4.2. Results

for constipation by anorectal manometry. This can be carried out by the traditional standard anorectal manometry or better now by HRM. The investigation allows to estimate the degree of sphincter dysfunction and to measure the baseline values of the anal sphincter. In continuation, the patient is trained to be able produce voluntary contractions and to follow on the screen the change in anal pressure in resting and during these exercises. A therapeutic session may last up to 45 min and should be repeated weekly. Every new session should start by the baseline measurement of the anal sphincter pressure. The recordings of these values may encourage the patient and reinforce him/her. One can also estimate the value of this management for the improvement of symptoms. The patient is asked to perform similar exercises at home daily. There are 6–10 sessions recommended. If no answer is obtained, one should stop

The strategy of approach in anorectal biofeedback for incontinence has three phases. The first step aims to develop the capacity to increase the amplitude of voluntary contractions. The patient follows on the screen his/her own contraction and contractile force. The contractions are repeated at 10 s and should be as strong as possible. Between contractions, pauses of 20 s are necessary. The second phase looks for the progressive extension of perineal muscle contractions. The contraction should be as long as possible, with rest pauses twice as long as the length of the contractions [3]. A third phase may be necessary: the proprioceptive reeducation. This phase means to let the patient progressively eliminate small amounts of air, with the aim to develop contraction reflexes at small volumes. To achieve this aim, the balloon is filled with about 60 ml air and the patient is asked to perform anal contractions when he/she feels distension in the rectum. Next steps are the exercises with decreasing air volumes in the intrarectal balloon, to increase the capacity of discrimination and retention [18]. There are good results with biofeedback, but relapse after the end of therapy is possible. We further describe a

single center study to look for success and failure factors in anorectal biofeedback.

Anorectal biofeedback is an established method for the therapy of defecation disorders. However, contradictory data are reported with respect to results and sustainability of the results [18–20]. Given the possibility to work in the busiest center of gastrointestinal motility in our country, we aimed to evaluate the value of the anorectal biofeedback. Impressed by the fact that many patients included in our biofeedback program dropped out, we wanted to look for reasons of failure. Therefore, we analyzed cases of patients submitted to anorectal biofeedback, stratified on presentation and etiology of the medical condition and recorded success or

This was a prospective study conducted in a tertiary medical center with interest in functional and motility disorders; it is the single center in this country performing the anorectal

this therapeutic approach.

26 Biofeedback

4. Original study

4.1. Methods

biofeedback.

failure, as well as reasons for these outcomes.

In anal incontinence, the results were favorable in 5/8 cases (60%). Patients were able to better retain the feces and were happy with the quality of life. The rest of three described no improvement. All had organic etiology. In terminal constipation, the outcome was as follows: 5/12 (42%) cases reported positive outcome: normalization or amelioration of bowel movement frequency, while in 7/12 (58%) patients the results were not good.

The patients with incontinence who could follow the biofeedback program till the end had a significant reduction of the number of stools in average from 5 stools/day to 2 stools /day. The result is explained by the reeducation of the anal sphincter. The cases with terminal constipation showed also a change in the bowel movements after the end of the program. Thus, subjects who finished the program and reported improvement showed in average 3 stools per

Evolution of symptoms

Table 1. The parameters investigated.

Adherence to the therapeutic program

Factors with positive or negative role in preserving adherence

Duration of intervention

Quality of life

week, while the patients who did not report any improvement after biofeedback remained with one stool per week.

4.4. Symptom evolution

The most embarrassing symptoms, that is, the incapacity to defecate, respectively to maintain feces, have been ameliorated after the biofeedback interventions. One can therefore conclude that the anorectal biofeedback is a useful method for treating defection disorders. Our study was a pilot study, including only a limited number of cases. The reason for this is the low frequency of cases accepting anorectal biofeedback and the reduced number of cases with severe conditions resistant to conventional therapy. This represents a limitation for our conclusions. The health-related quality of life has also been investigated, not by specific questionnaires but by qualitative interview. Addressing questions like these: are you happy with this therapy? Did biofeedback help you? Are your family members happy with this method? All 10 subjects with positive outcome answered to these questions in a positive way, emphasizing

Factors Predicting Failure in Anorectal Biofeedback http://dx.doi.org/10.5772/intechopen.76374 29

The main limit of our study is the reduced number of patients who accepted the program of anorectal biofeedback. On the other hand, we have to accept that the study was performed in the single center of this country performing this kind of management of defecation disorders. The indications for biofeedback are relatively scarce, and for some patients, there are no obvious early results, thus discouraging patients to continue next sessions. A success factor is the motivation of the patient, leading to increased adherence, and not all of possible patients are indeed motivated. Other patients refuse because they would have to travel long distance to the biofeedback laboratory. Our center is also very busy with usual manometric investigations; therefore, time left for biofeedback is reduced also from our side. But even in these conditions, our center is one of the few in East Europe working on anorectal biofeedback. Therapeutic results are important for the patients mainly in functional anal incontinence, but also for terminal constipation. The maintenance of the outcome in terminal constipation after the finishing of the biofeedback sessions is modest, and relapses have been described after the

Better results are observed in the functional anal incontinence and almost nil in organic anal incontinence. About 70% of cases positively respond to biofeedback but there are not predictive criteria to predict well the outcome of anorectal biofeedback in incontinence. Nor in functional incontinence are the results perfect, even if carried out in supervised laboratories. At the end of therapy, relapse can occur in up of one quarter of cases with fecal incontinence. The relationship between the operator and the patient is very important for success of failure, given the very intimate character of this procedure. Lack of appropriate behavior or of empathy will lead to failure. Lack of adherence is another failure factor. Female patients respond better than males, also possibly because the nurses/technicians working in the biofeedback laboratories are of the same gender [20–23]. The complexity of the physiological phenomena involved in defecation renders the therapeutic approach by biofeedback a difficult task. We

that positive outcome is associated with better quality of life.

5. Discussions and literature review

end of the interventions [19].

The adherence to the therapy was also analyzed. It was assessed by recording the presence of the patient to the periodical biofeedback sessions and by interviewing the patients. Thus, it has been observed that among the 10 patients with positive results (5 with terminal constipation, 5 with incontinence), 8 had a perfect adherence, while 2 withdraw with 2, respectively 3 sessions before finishing the program. Those with negative results, in total 10 (7 with constipation, 3 with incontinence) had less subjects who finished the full program. The non-adherent patients presented in three cases terminal constipation and none incontinence. These data show that the adherence to a program of biofeedback in such a sensitive aspect as the defecation is very important for its success. The lack of rapid response may represent the cause of the drop out in several cases.

#### 4.3. Factors influencing the results

We asked the 10 patients who presented favorable outcome on factors who influenced their adherence to therapy and can be determining the success of the biofeedback All mentioned that adherence was considered by them as an important success factor and that they were motivated to attend the biofeedback program. Factors positively associated with adherence to biofeedback therapy and thus with success are displayed in Table 2.

Patients who withdraw before the end were less susceptible to indicate positive results. Factors that negatively influenced the success and the adherence to therapy by biofeedback are displayed in Table 3.

Motivation to adhere to therapy Higher education Lack of invasiveness Length of the biofeedback program Lack of organic lesions

Table 2. Factors positively influencing the outcome of anorectal biofeedback.

Local pain caused by frequent catheterization of the anal orifice

Lack of obvious progress during the biofeedback sessions

Distance from the laboratory making the attendance difficult

Attempts to find out alternative therapies

Table 3. Factors negatively influencing the outcome of anorectal biofeedback.

### 4.4. Symptom evolution

week, while the patients who did not report any improvement after biofeedback remained

The adherence to the therapy was also analyzed. It was assessed by recording the presence of the patient to the periodical biofeedback sessions and by interviewing the patients. Thus, it has been observed that among the 10 patients with positive results (5 with terminal constipation, 5 with incontinence), 8 had a perfect adherence, while 2 withdraw with 2, respectively 3 sessions before finishing the program. Those with negative results, in total 10 (7 with constipation, 3 with incontinence) had less subjects who finished the full program. The non-adherent patients presented in three cases terminal constipation and none incontinence. These data show that the adherence to a program of biofeedback in such a sensitive aspect as the defecation is very important for its success. The lack of rapid response may represent the cause of the drop out in

We asked the 10 patients who presented favorable outcome on factors who influenced their adherence to therapy and can be determining the success of the biofeedback All mentioned that adherence was considered by them as an important success factor and that they were motivated to attend the biofeedback program. Factors positively associated with adherence to

Patients who withdraw before the end were less susceptible to indicate positive results. Factors that negatively influenced the success and the adherence to therapy by biofeedback are

biofeedback therapy and thus with success are displayed in Table 2.

Table 2. Factors positively influencing the outcome of anorectal biofeedback.

Table 3. Factors negatively influencing the outcome of anorectal biofeedback.

Local pain caused by frequent catheterization of the anal orifice Lack of obvious progress during the biofeedback sessions Distance from the laboratory making the attendance difficult

with one stool per week.

28 Biofeedback

several cases.

displayed in Table 3.

Motivation to adhere to therapy

Length of the biofeedback program

Attempts to find out alternative therapies

Higher education Lack of invasiveness

Lack of organic lesions

4.3. Factors influencing the results

The most embarrassing symptoms, that is, the incapacity to defecate, respectively to maintain feces, have been ameliorated after the biofeedback interventions. One can therefore conclude that the anorectal biofeedback is a useful method for treating defection disorders. Our study was a pilot study, including only a limited number of cases. The reason for this is the low frequency of cases accepting anorectal biofeedback and the reduced number of cases with severe conditions resistant to conventional therapy. This represents a limitation for our conclusions. The health-related quality of life has also been investigated, not by specific questionnaires but by qualitative interview. Addressing questions like these: are you happy with this therapy? Did biofeedback help you? Are your family members happy with this method? All 10 subjects with positive outcome answered to these questions in a positive way, emphasizing that positive outcome is associated with better quality of life.
