Management of Pelvic Floor Disorders: Biofeedback and More
- 263 Downloads
Defecatory disorders (DD) and fecal incontinence (FI) are common conditions. DD are primarily attributable to impaired rectoanal function during defecation or structural defects. FI is caused by one or more disturbances of anorectal continence mechanisms. Altered stool consistency may be the primary cause or may unmask anorectal deficits in both conditions. Diagnosis and management requires a systematic approach beginning with a thorough clinical assessment. Symptoms do not reliably differentiate a DD from other causes of constipation such as slow or normal transit constipation. Therefore, all constipated patients who do not adequately respond to medical therapy should be considered for anorectal testing to identify a DD. Preferably, two tests indicating impaired defecation are required to diagnose a DD. Patients with DD, or those for whom testing is not available and the clinical suspicion is high, should be referred for biofeedback-based pelvic floor physical therapy. Patients with FI should be managed with lifestyle modifications, pharmacotherapy for bowel disturbances, and management of local anorectal problems (e.g., hemorrhoids). When these measures are not beneficial, anorectal testing and pelvic floor retraining with biofeedback therapy should be considered. Sacral nerve stimulation or perianal bulking could be considered in patients who have persistent symptoms despite optimal management of bowel disturbances and pelvic floor retraining.
KeywordsConstipation Fecal incontinence Manometry Balloon expulsion test Defecography Biofeedback Botulinum toxin Sacral nerve stimulation Posterior tibial nerve stimulation STARR Peri-anal injectable bulking agents
Compliance with Ethics Guidelines
Conflict of Interest
David Prichard declares that he has no conflict of interest.
Adil E. Bharucha has received consultancy fees from Medspira and Gicare Pharma. Dr. Bharucha has also received royalty payments from and has a patent with Medspira (ARM device).
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Wald A et al. Functional anorectal disorders. In: Drossman DA, Corazziari E, Delvaux M, et al., editors. Rome III: the functional gastrointestinal disorders. McLean: Degnon Associates, Inc; 2006. p. 639–86.Google Scholar
- 6.Noelting J, Zinsmeister AR, Bharucha AE. Comparison of daily and weekly instruments of patient-reported outcomes for therapeutic trials in fecal incontinence (FI). Gastroenterology 2014;146(5):S-718;Mo2016.Google Scholar
- 7.Tremaine WJ et al. 561 Inflammatory bowel disease and nonrRelaxing pelvic floor dysfunction. Gastroenterology. 2013;144(5):S-104.Google Scholar
- 8.•Perera L et al. Dyssynergic defecation: a treatable cause of persistent symptoms when inflammatory bowel disease is in remission. Dig Dis Sci. 2013;58(12):3600–5. In this observational study, 29 of 30 patients with IBC who had persistent defecatory symptoms in the absence of left colonic inflammation had evidence of dyssynergia on anorectal testing. This research demonstrates the very high prevalence of DD in this cohort and highlights that a diagnosis of DD should be considered in all patients who continue to have symptoms despite apparently successful therapy for their IBD.PubMedCrossRefGoogle Scholar
- 11.Minguez M, Herreros B, Sanchiz V, et al. Predictive value of the balloon expulsion test for excluding the diagnosis of pelvic floor dyssynergia in constipation. Gastroenterology. 2004;126(1):57–62.Google Scholar
- 13.••Chiarioni G, et al. Validation of the balloon evacuation test: reproducibility and agreement with findings from anorectal manometry and electromyography. Clin Gastroenterol Hepatol 2014. Access to anorectal testing (ARM, electromyography, and defecography) is limited in community practice. This research demonstrates the high level of agreement between BET and ARM (78 %) and/or electromyography (83 %). The BET is a simple, cheap, and valid test that can be used to screen for DD among constipated patients responding incompletely to conservative therapy in the community.Google Scholar
- 15.••Ratuapli S et al. Phenotypic identification and classification of functional defecatory disorders using high resolution anorectal manometry. Gastroenterology. 2013;144:314–22. Principal component analysis of high-resolution manometry parameters in healthy controls (n = 62), constipated patients with a normal BET (n = 224), and constipated patients with an abnormal BET (n = 71) identified three manometric patterns associated with an abnormal BET (i.e., DD): (1) high anal tone at rest and during simulated evacuation, (2) inadequate rectal propulsive forces during simulated evacuation; and (3) a hybrid of the two. Clinical symptoms correlated only weakly with an abnormal BET or any of the manometric patterns suggestive of DD. This paper highlights that anorectal testing is crucial in identifying patients with DD.PubMedCrossRefPubMedCentralGoogle Scholar
- 17.•Wald A et al. ACG clinical guidelines: management of benign anorectal disorders. Am J Gastroenterol. 2014;109(8):1141–57. This review paper is the most recent and comprehensive review of the literature relating to the definitions, diagnostic criteria, differential diagnoses, and treatments of benign anorectal disorders, including defecation disorders, fecal incontinence, proctalgia syndromes, anal fissure, and hemorrhoids.PubMedCrossRefGoogle Scholar
- 21.•Jodorkovsky D et al. Biofeedback therapy for defecatory dysfunction: “real life” experience. J Clin Gastroenterol. 2013;47(3):252–5. Randomized trials demonstrate that biofeedback therapy is effective for DD and FI. In this retrospective review from a tertiary referral center, less than 50 % of patients with constipation or FI in whom biofeedback-based pelvic floor retraining was recommended underwent biofeedback therapy because of limitations related to a lack of insurance coverage, travel to facilities, and acute medical issues taking precedence. However, the response rate was similar to that reported in clinical trials.PubMedCrossRefGoogle Scholar
- 42.••Bharucha AE et al. Obstetric trauma, pelvic floor injury and fecal incontinence: a population-based case-control study. Am J Gastroenterol. 2012;107(6):902–11. This research used a nested case–control study to evaluate the antecedent risk factors for FI. Urgency (odds ratio [OR] [per 10 %] 3.0; 95 % confidence interval [CI] 1.4–6.5, p = 0.005) and stool consistency (OR [per unit] 10; 95 % CI 1.9–58, p = 0.008) were associated with an increased risk of FI, while anal and pelvic floor injuries were not. These findings suggest that, in community practice, initial emphasis should be placed on modifying bowel disturbances and toileting habits rather than identifying anatomical deficits of the anus and pelvic floor.PubMedCrossRefPubMedCentralGoogle Scholar
- 49.Whitehead WE, et al. Treatment of fecal incontinence: state of the science and directions for future research. Am J Gastroenterol. 2014; In press.Google Scholar
- 66.••Hull T et al. Long-term durability of sacral nerve stimulation therapy for chronic fecal incontinence. Dis Colon Rectum. 2013;56(2):234–45. This paper 5-year follow-up data from patients who had permanent SNS implantation for refractory FI. Among the 63 % of the original cohort available for analysis, FI episodes per week decreased from a mean of 9.1 at baseline to 1.7 at 5 years, with 89 % of patients having ≥50 % improvement and 36 % having complete continence. These data demonstrate that SNS is both effective and durable in treating FI refractory to conservative management.PubMedCrossRefGoogle Scholar