Skip to main content

Advertisement

SpringerLink
Log in

Management of Pelvic Floor Disorders: Biofeedback and More

  • Motility (T Lembo, Section Editor)
  • Published:
Current Treatment Options in Gastroenterology Aims and scope Submit manuscript

Opinion statement

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

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 

  2. Bharucha AE, Locke GR, Pemberton JH. AGA practice guideline on constipation: technical review. Gastroenterology. 2013;144:218–38.

    Article  PubMed  PubMed Central  Google Scholar 

  3. American Gastroenterological Association. American gastroenterological association medical position statement on constipation. Gastroenterology. 2013;144(1):211–7.

    Article  Google Scholar 

  4. Chiarioni G et al. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology. 2006;130(3):657–64.

    Article  PubMed  Google Scholar 

  5. Chiarioni G, Salandini L, Whitehead WE. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology. 2005;129(1):86–97.

    Article  PubMed  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.

  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.

    Article  PubMed  Google Scholar 

  9. Vijayvargiya P et al. Novel association of rectal evacuation disorder and rumination syndrome: diagnosis, co-morbidities and treatment. United Eur Gastroenterol J. 2014;2(1):38–46.

    Article  Google Scholar 

  10. Videlock EJ, Lembo A, Cremonini F. Diagnostic testing for dyssynergic defecation in chronic constipation: meta-analysis. Neurogastroenterol Motil. 2013;25(6):509–20.

    Article  PubMed  CAS  Google 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.

  12. Ratuapli S et al. Comparison of rectal balloon expulsion test in seated and left lateral positions. Neurogastroenterol Motil. 2013;25(12):e813–20.

    Article  PubMed  CAS  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.

  14. Noelting J et al. Normal values for high-resolution anorectal manometry in healthy women: effects of age and significance of rectoanal gradient. Am J Gastroenterol. 2012;107(10):1530–6.

    Article  PubMed  PubMed Central  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.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Rao SS et al. Manometric tests of anorectal function in healthy adults. Am J Gastroenterol. 1999;94(3):773–83.

    Article  PubMed  CAS  Google 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.

    Article  PubMed  Google Scholar 

  18. Bharucha AE et al. Phenotypic variation in functional disorders of defecation. Gastroenterology. 2005;128:1199–210.

    Article  PubMed  Google Scholar 

  19. Bharucha AE, Wald AM. Anorectal disorders. Am J Gastroenterol. 2010;105(4):786–94.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Woodward S, Norton C, Chiarelli P. Biofeedback for treatment of chronic idiopathic constipation in adults. Cochrane Database Syst Rev. 2014;3, CD008486.

    PubMed  Google 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.

    Article  PubMed  Google Scholar 

  22. Maria G et al. Botulinum toxin in the treatment of outlet obstruction constipation caused by puborectalis syndrome. Dis Colon Rectum. 2000;43(3):376–80.

    Article  PubMed  CAS  Google Scholar 

  23. Ron Y et al. Botulinum toxin type-A in therapy of patients with anismus. Dis Colon Rectum. 2001;44(12):1821–6.

    Article  PubMed  CAS  Google Scholar 

  24. Maria G et al. Experience with type A botulinum toxin for treatment of outlet-type constipation. Am J Gastroenterol. 2006;101(11):2570–5.

    Article  PubMed  Google Scholar 

  25. Thomas GP et al. Sacral nerve stimulation for constipation. Br J Surg. 2013;100(2):174–81.

    Article  PubMed  CAS  Google Scholar 

  26. Knowles CH et al. Prospective randomized double-blind study of temporary sacral nerve stimulation in patients with rectal evacuatory dysfunction and rectal hyposensitivity. Ann Surg. 2012;255(4):643–9.

    Article  PubMed  Google Scholar 

  27. Farouk R, Bhardwaj R, Phillips RKS. Stapled transanal resection of the rectum (STARR) for the obstructed defaecation syndrome. Ann R Coll Surg Engl. 2009;91(4):287–91.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Harmston C et al. Comment on: Stapled transanal resection of the rectum (STARR) for obstructed defaecation syndrome. Ann R Coll Surg Engl. 2010;92(1):85–6.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  29. Lehur PA et al. Outcomes of stapled transanal rectal resection vs. biofeedback for the treatment of outlet obstruction associated with rectal intussusception and rectocele: a multicenter, randomized, controlled trial. Dis Colon Rectum. 2008;51(11):1611–8.

    Article  PubMed  Google Scholar 

  30. Gagliardi G et al. Results, outcome predictors, and complications after stapled transanal rectal resection for obstructed defecation. Dis Colon Rectum. 2008;51(2):186–95. discussion 195.

    Article  PubMed  Google Scholar 

  31. Reboa G et al. The impact of stapled transanal rectal resection on anorectal function in patients with obstructed defecation syndrome. Dis Colon Rectum. 2009;52(9):1598–604.

    Article  PubMed  Google Scholar 

  32. Titu LV et al. Stapled transanal rectal resection for obstructed defecation: a cautionary tale. Dis Colon Rectum. 2009;52(10):1716–22.

    Article  PubMed  Google Scholar 

  33. Schwandner T et al. Does the STARR procedure change the pelvic floor: a preoperative and postoperative study with dynamic pelvic floor MRI. Dis Colon Rectum. 2011;54(4):412–7.

    Article  PubMed  Google Scholar 

  34. Corman ML et al. Consensus conference on the stapled transanal rectal resection (STARR) for disordered defaecation. Color Dis. 2006;8(2):98–101.

    Article  CAS  Google Scholar 

  35. Dodi G et al. Bleeding, incontinence, pain and constipation after STARR transanal double stapling rectotomy for obstructed defecation. Tech Coloproctol. 2003;7(3):148–53.

    Article  PubMed  CAS  Google Scholar 

  36. Madbouly K, Abbas K, Hussein A. Disappointing long-term outcomes after stapled transanal rectal resection for obstructed defecation. World J Surg. 2010;34(9):2191–6.

    Article  PubMed  Google Scholar 

  37. Bharucha AE et al. Prevalence and burden of fecal incontinence: a population based study in women. Gastroenterology. 2005;129:42–9.

    Article  PubMed  Google Scholar 

  38. Whitehead WE et al. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology. 2009;137(2):512–7.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Johanson JF, Lafferty J. Epidemiology of fecal incontinence: the silent affliction. Am J Gastroenterol. 1996;91(1):33–6.

    PubMed  CAS  Google Scholar 

  40. Boreham MK et al. Anal incontinence in women presenting for gynecologic care: prevalence, risk factors, and impact upon quality of life. Am J Obstet Gynecol. 2005;192(5):1637–42.

    Article  PubMed  Google Scholar 

  41. Bliss DZ, Norton C, Vodusek DB. Raising awareness about fecal incontinence. Neurourol Urodyn. 2010;29(4):612–5.

    Article  PubMed  Google 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.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Bharucha AE et al. Risk factors for fecal incontinence: a population based study in women. Am J Gastroenterol. 2006;101:1305–12.

    Article  PubMed  Google Scholar 

  44. Heymen S et al. Mo2024 Patient preference for what should be included in the definition of fecal incontinence. Gastroenterology. 2014;146(5):S-720–1.

    Article  Google Scholar 

  45. Heymen S et al. Mo2025 Patient preference for defining success in fecal incontinence treatment trials. Gastroenterology. 2014;146(5):S-721.

    Article  Google Scholar 

  46. Bharucha AE, Rao SSC. An update on anorectal disorders for gastroenterologists. Gastroenterology. 2014;146(1):37–45.e2.

    Article  PubMed  Google Scholar 

  47. Bliss DZ et al. Supplementation with dietary fiber improves fecal incontinence. Nurs Res. 2001;50(4):203–13.

    Article  PubMed  CAS  Google Scholar 

  48. Markland AD et al. 883 Fiber or imodium prescription (Rx) management for bowel incontinence: the FIRM randomized clinical trial. Gastroenterology. 2014;146(5):S-154–5.

    Article  Google 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.

  50. Remes-Troche JM et al. Cholestyramine: a useful adjunct for the treatment of patients with fecal incontinence. Int J Color Dis. 2008;23(2):189–94.

    Article  Google Scholar 

  51. Bharucha AE et al. Effects of clonidine in women with fecal incontinence. Clin Gastroenterol Hepatol. 2014;12(5):843–851.e2.

    Article  PubMed  CAS  Google Scholar 

  52. Bharucha AE, Seide BM, Zinsmeister AR. The effects of clonidine on symptoms and anorectal sensorimotor function in women with faecal incontinence. Aliment Pharmacol Ther. 2010;32(5):681–8.

    PubMed  CAS  PubMed Central  Google Scholar 

  53. Carapeti EA, Kamm MA, Phillips RK. Randomized controlled trial of topical phenylephrine in the treatment of faecal incontinence. Br J Surg. 2000;87(1):38–42.

    Article  PubMed  CAS  Google Scholar 

  54. Cheetham MJ, Kamm MA, Phillips RK. Topical phenylephrine increases anal canal resting pressure in patients with faecal incontinence. Gut. 2001;48(3):356–9.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  55. Heymen S et al. Randomized controlled trial shows biofeedback to be superior to pelvic floor exercises for fecal incontinence. Dis Colon Rectum. 2009;52(10):1730–7.

    Article  PubMed  Google Scholar 

  56. Bharucha AE. Outcome measures for fecal incontinence: anorectal structure and function. Gastroenterology. 2004;126:S90–8.

    Article  PubMed  Google Scholar 

  57. Norton C et al. Randomized controlled trial of biofeedback for fecal incontinence. Gastroenterology. 2003;125:1320–9.

    Article  PubMed  Google Scholar 

  58. Solomon MJ et al. Randomized, controlled trial of biofeedback with anal manometry, transanal ultrasound, or pelvic floor retraining with digital guidance alone in the treatment of mild to moderate fecal incontinence. Dis Colon Rectum. 2003;46(6):703–10.

    Article  PubMed  Google Scholar 

  59. Heymen S et al. Randomized controlled trial shows biofeedback to be superior to alternative treatments for fecal incontinence. Dis Colon Rectum. 2009;52:1730–7.

    Article  PubMed  Google Scholar 

  60. Whitehead WE, Bharucha AE. Diagnosis and treatment of pelvic floor disorders: what's new and what to do. Gastroenterology. 2010;138(4):1231–5.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Graf W et al. Efficacy of dextranomer in stabilised hyaluronic acid for treatment of faecal incontinence: a randomised, sham-controlled trial. Lancet. 2011;377(9770):997–1003.

    Article  PubMed  CAS  Google Scholar 

  62. Mellgren A et al. Long-term efficacy of NASHA Dx injection therapy for treatment of fecal incontinence. Neurogastroenterol Motil. 2014;26(8):1087–94.

    Article  PubMed  CAS  Google Scholar 

  63. Dehli T et al. Sphincter training or anal injections of dextranomer for treatment of anal incontinence: a randomized trial. Scand J Gastroenterol. 2013;48(3):302–10.

    Article  PubMed  Google Scholar 

  64. Wexner SD et al. Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study. Ann Surg. 2010;251(3):441–9.

    Article  PubMed  Google Scholar 

  65. Mellgren A et al. Long-term efficacy and safety of sacral nerve stimulation for fecal incontinence. Dis Colon Rectum. 2011;54(9):1065–75.

    Article  PubMed  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.

    Article  PubMed  Google Scholar 

  67. Patton V et al. The effect of sacral nerve stimulation on distal colonic motility in patients with faecal incontinence. Br J Surg. 2013;100(7):959–68.

    Article  PubMed  CAS  Google Scholar 

  68. Thomas GP et al. A review of posterior tibial nerve stimulation for faecal incontinence. Color Dis. 2013;15(5):519–26.

    Article  CAS  Google Scholar 

  69. Leroi AM et al. Transcutaneous electrical tibial nerve stimulation in the treatment of fecal incontinence: a randomized trial (consort 1a). Am J Gastroenterol. 2012;107(12):1888–96.

    Article  PubMed  CAS  Google Scholar 

  70. George AT et al. Randomized controlled trial of percutaneous versus transcutaneous posterior tibial nerve stimulation in faecal incontinence. Br J Surg. 2013;100(3):330–8.

    Article  PubMed  CAS  Google Scholar 

  71. Thin NN et al. 882 Randomised mixed methods trial of sacral and percutaneous tibial nerve stimulation for faecal incontinence. Gastroenterology. 2014;146(5 Supple 1):S-154.

    Article  Google Scholar 

  72. Butt S et al. Mo2015 Preliminary significant findings from a randomised control trial of posterior tibial nerve stimulation in systemic sclerosis associated faecal incontinence. Gastroenterology. 2014;146(5):S-717–8.

    Article  Google Scholar 

Download references

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.

Author information

Authors and Affiliations

  1. Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA

    David Prichard MB, PhD & Adil E. Bharucha MBBS, MD

Authors
  1. David Prichard MB, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Adil E. Bharucha MBBS, MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Adil E. Bharucha MBBS, MD.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Prichard, D., Bharucha, A.E. Management of Pelvic Floor Disorders: Biofeedback and More. Curr Treat Options Gastro 12, 456–467 (2014). https://doi.org/10.1007/s11938-014-0033-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11938-014-0033-8

Keywords

Search

Navigation