Biofeedback for pelvic floor dysfunction in constipation
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《英国医生杂志》
1 Gastroenterology and Hepatology Section, Department of Clinical and Experimental Medicine, University of Perugia, Via Enrico Dal Pozzo, 06100 Perugia, Italy, 2 Gastrointestinal Rehabilitation Division, Valeggio sul Mincio Hospital, Azienda Ospedaliera and University of Verona, Valeggio sul Mincio (VR), Italy
Correspondence to: G Bassotti, Strada del Cimitero, 2/a, 06131 San Marco (Perugia), Italy gabassot@tin.it
Pelvic floor dyssynergia is one of the commonest subtypes of constipation, and the conventional treatment (dietary fibre and laxatives) is often unsatisfactory. Recently biofeedback training has been introduced as an alternative treatment. The authors review the evidence for this approach and conclude that, although controlled studies are few and open to criticism, about two thirds of patients with pelvic floor dyssynergia should benefit from biofeedback training
Introduction
The common treatment for chronic constipation is with high dietary fibre and laxatives. However, some patients (and especially those with pelvic floor dyssynergia) are unresponsive to these measures, which has encouraged the use of alternative treatments such as biofeedback training.4 Biofeedback is thought to be appropriate when specific pathophysiological mechanisms are known, and the control of relevant responses can be learnt with the aid of systematic information about a function that is not usually monitored consciously.4 We have critically reviewed the evidence on use of biofeedback to treat pelvic floor dyssynergia.
Methods
Paradoxically increased anal pressure or electromyographic activity during straining is readily detected in patients with pelvic floor dyssynergia.4 Some authors have measured the pressure gradient between the rectum and the anus on straining, but its clinical relevance is unclear.5 Radiological examination of rectal evacuation (defecography) has shown that pelvic floor dyssynergia is associated with the contour of the puborectal muscle increasing or the anorectal angle decreasing (fig 2). In addition, the suspicion of impaired defecation may be confirmed by the patient's inability to expel a rectal balloon. The diagnostic relevance of other techniques (ultrasonography, evacuation scintigraphy, pelvic floor magnetic resonance imaging, etc) is under evaluation.
Fig 2 Representative defecographic sequence of a patient with pelvic floor dyssynergia, showing insufficient opening of the anal canal and of the anorectal angle, with most of the contrast medium retained after straining. The sequence shows resting (upper left), contracting (upper right), straining (lower left), and after straining (lower right)
The three main biofeedback techniques used to treat pelvic floor dyssynergia are sensory training, electromyographic feedback, and manometric feedback.6 However, it should be remembered that measurements of pelvic floor dyssynergia may vary in different situations, likely to be minimal during home ambulatory monitoring and maximal under laboratory conditions.w1 Some authors provide additional sensory retraining to lower defecation threshold by means of progressively reducing the distension volume of a rectal balloon.5 The use of rectal sensory retraining is well standardised in faecal incontinence,7 but its clinical relevance in constipation is not yet confirmed.
Rome II criteria for constipation
Adults
Two or more of the following for at least 12 weeks (not necessarily consecutive) in the previous 12 months: Straining in 25% of bowel movements
Lumpy or hard stools in 25% of bowel movements
Sensation of incomplete evacuation in 25% of bowel movements Sensation of anorectal obstruction or blockage in 25% of bowel movements
Manual manoeuvres to facilitate 25% of bowel movements
Fewer than three defecations a week
Loose stools not present, and insufficient criteria for irritable bowel syndrome
Children
Pebble-like, hard stools for most bowel movements for 2 weeks
Firm stools less than two times a week for 2 weeks
No evidence of structural, endocrine, or metabolic disease
Sensory training was the first biofeedback technique to be used in clinical practice. It entails simulated defecation by means of a water filled balloon introduced in the rectum; this is then slowly withdrawn, while patients are asked to concentrate on the sensations evoked by the balloon and to try to ease its passage.8 Variations of this technique involve defecation of a balloon or simulated stools to improve defecatory dynamics.9
Electromyography consists of recording a patient's averaged electromyographic activity from the pelvic floor muscles for training.10 Measurements may be obtained from intraluminal probes or from surface electrodes taped to the perianal skin. By watching the recording, the patient first learns to relax the pelvic floor muscles during attempts to defecate, and then gradually increases straining efforts to increase intra-abdominal pressure while keeping the pelvic floor muscles relaxed.6
Manometry—Anal canal pressure can also be measured (by means of balloons, perfused catheters, or solid-state probes) to detect the contraction and relaxation of the pelvic floor muscles.6 The training procedures are almost identical to those described above for electromyographic training.
Few studies have compared the different biofeedback protocols. No differences were reported between electromyographic biofeedback and simulated defecation in one study,11 whereas a recent meta-analysis showed that the mean success rate with manometric biofeedback was superior to that with electromyographic biofeedback (78% v 70%).12 No differences were found between different electromyographic techniques.
Effectiveness of biofeedback in treating pelvic floor dyssynergia
Notwithstanding some pessimistic views about the effects of biofeedback interventions for gastrointestinal conditions,w6 biofeedback training seems to be a good treatment for lower gastrointestinal disturbances, especially for pelvic floor dyssynergia. The effects of such training may not be limited to the anorectum and might also be useful in other conditions in which pelvic floor dyssynergia plays a role.w7
However, good quality research in this subject is lacking. Validated scoring systems and quantitative tests are still needed, as well as more uniform and strict criteria for pelvic floor dyssynergia.1 For good quality studies, we also need improved experimental designs, larger numbers of participants, clearly defined outcome measures, knowledge of the best treatment protocol, and long term follow up.12 Finally, it remains to be established whether other promising treatments for pelvic floor dyssynergia, whether used alone25 or in combination with biofeedback,w8 could provide better clinical outcomes.
Details of extra references w1-w8 appear on bmj.com
Contributors: GB and GC conceived of and planned the review, and wrote the final draft. FC, FSN, GdR, and AM did the literature search, wrote the first draft, and helped in evaluating the review.
Funding sources: None.
Competing interests: None declared.
References
D'Hoore A, Penninckx F. Obstructed defecation. Colorectal Dis 2003;5: 280-7.
Whitehead WE, Wald A, Diamant NE, Enck P, Pemberton JH, Rao SSC. 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. McLean, VA: Degnon Associates, 2000: 483-529.
Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut 1999;45(suppl II): II43-7.
Bassotti G, Whitehead WE. Biofeedback, relaxation training, and cognitive behaviour modification as treatments for lower functional gastrointestinal disorders. QJ Med 1997;90: 545-50.
Rao SC, Welcher KD, Pelsang RE. Effects of biofeedback therapy on anorectal function in obstructive defecation. Dig Dis Sci 1997;42: 2197-205.
Whitehead WE, Heymen S, Schuster MM. Motility as a therapeutic modality: biofeedback treatment of gastrointestinal disorders. In: Schuster MM, Crowell MD, Koch KL, eds. Schuster atlas of gastrointestinal motility. 2nd ed. Hamilton, Ontario: BC Decker, 2002: 381-97.
Chiarioni G, Bassotti G, Stanganini S, Vantini I, Whitehead WE. Sensory retraining is key to biofeedback therapy for formed stool fecal incontinence. Am J Gastroenterol 2002, 97: 109-17.
Bleijenberg G, Kuijpers HC. Treatment of the spastic pelvic floor with biofeedback. Dis Colon Rectum 1987;30: 108-11.
Kawimbe BM, Papachysostomou M, Binnie NR, Clare N, Smith AN. Outlet obstruction constipation (anismus) managed by biofeedback. Gut 1991;35: 1175-9.
Cox DJ, Sutphen J, Borowitz S, Dickens MN, Singles J, Whitehead WE. Simple electromyographic biofeedback treatment for chronic pediatric constipation/encopresis: preliminary report. Biofeedback Self Regul 1994;19: 41-50.
Glia A, Gylin M, Gullberg K, Lindberg G. Biofeedback retraining in patients with functional constipation and paradoxical puborectalis contraction: comparison of anal manometry and sphincter electromyography for feedback. Dis Colon Rectum 1997;40: 889-95.
Heymen S, Jones KR, Scarlett Y, Whitehead WE. Biofeedback treatment of constipation: a critical review. Dis Colon Rectum 2003;46: 1208-17.
Wald A, Chandra R, Gabel S, Chiponis D. Evaluation of biofeedback in childhood encopresis. J Pediatr Gastroenterol Nutr 1987;6: 554-8.
Loenig-Baucke V. Modulation of abnormal defecation dynamics by biofeedback treatment in chronically constipated children with encopresis. J Pediatr 1990;116: 214-22.
Van der Plas RN, Benninga MA, Buller HA, Bossuyt PM, Akkermans LM, Redekop WK, et al. Biofeedback training of childhood constipation: a randomized controlled study. Lancet 1996;348: 776-80.
Nolan TM, Catto-Smith T, Coffey C, Wells J. Randomised controlled trial of biofeedback training in persistent encopresis with anismus. Arch Dis Child 1998;79: 131-5.
Sunic-Omejc M, Mihanovic M, Bilic A, Jurcic D, Restek-Petrovic B, Maric N, et al. Efficiency of biofeedback therapy for chronic constipation in children. Coll Antropol 2002;26(suppl): 93-101.
Bleijenberg G, Kuijpers HC. Biofeedback treatment of constipation: a comparison of two methods. Am J Gastroenterol 1994;89: 1021-6.
Koutsomanis D, Lennard-Jones JE, Roy AJ, Kamm MA. Controlled randomized trial of visual biofeedback versus muscle training without a visual display for intractable constipation. Gut 1995;37: 95-9.
Heymen S, Wexner SD, Vickers D, Nogueras JJ, Weiss EG, Pikarsky AJ. Prospective, randomized trial comparing four biofeedback techniques for patients with constipation. Dis Colon Rectum 1999;42: 1388-93.
Mason HJ, Serrano-Ikkos E, Kamm MA. Psychological state and quality of life in patients during behavioral treatment (biofeedback) for intractable constipation. Am J Gastroenterol 2002;97: 3154-9.
Battaglia E, Serra AM, Buonafede G, Dughera L, Chistolini F, Morelli A, et al. Long-term study on the effects of visual biofeedback and muscle training as a therapeutic modality in pelvic floor dyssynergia and slow-transit constipation. Dis Colon Rectum 2004;47: 90-5.
Wang J, Luo MH, Hui Q, Dong ZL. Prospective study of biofeedback retraining in patients with chronic idiopathic functional constipation. World J Gastroenterol 2003;9: 2109-13.
Gilliland R, Heymen S, Altomare DF, Park UC, Vickers D, Wexner SD. Outcome and predictors of success of biofeedback for constipation. Br J Surg 1997;84: 1123-6.
Chiarioni G, Chistolini F, Menegotti M, Salandini L, Vantini I, Morelli A, et al. A one-year follow-up study on the effects of electrogalvanic stimulation in chronic idiopathic constipation with pelvic floor dyssynergia. Dis Colon Rectum (in press).(G Bassotti, deputy chief1)
Correspondence to: G Bassotti, Strada del Cimitero, 2/a, 06131 San Marco (Perugia), Italy gabassot@tin.it
Pelvic floor dyssynergia is one of the commonest subtypes of constipation, and the conventional treatment (dietary fibre and laxatives) is often unsatisfactory. Recently biofeedback training has been introduced as an alternative treatment. The authors review the evidence for this approach and conclude that, although controlled studies are few and open to criticism, about two thirds of patients with pelvic floor dyssynergia should benefit from biofeedback training
Introduction
The common treatment for chronic constipation is with high dietary fibre and laxatives. However, some patients (and especially those with pelvic floor dyssynergia) are unresponsive to these measures, which has encouraged the use of alternative treatments such as biofeedback training.4 Biofeedback is thought to be appropriate when specific pathophysiological mechanisms are known, and the control of relevant responses can be learnt with the aid of systematic information about a function that is not usually monitored consciously.4 We have critically reviewed the evidence on use of biofeedback to treat pelvic floor dyssynergia.
Methods
Paradoxically increased anal pressure or electromyographic activity during straining is readily detected in patients with pelvic floor dyssynergia.4 Some authors have measured the pressure gradient between the rectum and the anus on straining, but its clinical relevance is unclear.5 Radiological examination of rectal evacuation (defecography) has shown that pelvic floor dyssynergia is associated with the contour of the puborectal muscle increasing or the anorectal angle decreasing (fig 2). In addition, the suspicion of impaired defecation may be confirmed by the patient's inability to expel a rectal balloon. The diagnostic relevance of other techniques (ultrasonography, evacuation scintigraphy, pelvic floor magnetic resonance imaging, etc) is under evaluation.
Fig 2 Representative defecographic sequence of a patient with pelvic floor dyssynergia, showing insufficient opening of the anal canal and of the anorectal angle, with most of the contrast medium retained after straining. The sequence shows resting (upper left), contracting (upper right), straining (lower left), and after straining (lower right)
The three main biofeedback techniques used to treat pelvic floor dyssynergia are sensory training, electromyographic feedback, and manometric feedback.6 However, it should be remembered that measurements of pelvic floor dyssynergia may vary in different situations, likely to be minimal during home ambulatory monitoring and maximal under laboratory conditions.w1 Some authors provide additional sensory retraining to lower defecation threshold by means of progressively reducing the distension volume of a rectal balloon.5 The use of rectal sensory retraining is well standardised in faecal incontinence,7 but its clinical relevance in constipation is not yet confirmed.
Rome II criteria for constipation
Adults
Two or more of the following for at least 12 weeks (not necessarily consecutive) in the previous 12 months: Straining in 25% of bowel movements
Lumpy or hard stools in 25% of bowel movements
Sensation of incomplete evacuation in 25% of bowel movements Sensation of anorectal obstruction or blockage in 25% of bowel movements
Manual manoeuvres to facilitate 25% of bowel movements
Fewer than three defecations a week
Loose stools not present, and insufficient criteria for irritable bowel syndrome
Children
Pebble-like, hard stools for most bowel movements for 2 weeks
Firm stools less than two times a week for 2 weeks
No evidence of structural, endocrine, or metabolic disease
Sensory training was the first biofeedback technique to be used in clinical practice. It entails simulated defecation by means of a water filled balloon introduced in the rectum; this is then slowly withdrawn, while patients are asked to concentrate on the sensations evoked by the balloon and to try to ease its passage.8 Variations of this technique involve defecation of a balloon or simulated stools to improve defecatory dynamics.9
Electromyography consists of recording a patient's averaged electromyographic activity from the pelvic floor muscles for training.10 Measurements may be obtained from intraluminal probes or from surface electrodes taped to the perianal skin. By watching the recording, the patient first learns to relax the pelvic floor muscles during attempts to defecate, and then gradually increases straining efforts to increase intra-abdominal pressure while keeping the pelvic floor muscles relaxed.6
Manometry—Anal canal pressure can also be measured (by means of balloons, perfused catheters, or solid-state probes) to detect the contraction and relaxation of the pelvic floor muscles.6 The training procedures are almost identical to those described above for electromyographic training.
Few studies have compared the different biofeedback protocols. No differences were reported between electromyographic biofeedback and simulated defecation in one study,11 whereas a recent meta-analysis showed that the mean success rate with manometric biofeedback was superior to that with electromyographic biofeedback (78% v 70%).12 No differences were found between different electromyographic techniques.
Effectiveness of biofeedback in treating pelvic floor dyssynergia
Notwithstanding some pessimistic views about the effects of biofeedback interventions for gastrointestinal conditions,w6 biofeedback training seems to be a good treatment for lower gastrointestinal disturbances, especially for pelvic floor dyssynergia. The effects of such training may not be limited to the anorectum and might also be useful in other conditions in which pelvic floor dyssynergia plays a role.w7
However, good quality research in this subject is lacking. Validated scoring systems and quantitative tests are still needed, as well as more uniform and strict criteria for pelvic floor dyssynergia.1 For good quality studies, we also need improved experimental designs, larger numbers of participants, clearly defined outcome measures, knowledge of the best treatment protocol, and long term follow up.12 Finally, it remains to be established whether other promising treatments for pelvic floor dyssynergia, whether used alone25 or in combination with biofeedback,w8 could provide better clinical outcomes.
Details of extra references w1-w8 appear on bmj.com
Contributors: GB and GC conceived of and planned the review, and wrote the final draft. FC, FSN, GdR, and AM did the literature search, wrote the first draft, and helped in evaluating the review.
Funding sources: None.
Competing interests: None declared.
References
D'Hoore A, Penninckx F. Obstructed defecation. Colorectal Dis 2003;5: 280-7.
Whitehead WE, Wald A, Diamant NE, Enck P, Pemberton JH, Rao SSC. 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. McLean, VA: Degnon Associates, 2000: 483-529.
Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut 1999;45(suppl II): II43-7.
Bassotti G, Whitehead WE. Biofeedback, relaxation training, and cognitive behaviour modification as treatments for lower functional gastrointestinal disorders. QJ Med 1997;90: 545-50.
Rao SC, Welcher KD, Pelsang RE. Effects of biofeedback therapy on anorectal function in obstructive defecation. Dig Dis Sci 1997;42: 2197-205.
Whitehead WE, Heymen S, Schuster MM. Motility as a therapeutic modality: biofeedback treatment of gastrointestinal disorders. In: Schuster MM, Crowell MD, Koch KL, eds. Schuster atlas of gastrointestinal motility. 2nd ed. Hamilton, Ontario: BC Decker, 2002: 381-97.
Chiarioni G, Bassotti G, Stanganini S, Vantini I, Whitehead WE. Sensory retraining is key to biofeedback therapy for formed stool fecal incontinence. Am J Gastroenterol 2002, 97: 109-17.
Bleijenberg G, Kuijpers HC. Treatment of the spastic pelvic floor with biofeedback. Dis Colon Rectum 1987;30: 108-11.
Kawimbe BM, Papachysostomou M, Binnie NR, Clare N, Smith AN. Outlet obstruction constipation (anismus) managed by biofeedback. Gut 1991;35: 1175-9.
Cox DJ, Sutphen J, Borowitz S, Dickens MN, Singles J, Whitehead WE. Simple electromyographic biofeedback treatment for chronic pediatric constipation/encopresis: preliminary report. Biofeedback Self Regul 1994;19: 41-50.
Glia A, Gylin M, Gullberg K, Lindberg G. Biofeedback retraining in patients with functional constipation and paradoxical puborectalis contraction: comparison of anal manometry and sphincter electromyography for feedback. Dis Colon Rectum 1997;40: 889-95.
Heymen S, Jones KR, Scarlett Y, Whitehead WE. Biofeedback treatment of constipation: a critical review. Dis Colon Rectum 2003;46: 1208-17.
Wald A, Chandra R, Gabel S, Chiponis D. Evaluation of biofeedback in childhood encopresis. J Pediatr Gastroenterol Nutr 1987;6: 554-8.
Loenig-Baucke V. Modulation of abnormal defecation dynamics by biofeedback treatment in chronically constipated children with encopresis. J Pediatr 1990;116: 214-22.
Van der Plas RN, Benninga MA, Buller HA, Bossuyt PM, Akkermans LM, Redekop WK, et al. Biofeedback training of childhood constipation: a randomized controlled study. Lancet 1996;348: 776-80.
Nolan TM, Catto-Smith T, Coffey C, Wells J. Randomised controlled trial of biofeedback training in persistent encopresis with anismus. Arch Dis Child 1998;79: 131-5.
Sunic-Omejc M, Mihanovic M, Bilic A, Jurcic D, Restek-Petrovic B, Maric N, et al. Efficiency of biofeedback therapy for chronic constipation in children. Coll Antropol 2002;26(suppl): 93-101.
Bleijenberg G, Kuijpers HC. Biofeedback treatment of constipation: a comparison of two methods. Am J Gastroenterol 1994;89: 1021-6.
Koutsomanis D, Lennard-Jones JE, Roy AJ, Kamm MA. Controlled randomized trial of visual biofeedback versus muscle training without a visual display for intractable constipation. Gut 1995;37: 95-9.
Heymen S, Wexner SD, Vickers D, Nogueras JJ, Weiss EG, Pikarsky AJ. Prospective, randomized trial comparing four biofeedback techniques for patients with constipation. Dis Colon Rectum 1999;42: 1388-93.
Mason HJ, Serrano-Ikkos E, Kamm MA. Psychological state and quality of life in patients during behavioral treatment (biofeedback) for intractable constipation. Am J Gastroenterol 2002;97: 3154-9.
Battaglia E, Serra AM, Buonafede G, Dughera L, Chistolini F, Morelli A, et al. Long-term study on the effects of visual biofeedback and muscle training as a therapeutic modality in pelvic floor dyssynergia and slow-transit constipation. Dis Colon Rectum 2004;47: 90-5.
Wang J, Luo MH, Hui Q, Dong ZL. Prospective study of biofeedback retraining in patients with chronic idiopathic functional constipation. World J Gastroenterol 2003;9: 2109-13.
Gilliland R, Heymen S, Altomare DF, Park UC, Vickers D, Wexner SD. Outcome and predictors of success of biofeedback for constipation. Br J Surg 1997;84: 1123-6.
Chiarioni G, Chistolini F, Menegotti M, Salandini L, Vantini I, Morelli A, et al. A one-year follow-up study on the effects of electrogalvanic stimulation in chronic idiopathic constipation with pelvic floor dyssynergia. Dis Colon Rectum (in press).(G Bassotti, deputy chief1)