2. Technique of anorectal biofeedback

the application of feedback in the gastrointestinal tract. If you look to the well-known French dictionary Larousse, one cannot easily understand the use of biofeedback by gastroenterologists:" Méthode de rééducation utilisant l'action du système nerveux sur les réactions physiologiques "(Method for reducation using the action of the nervous system on physiological recations). To our disappointment, the explicatory dictionary of our tongue mother, Romanian, simply ignores the word biofeedback, maximum it offers is only "feedback." According to these definitions, nonspecialists could believe that biofeedback is something for the patients with disorders of the nervous system. However, the gastrointestinal tract has its own nervous system as well,

Which is the segment of the gastrointestinal tract best suitable for the application of biofeedback? This is the anorectal segment, having important innervation and requiring a perfect correlation between the contraction and relaxation of its different components during defecation [1]. Defecation is a complex function and its deterioration may have very important impact on the quality of life of any patient with defecation disorders [2]. The application of the biofeedback for the correction of defecation disorders caused by the impairment of the

The physiological signal triggering the biofeedback activity is represented by the pressure of the anorectum in relaxation and contraction. Thus, anorectal biofeedback relies on anorectal manometry. One can claim that anorectal biofeedback represents the field where anorectal manometry evolves from the diagnostic role to the therapeutic role [3]. The clinical conditions where anorectal biofeedback based on anorectal manometry is useful are represented by defecation disorders: anal incontinence and terminal constipation. Both may become severe

The anatomical and physiological background of the normal defecation relies on the integrity of the anorectal structure and function, and these may be influenced by general or systemic conditions or by local changes [8]. The retentions of the fecal bolus are a complex mechanism that involves the two anal sphincters as well as the 90 anorectal flexure. During defecation, the external anal sphincter is relaxing, the puborectal muscle is relaxing as well, and this leads to changes of the anorectal angle to 140; meanwhile, the abdominal wall muscles contract to increase the intraabdominal pressure. The anal canal is situated in the thickness of the perineum. Posterior to the anus are found in the levator ani muscles and laterally the ischioanal fossa is found. The anatomical relations of the anterior aspect of the anus are different in

The internal structure of the anal canal is covered by a mucosa formed from simple epithelium. At this level are present the vertical folds that form the anal columns. The inferior third of anal canal is covered by a stratified squamous epithelium that is continuous with the perineal skin. The external anal sphincter is formed from three circular striated muscles the surround the anal canal. The internal anal sphincter lies directly superiorly to the external sphincter. While the control of the external sphincter is voluntary, the internal one is controlled entirely involuntary. The innervations of the sphincter apparatus are realized through fibers from the

thus biofeedback should work also for the gastrointestinal system.

anorectal segment of the digestive tract is called anorectal biofeedback.

women and men. In woman, we found the vagina and in men the prostate.

conditions deteriorating the quality of life [4–7].

lumbosacral plexus.

22 Biofeedback

The performance of anorectal biofeedback requires the availability of a manometry laboratory [1, 9]. Figure 1 displays a room for gastrointestinal manometry which is useful also for anorectal anometry and biofeedback. The equipment needed for biofeedback is any good system of standard anorectal manometry or of high-resolution manometry (HRM).

We started the procedure with water-perfused systems, using balloons. The balloons were inflated during the procedure and following anorectal manometry, asking the patient to expel the balloon. The patients were also looking to the screen to observe the pressure variations on the screen. Figure 2 shows the catheter and the balloon used for biofeedback. More recently, after finishing the investigations described here, we started working with a solid-state highresolution device.

The investigation of the anorectal function in patients with defecation disorders should be carried out in a dedicated room of the laboratory for gastrointestinal motility studies in conditions of

Figure 1. Laboratory for anorectal manometry and biofeedback.

Figure 2. Balloon used for anorectal biofeedback.

comfort (termic and social) respecting patients intimacy. It is advisable to do not accept many trainees during the investigation, as patients could feel stressed and unable to relax the external anal sphincter when asked to do so. One should begin by assessing the anorectal pressures in order to have a correct manometric diagnosis (either incontinence or terminal constipation). During the investigation, the patient is able to look to its own curves of pressure in the anorectal canal, in relaxed condition or in contraction state. Thus, the patient receives the signal offered by the recording of the pressure either by standard manometry or by HRM. The patient becomes aware of the functional deficit of his/her anorectal disorder. The pressure recordings represent in continuation the starting baseline for the exercises to correct these functional disorders [9, 10]. The investigation is carried out by a specialist (can be medical doctor, fellow or technician/nurse), but the biofeedback session should be performed by a very dedicated person, preferably a technician or nurse. The staff should have experience, empathy, patience and tolerance with the patient.

If the terminal constipation cannot be managed with normal dietary and pharmacological measures, one should proceed to anorectal biofeedback. The first session starts with the routine anorectal manometry just to identify the pathogenic background and to explain it to the patient. This investigation represents the baseline for consecutive measurements during next sessions. The patient has the possibility to look to the screen of the manometric device and

Factors Predicting Failure in Anorectal Biofeedback http://dx.doi.org/10.5772/intechopen.76374 25

The sessions are grouped in four steps [15]. During the first step, the patient learns how to try to expel the fecal bolus; during these exercises, the patient tries to relax the anal sphincter to allow to the stool to pass through out. Simultaneously the patient learns how to increase the abdominal pressure. These exercises should be repeated after at least 1 min, several times, for 30 min. If fatigue occurs, the rhythm of exercises should be diminished. During this exercise, one shows to the patient how the correct modality to expel the stool is and is encouraged to continue practicing. In the second step, the patient is helped to become aware of the independence of abdominal and anal contractions. The patient has to contract the anal sphincter without contracting the abdominal muscles and later to contract the abdominal muscles without contracting the anal sphincter. During the third step, the anal relaxation is practiced. After few exercises with the anorectal balloon, the patient is instructed to perform the Valsalva maneuver. The fourth and last step is the forced push to correctly expel the balloon. This movement starts with a diaphragmatic aspiration followed by a respiratory blocking; pushing the balloon has to be energic, progressive and direct. The abdomen of the patient has to become convex. The aim of this maneuver is to obtain three steps elimination of the rectal content: balloon during feedback exercises, feces in real life. The three steps are: anal sphincter relaxation, aspiration of the diaphragm and apnea, correct pushing maintaining the sphincter

These sessions of anorectal biofeedback should be repeated weekly. Patients can perform also at home these exercises, either without computer, or with transportable biofeedback devices. The length of the therapy is at least 3 months of weekly sessions followed by monthly sessions

The fecal incontinence called also anal incontinence is a serious medical condition about which neither doctors nor patients like to discuss [1, 16]. Of organic or functional etiology, this condition is impairing the quality of life very much. Most people do not like to complain of

The biofeedback in fecal incontinence is recommended for incontinence caused by the dysfunction of the anal sphincter. In functional incontinence, the results are superior to the organic incontinence; therefore, it should be indicated in functional incontinence, while other conditions present only a relative indication. Incontinence following medullar section, like after

The principle of the intervention is to practice a kind of gymnastics for the anal sphincter in order to develop its capacity to retain the fecal material in the rectum. The procedure starts like

to find out pressure and relaxation alterations.

in relaxed state.

for another interval of 3–6 months.

3.2. Anorectal biofeedback in fecal incontinence

this; therefore, the diagnosis is largely underestimated.

traffic accidents, has almost no success at all [3, 17].

Of course, the patient requires a preliminary preparation for every biofeedback session. This is the same as for anorectal manometric investigation: empty rectum (easy in incontinence, difficult in terminal constipation), emesis should be required at least 60 min before the intervention. All these prerequisites make very much necessary a good collaboration between patient and investigator.
