Biofeedback for Constipation and Fecal Incontinence

Constipation and associated symptoms are the most common chronic gastrointestinal complaints, accounting for 2.5 million physician visits per year with a prevalence of 2% in the United States population (1,2). The Rome II Diagnostic Criteria for the Definition of Constipation as a Symptom Complex is specified in Table 6.5-1 (3). After identification and exclusion of extracolonic or anatomic causes, many patients respond favorably to medical and dietary management. However, patients unresponsive to simple treatment may require further physiologic investigation to evaluate the pathophysiologic process underlying these symptoms. Physiologic investigation generally includes a colonic transit time study, cinedefecography, anorectal manometry, and electromyography (EMG) (4), which allows for definitive diagnosis of treatable conditions including anismus, colonic inertia, rectocele, and sigmoidocele (5). Anismus—also termed pelvic floor dyssynergia, spastic pelvic floor syndrome, paradoxical puborectalis contraction, and nonrelaxing puborectalis syndrome—accounts for an estimated 50% of patients with symptoms of chronic constipation (6). The Rome II Diagnostic Criteria for a Diagnosis of Pelvic Floor Dyssynergia are specified in Table 6.5-2 (3). This disorder of unknown etiology is characterized by a failure of the puborectalis muscle to relax during defecation. Invasive surgical therapies or injection of botulinum neurotoxin (7) may be associated with an unacceptable incidence of incontinence in this disorder, and in 1993, Enck’s critical review summarized the role for biofeedback, which has become widely accepted as the treatment of choice for anismus (8) (see Chapter 6.4).