Gastroenterology

Gastroenterology

Volume 126, Supplement 1, January 2004, Pages S64-S70
Gastroenterology

Treatment options for fecal incontinence
Behavioral management of fecal incontinence in adults

https://doi.org/10.1053/j.gastro.2003.10.058Get rights and content

Abstract

Biofeedback has been advocated as first-line therapy for patients whose symptoms of mild to moderate fecal incontinence have not responded to simple dietary advice or medication. Three main modalities have been described: (1) use of an intra-anal electromyographic sensor, a probe to measure intra-anal pressure, or perianal surface electromyographic electrodes to teach the patient how to exercise the anal sphincter; (2) use of a 3-balloon system to train the patient to correctly identify the stimulus of rectal distention and to respond without delay; and (3) use of a rectal balloon to retrain the rectal sensory threshold, usually with the aim of enabling the patient to discriminate and respond to smaller rectal volumes. Although a systematic review found that biofeedback eliminated symptoms in up to one half of patients and decreased symptoms in up to two thirds, these studies suffered from methodological problems, a lack of controls, and a lack of validated outcome measures. No studies have compared different exercise instructions, measured patient compliance with those instructions, or determined any trends in symptom response to the exercises prescribed. A recent study by the author suggests that patient-therapist interaction and patient coping strategies may be more important in improving continence than performing exercises or receiving physiological feedback on sphincter function. Better-designed randomized, controlled trials are needed to evaluate different exercise programs and different elements of biofeedback. Development and validation of outcome measures are important, and predictors of outcome and effects in patient subgroups, especially elderly and neurologically impaired patients, should also be investigated.

Section snippets

Elements of biofeedback

Many different treatments have been used in the name of biofeedback. The clinicians who originally devised biofeedback training for fecal incontinence described it as an operant conditioning therapy.1 The aim was for the patient to learn to enhance the presumed reflex contraction of the external anal sphincter (EAS) muscle in response to a reflex relaxation of the internal anal sphincter muscle, which was induced by stimulating the rectoanal inhibitory reflex by using distention with a rectal

Lack of standardization in studies

Three randomized, controlled trials have attempted to evaluate the different components of biofeedback.10, 14, 15 Unfortunately, 2 of those trials had very complex designs that, on the basis of the data presented, make analysis of the different components impossible.10, 15 In one trial, decreasing the threshold for sensing rectal distention did seem to help reduce symptoms.10 Heymen et al.16 compared 4 methods of biofeedback (EMG; EMG plus rectal balloon; EMG plus home biofeedback; and EMG,

Variety of outcome measures

In a systematic review of studies involving anal sphincter biofeedback and pelvic floor exercises for fecal incontinence, we noted a wide variety of outcome measures.20 Most studies considered in this review chose reduction of episodes of fecal incontinence as the primary end point; however, few studies explicitly stated that diaries or questionnaires were used to gather this information. The criteria for success in these studies varied from a 90% reduction21, 22 to a 50% reduction23 in

Cochrane systematic review of controlled clinical trials

A separate Cochrane review of controlled studies of biofeedback and exercises for fecal incontinence has been conducted.38 Cochrane reviews include only evidence from randomized or quasi-randomized controlled trials that are considered to have the highest-quality evidence for efficacy of healthcare interventions. The Cochrane review of controlled studies of biofeedback and exercises for fecal incontinence concluded that “there is not enough evidence from trials to judge whether these treatments

Report of a randomized, controlled trial of biofeedback in adults

Our aim was to conduct a randomized, controlled trial to determine whether exercises or biofeedback produced any change in patients’ fecal incontinence symptoms.

Future research needs

There is a need for better-designed randomized, controlled trials with adequate numbers of patients to evaluate different exercise programs and different elements of biofeedback. Control groups are essential for distinguishing between true therapeutic effects of treatment and the inevitably large effect of intervening per se in any functional problem with behavioral methods. Clinical series have indicated that biofeedback, as it is practiced in most clinics, has a positive effect on fecal

Summary

Behavioral management, or biofeedback, has been advocated as the management technique of first choice for symptoms of mild to moderate fecal incontinence.46 A recent systematic review found that in clinical series, up to one half of patients with fecal incontinence were rendered symptom free and up to two thirds had decreased symptoms after biofeedback.20 However, evidence from studies using rigorous scientific methods is scant.38 Results of a recent study by this author suggest that the

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    Copyright © 2004 American Gastroenterological Association. Published by Elsevier Inc. All rights reserved.