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Biofeedback treatment of fecal incontinence

A critical review

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Diseases of the Colon & Rectum

Abstract

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 usingCoordination training (i.e., coordinating pelvic floor muscle contraction with the sensation of rectal filling) was 67 percent, while the mean success rate for studies usingStrength training (i.e., pelvic floor muscle contraction) was 70 percent. Furthermore, the mean success rate for thoseStrength training studies using electromyographic biofeedback was 74 percent, while the mean success rate for studies using anal canal pressure biofeedbackStrength 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.

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References

  1. Rao SS, Enck P, Loening-Baucke V. Biofeedback therapy for defecation disorders. Dig Dis Sci 1997;15(Suppl 1):S78–92.

    Google Scholar 

  2. Whitehead WE, Wald A, Diamant N, Enck P, Pemberton J, Rao S. Functional disorders of the anus and rectum. In: Drossman DA, Corazziari E, Talley NJ, Thompson WG, Whitehead WE, eds. Rome II: the functional gastrointestinal disorders. 2nd ed. McLean, VA: Degnon Associates, 2000:483–532.

    Google Scholar 

  3. Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993;36:77–97.

    Google Scholar 

  4. Bellman M. Studies on encopresis. Acta Paediatr Scand 1966;56(Suppl 170):S1–151.

    Google Scholar 

  5. Levine MD, Children with encopresis: a descriptive analysis. Pediatrics 1975;56:412–6.

    Google Scholar 

  6. Drossman DA, Li Z, Andruzzi E, Temple RD,et al. U.S. householder survey of functional gastrointestinal disorders. Dig Dis Sci 1993;38:1569–80.

    Google Scholar 

  7. Kinnunen O. Study of constipation in a geriatric hospital, day hospital, old people's home and at home. Aging 1991;3:161–70.

    Google Scholar 

  8. Cheskin LJ, Schuster MM. Fecal incontinence. In: Hazzard WR, Andres R, Bierman EL, Blass JP, eds. Principles of geriatric medicine and gerontology. 2nd ed. New York: McGraw-Hill, 1990:1143–5.

    Google Scholar 

  9. Nelson R, Furner S, Jesudason V. Fecal incontinence in Wisconsin nursing homes: prevalence and associations. Dis Colon Rectum 1998;41:1226–9.

    Google Scholar 

  10. Thomas TM, Egan M, Walgrove A, Meade TW. The prevalence of fecal and double incontinence. Community Med 1984;6:216–20.

    Google Scholar 

  11. Lahr CJ. Evaluation and treatment of incontinence. Practical Gastroenterol 1988;12:27–35.

    Google Scholar 

  12. Huppe D, Enck P, Kruskemper G, May B. Psychosocial aspects of fecal incontinence [in German]. Leber Magen Darm 1992;22:138–42.

    Google Scholar 

  13. O'Keefe EA, Talley NJ, Zinsmeister AR, Jacobsen SJ. Bowel disorders impair functional status and quality of life in the elderly: a population-based study. J Gerontol A Biol Sci Med Sci 1995;50:M184–9.

    Google Scholar 

  14. Burnett C, Whitehead WE, Drossman D. Psychological distress and impaired quality of life in patients with functional anorectal disorders [abstract]. Gastroenterology 1998;114:A729.

    Google Scholar 

  15. Johanson JF, Lafferty J. Epidemiology of fecal incontinence: The silent affliction. Am J Gastroenterol 1996;91:33–6.

    Google Scholar 

  16. Enck P, Gabor S, von Ferber L, Rathmann W, Erckenbrecht JF. Prevalence of fecal incontinence and degree of information possessed by family physicians and health insurance. [in German] Z Gastroenterol 1991;29:538–40.

    Google Scholar 

  17. Whitehead WE, Wald A, Norton NJ. Treatment options for fecal incontinence. Dis Colon Rectum, (in press).

  18. Engel BT, Nikoomanesh P, Schuster MM. Operant conditioning of rectosphincteric responses in the treatment of fecal incontinence. N Engl J Med 1974;290:646–9.

    Google Scholar 

  19. Glia A, Gylin M, Akerlund JE, Lindfors U, Lindberg G. Biofeedback training in patients with fecal incontinence. Dis Colon Rectum 1998;41:359–64.

    Google Scholar 

  20. Riboli EB, Frascio MD, Pitto G, Reboa G, Zanolla R. Biofeedback conditioning for fecal incontinence. Arch Phys Med Rehabil 1988;69:29–31.

    Google Scholar 

  21. Enck P, Kranzle U, Schwiese J,et al. Biofeedback training in fecal incontinence [in German]. Deutsche Medizinische Wochenschrift 1988;113:1789–94.

    Google Scholar 

  22. Buser WE, Miner PB. Delayed rectal sensation with fecal incontinence. Gastroenterology 1986;91:1186–91.

    Google Scholar 

  23. Whitehead WE, Burgio KL, Engel BT. Biofeedback treatment of fecal incontinence in geriatric patients. J Am Geriatr Soc 1985;33:320–4.

    Google Scholar 

  24. Wald A, Tunuguntla AK. Anorectal sensorimotor dysfunction in fecal incontinence and diabetes mellitus. Modification with biofeedback therapy. N Engl J Med 1984;310:1282–7.

    Google Scholar 

  25. Wald A. Biofeedback therapy for fecal incontinence. Ann Int Med 1981;95:146–9.

    Google Scholar 

  26. Goldenberg DA, Hodges K, Hershe T, Jinich H. Biofeedback therapy for fecal incontinence. Am J Gastroenterol 1980;74:342–5.

    Google Scholar 

  27. Cerulli M, Nikoomanesh P, Schuster MM. Progress in biofeedback conditioning for fecal incontinence. Gastroenterology 1979;76:742–6.

    Google Scholar 

  28. Faure N, Ferriere S, Maurauge C, Rolland JC. Biofeedback treatment in chronically constipated children [in French]. Arch Pediatr 1995;2:1055–9.

    Google Scholar 

  29. Arhan P, Faverdin C, Devroede G,et al. Biofeedback re-education of faecal continence in children. Int J Colorectal Dis 1994;9:128–33.

    Google Scholar 

  30. Chiarioni G, Scatttolini C, Bonafante F, Vantini I. Liquid stool incontinence with severe urgency: anorectal function and effective biofeedback treatment. Gut 1993;34:1576–80.

    Google Scholar 

  31. Loening-Baucke V, Desch L, Wolraich M. Biofeedback training for patients with myelomeningocele and fecal incontinence. Dev Med Child Neurol 1988;30:781–90.

    Google Scholar 

  32. Whitehead WE, Parker L, Bosmajian L,et al. Treatment of fecal incontinence in children with spina bifida: Comparison of biofeedback and behavior modification. Arch Phys Med Rehabil 1986;67:218–24.

    Google Scholar 

  33. Wald A. Biofeedback for neurogenic fecal incontinence: rectal sensation is a determinant of outcome. J Pediatr Gastroenterol Nutr 1983;2:302–6.

    Google Scholar 

  34. Whitehead WE, Parker LH, Masek BJ, Cataldo MF, Freeman JM. Biofeedback treatment of fecal incontinence in myelomeningocele. Dev Med Child Neurol 1981;23:313–22.

    Google Scholar 

  35. Wald A. The use of biofeedback in the treatment of fecal incontinence in patients with meningomyelocele. Pediatrics 1981;68:45–9.

    Google Scholar 

  36. Ko CY, Tong J, Lehman RE, Shelton AA, Schrock TR, Welton ML. Biofeedback is effective therapy for fecal incontinence and constipation. Arch Surg 1997;132:829–34.

    Google Scholar 

  37. Rieger NA, Wattchow DA, Sarre RG,et al. Prospective trial of pelvic floor retraining in patients with fecal incontinence. Dis Colon Rectum 1997;40:821–6.

    Google Scholar 

  38. Patankar SK, Ferrara A, Larach SW,et al. Electromyographic assessment of biofeedback training for fecal incontinence and chronic constipation. Dis Colon Rectum 1997;40:907–11.

    Google Scholar 

  39. van Tets WF, Kuijpers JH, Bleijenberg G. Biofeedback treatment is ineffective in neurogenic fecal incontinence. Dis Colon Rectum 1996;39:992–4.

    Google Scholar 

  40. McIntosh LJ, Frahm JD, Mallet VT, Richardson DA. Pelvic floor rehabilitation in the treatment of incontinence. J Reprod Med 1993;38:662–6.

    Google Scholar 

  41. MacLeod JH. Biofeedback in the management of partial anal incontinence. Dis Colon Rectum 1983;26:244–6.

    Google Scholar 

  42. Tiomny E, Ringel Y, Kimel R, Moshkowitz M, Brill S, Halpern Z. Biofeedback treatment in patients with pelvic floor dysfunction [abstract]. Digestion 1998;59(Suppl 3):S741.

    Google Scholar 

  43. Ho YH, Tan M. Biofeedback therapy for bowel dysfunction following low anterior resection. Ann Acad Med Singapore 1997;26:299–302.

    Google Scholar 

  44. Sangwan YP, Coller JA, Barrett RC, Roberts PL, Murray JJ, Schoetz DJ Jr. Can manometric parameters predict response to biofeedback therapy in fecal incontinence? Dis Colon Rectum 1995;38:1021–5.

    Google Scholar 

  45. Keck JO, Staniunas RJ, Coller JA,et al. Biofeedback is useful in fecal incontinence but disappointing in constipation. Dis Colon Rectum 1994;37:1271–6.

    Google Scholar 

  46. Iwai N, Iwata G, Kimura O, Yanagihara J. Is a new biofeedback therapy effective for fecal incontinence in patients who have anorectal malformations? J Pediatr Surg 1997;32:1616–29.

    Google Scholar 

  47. Olness K, McParland FA, Piper J. Biofeedback. A new modality in management of children with fecal soiling. J Pediatr 1980;96:505–9.

    Google Scholar 

  48. Guillemot F, Bouche B, Gower-Rosseau C,et al. Biofeedback for the treatment of fecal incontinence: long-term clinical results. Dis Colon Rectum 1995;38:393–7.

    Google Scholar 

  49. Latimer PR, Campbell D, Kasperski J. A component analysis of biofeedback in the treatment of fecal incontinence. Biofeedback Self Regul 1984;9:311–24.

    Google Scholar 

  50. Miner PB, Donnelly TC, Read NW. Investigation of mode of action of biofeedback in treatment of fecal incontinence. Dig Dis Sci 1990;35:1291–8.

    Google Scholar 

  51. Rao SS, Welcher KD, Happel J. Can biofeedback therapy improve anorectal function in fecal incontinence? Am J Gastroenterol 1996;91:2360–6.

    Google Scholar 

  52. Heymen S, Pikarsky AJ, Weiss EG, Vickers D, Nogueras JJ, Wexner SD. A prospective randomized trial comparing four biofeedback techniques for patients with fecal incontinence. Colorectal Dis 2000;2:88–92.

    Google Scholar 

  53. Miller R, Bartolo DC, Lock-Edmunds JC, Mortensen NJ. Prospective study of conservative and operative treatment for faecal incontinence. Br J Surg 1988;75:101–5.

    Google Scholar 

  54. Keighley MR, Fielding WL. Management of faecal incontinence and results of surgical treatment. Br J Surg 1983;70:463–8.

    Google Scholar 

  55. Pescatori M, Anastasio G, Bottini C, Mentasti A. New grading and scoring for anal incontinence: evaluation of 335 patients. Dis Colon Rectum 1992;35:482–7.

    Google Scholar 

  56. Reilly WT, Talley NJ, Pemberton JH, Zinsmeister AR. Validation of a questionnaire to assess fecal incontinence and associated risk factors: fecal incontinence questionnaire. Dis Colon Rectum 2000;43:146–54.

    Google Scholar 

  57. Rockwood TH, Church JM, Fleshman JW,et al. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum 1999;42:1525–32.

    Google Scholar 

  58. Rockwood TH, Church JM, Fleshman JW,et al. Fecal incontinence quality of life scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 2000;43:9–17.

    Google Scholar 

  59. Veldhuyzen van Zanten SJ, Talley NJ, Bytzer P, Klein KB, Whorwell PJ, Zinsmeister AR. Design of treatment trials for functional gastrointestinal disorders. Gut 1999;45(Suppl 2):SII69–77.

    Google Scholar 

  60. Whitehead WE, Corazziari E, Prizont R,et al. Definition of a responder in clinical trials for functional gastrointestinal disorders. Report on a symposium. Gut 1999;45(Suppl 2):1178–9.

    Google Scholar 

  61. Gilliland R, Heymen S, Altomare DF, Park UC, Vickers D, Wexner SD. Outcome and predictors of success of biofeedback for constipation. Br J Surgery 1997;84:1123–6.

    Google Scholar 

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Authors and Affiliations

  1. From the Center for Functional Gastrointestinal and Motility Disorders, Department of Medicine, The University of North Carolina, Chapel Hill, North Carolina

    Steve Heymen M.S., Kenneth R. Jones Ph.D., Yehuda Ringel M.D., Yolanda Scarlett M.D. & William E. Whitehead Ph.D.

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  1. Steve Heymen M.S.
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  2. Kenneth R. Jones Ph.D.
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  3. Yehuda Ringel M.D.
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  4. Yolanda Scarlett M.D.
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  5. William E. Whitehead Ph.D.
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Additional information

Preparation of this manuscript was supported in part by NIH grant #R01DK57048 and the National Institute of Health National Center for research resources, General Clinical Research Center, grant #M01RR00046.

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Heymen, S., Jones, K.R., Ringel, Y. et al. Biofeedback treatment of fecal incontinence. Dis Colon Rectum 44, 728–736 (2001). https://doi.org/10.1007/BF02234575

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