

We report the results of biofeedback (BF) on patients with outlet obstruction defecation (OOC), including those with and without measurable paradoxical puborectalis contractions (PP). Clinical and anorectal physiologic parameters (ARP) were assessed one week before and after a standardized course of BF.

METHODS

Sixty-two consecutive patients (24 men, 38 women; mean age, 48 (standard error of the mean, 2.3) years) were recruited. All had persistent constipation despite six weeks of dietary fiber supplements. Colonic inertia was excluded by transit marker studies. Defecating proctography excluded anatomic abnormalities causing outlet obstruction. Patients underwent four outpatient sessions of biofeedback, each session lasting one hour.

RESULTS

After BF, 56 patients (90.3 percent) were subjectively improved. Frequency of spontaneous bowel movements were significantly increased (P = 0.003). Frequency of laxative-induced (P = 0.004) and enema-induced (P = 0.005) stools were reduced. Anal resting (P = 0.04) and squeeze (P = 0.002) pressures were increased. Number of patients with PP was reduced from 40 to 31 (P = 0.004). Presence of PP did not affect response to BF. There were no differences in ARP between the 56 patients who improved and the 6 who did not. There were no side effects or clinical regressions after a mean follow-up of 14.9 (standard error of the means, 0.9) months.

CONCLUSIONS

BF effectively treated OOC in 90.3 percent, regardless of PP. Anal pressures were increased, and PP was decreased.

Physiological and clinical outcome of anterior sphincteroplasty

A total of 55 women underwent sphincteroplasty for the treatment of faecal incontinence related to anterior defects. Patients were followed prospectively for a mean of 29 months to evaluate the outcome overall and according to age. All patients were evaluated clinically by means of a questionnaire and graded using an incontinence scoring system ranging from 0 (perfect continence) to 20 (complete incontinence). Some 52 patients (95 per cent) had had a previous vaginal delivery and 30 (55 per cent) had a history of previous anal sphincter repair. Physiological and functional parameters in patients with a successful outcome (n = 39) were compared with those in patients with a poor outcome (n = 16). The results were also compared in patients under (n = 39) and over (n = 16) 60 years of age. Overall, patients with a successful outcome had a significant change in mean and maximal resting and squeeze pressures. These changes correlated well with the increase in the high-pressure zone (HPZ) length from 1.0-2.2 cm (P = 0.0002) and with functional outcome (change in incontinence score from 15.3 to 5.8; P < 0.0001). In patients over 60 years of age, a significant change in mean squeeze pressure (P = 0.03) and HPZ length (P = 0.01) was noted and correlated with functional outcome (change in incontinence score from 14.3 to 6.4; P < 0.0001). A successful outcome after anterior sphincteroplasty is related to improvement in sphincter function even in an older population. These results demonstrate that age itself does not seem to be a predictor of poor outcome. Patients should not be denied a repair exclusively on grounds of age.