3.2. Anorectal biofeedback in fecal incontinence

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.

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

Chronic constipation is defined as the evacuation of stools from the bowel less frequently than once every 3 days [11]. It also corresponds to the types 1 and 2 of the Bristol Stool Form Scale [12]. Two main factors may cause chronic constipation: slow transportation or difficult evacuation [13]. Therefore, we may encounter two types of constipation: transportation constipation and terminal constipation or dyskesia. Sometimes both factors are contributing to constipation. In this case, we speak of mixed constipation. The indication to use biofeedback in terminal constipation relies first on the identification of this kind of constipation. The diagnosis of terminal constipation is assessed by the measurement of colonic transit time with radiopaque markers [14]. This is a simple method allowing the estimation of total colonic transit time, as well as of segmental transit times for proximal colon, distal colon and rectosigmoid. A normal transit time of the colon rules out the transportation constipation. It is not uncommon to observe a difference between patients' symptoms and real transit time when assessed by radiopaque markers. This difference might be explained either by over reporting of anxious

constipated patients or by variability of transit from day to day in same subject.

altered visceral sensitivity or of the enlargement of the rectal ampulla.

Terminal constipation has to be confirmed by anorectal manometry. Anorectal manometry is able to diagnose terminal constipation when rest anal pressures are high or when the anal sphincter does not relax after the dilation of an intrarectal balloon. This is caused by the lack of the inhibitory recto-anal reflex. In some cases, the fecal bolus is not perceived because of

patient and investigator.

24 Biofeedback

3. Clinical use of anorectal biofeedback

3.1. Anorectal biofeedback in terminal constipation

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 this; therefore, the diagnosis is largely underestimated.

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

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 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 this therapeutic approach.

As subjects, we included in this study 20 patients. Eight of them presented with anal incontinence (2 males, 6 females, aged 46–71 years, median 55 years) and twelve patients with terminal constipation (6 males, 6 females, aged 58–78 years, median 67 years). All constipated patients presented only terminal constipation and not transportation constipation. The patients with anal incontinence were functional: 6 cases, or organic: 6 cases (2 after vaginal delivery, 1 after medullar trauma, 2 because of neuropathy). All these patients expressed their informed consent. The study was carried out according to the ethical criteria respected in any human research. They were included after anorectal manometry because conventional therapy was not helpful. Exclusion criteria were represented by the refuse to participate and contraindication to biofeedback. The biofeedback procedure was according to the description of the abovementioned methods. The constipated patients have previously been investigated for colonic transit with radiopaque pellets, and the results were normal in every case. Biofeedback sessions were scheduled twice per week for 2–3 months followed by monthly sessions for another 3–6 months. This rhythm is different from the rhythm described above, but we wanted to have more rapid results and to test the role of such intensive procedure. Patients were advised to repeat daily at home the exercises even in the absence of equipment for biofeed-

Factors Predicting Failure in Anorectal Biofeedback http://dx.doi.org/10.5772/intechopen.76374 27

All these parameters were evaluated by a qualitative method based on interviews with the

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

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

patients and using a structured interview appropriate for their understanding.

Descriptive statistics were used according to a commercial package.

frequency, while in 7/12 (58%) patients the results were not good.

back. Following parameters were investigated (Table 1).

4.2. Results

Adherence to the therapeutic program

Table 1. The parameters investigated.

Duration of intervention Evolution of symptoms

Quality of life

Factors with positive or negative role in preserving adherence

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.
