Pelvic Floor Training and Biofeedback

Both pelvic floor training and biofeedback have been reported to be effective in many patients with fecal incontinence associated with impaired functioning of the puborectalis muscle and/or the external anal sphincter. In contrast to pelvic floor retraining, which is directed exclusively at reeducating weakened or impaired muscles, biofeedback often employs techniques to alter rectal sensation and sphincter muscle responsiveness to intrarectal stimuli such as balloon distension. However, the biofeedback literature does not reflect a unified mechanistic approach. There appears to be a general consensus that improvement of thresholds of perception of rectal sensation and the synchronization of external anal sphincter contractions to rectal distension are important factors associated with improvement [28]. In contrast, increased striated muscle strength and endurance after biofeedback training have not been shown consistently.

There is widespread agreement that biofeedback is effective in many patients who fulfill entry criteria, and it has no adverse consequences. However, the biofeedback literature has been plagued by methodological inadequacies, few long-term follow-up studies, and absence of consistent and validated outcomes. There is no consensus concerning which components of biofeedback are important, including the critical role of the patient-therapist relationship [28]. To address these issues, a recent study examined critical components of the biofeedback process by randomizing 171 patients with fecal incontinence into four therapeutic groups [29]. Slightly more than 50% of patients reported clinical improvement on an intention-to-treat analysis. However, there were no differences between patients who received only advice from nurse therapists about strategies to reduce incontinence, those who received both advice and verbal instructions about sphincter exercises, those who received advice together with a hospital-based biofeedback program, and those who received both hospital and home biofeedback. At present, the evidence for using instrument-based training is insufficient, but the value of dedicated and trained individuals to work with patients cannot be overstated [29].

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