Efficacy of biofeedback training in improving faecal

Transcription

1 Gut, 199, 31, Deprtment of Peditrics, niversity of Iow, Iow City, Iow, SA V Loening-Bucke Correspondence to: Dr V Loening-Bucke, Deprtment of Peditrics, niversity of Iow Hospitls nd Clinics, Iow City, Iow 52242, SA. Accepted for publiction 2 Februry 199 TABLE I Efficcy of biofeedbck trining in improving fecl incontinence nd norectl physiologic function V Loening-Bucke Abstrct The efficcy of biofeedbck on fecl incontinence nd norectl function ws evluted in eight ptients with fecl incontinence treted with biofeedbck trining nd medicl therpy. Outcome nd norectl function were compred with nine fecl incontinent ptients who received medicl therpy lone. Three month follow up showed tht 5% of ptients in the biofeedbck plus conventionl group nd 56% of those treted conventionlly only hd improved. One yer follow up showed tht 13% in the biofeedbck group were free of soiling nd n dditionl 25% hd improved. The results were similr in the conventionlly treted group -11% were free of soiling nd n dditionl 44% improved. Anl pressures t rest nd squeeze, the rectl distension volume tht induced sustined inhibition of both the externl nd internl nl sphincter, nd continence to rectlly infused sline were signiiicntly reduced in both groups of ptients compred with (p<5). hd no effect on these bnorml norectl functions in either ptients who improved or those who did not. The improvement in fecl incontinence ws probbly due to medicl intervention or regression of symptoms with time, or both, nd not the result of biofeedbck trining. Continence depends on the nl sphincters, the rectl reservoir, nd the mechnisms tht govern wter nd electrolyte trnsport in the gut nd determine stool consistency. Fecl incontinence is defined s the inbility to retin solid or liquid stool. p to 8% of ptients with fecl Chrcteristics of biofeedbck treted incontinent ptients nd results of three month nd oneyer follow up incontinence present without evidence of generlised neurologicl disorders or of other norectl bnormlities,' nd this hs been referred to s idiopthic fecl incontinence.2 Ptients with idiopthic incontinence hve lower sustined intr-nl squeeze pressures thn norml control subjects nd bnorml resting electromyogrphic ctivity in the externl nl sphincter.3 Histologicl studies of the pelvic floor nd the externl sphincter hve shown bnormlities which could be explined on the bsis of prtil denervtion.4 This denervtion injury is thought to be cused by chronic strining to defecte, child bering, childbirth, or rectl prolpse. In the pst decde new, biofeedbck, hs been developed for vriety of illnesses. utilises the ptient's self control over bodily functions. As therpy for gstrointestinl disorders, biofeedbck hs been pplied most successfully nd extensively to ptients with fecl incontinence. During biofeedbck trining the ptient is provided instntly with informtion on the current function of the externl nl sphincter by giving him or her visul or uditory informtion, or both, using n electronic device. This procedure is bsed on the ssumption tht the supposedly involuntry nture of some physiologicl responses nd hence the impossibility of their self control stem from the poor fferent informtion from the norectl continence mechnisms rther thn irremedil defects in efferent informtion. In number of uncontrolled studies, biofeedbck trining hs been reported to result in continence or considerbly reduced frequency of fecl incontinence in 73-8% of ptients.5-" Therpeutic gins seem to be mintined t one I yer Incontinent of 3 month follow up follow up Age Incontinence Frequency Formed Dirrhoel rinry Grvl Subjective Frequency Frequency Ptient (yrs) (yrs) ofsoiling stool stool Gs Pst history incontinence pr Medictions outcome of soiling of soiling /dy + + Yes 11/6 Modne fibre Improved, 2/wk None, decresed dirrhoe dirrhoe resolved /wk Occ. + + Yes 4/4 Kopectte Improved -2/wk 1/wk metmucil fibre Dily Occ. + + Stress only 3/3 Fibre Improved, 5/wk 5/wk decresed dirrhoe Dily No + + Constiption No 7/7 Fibre Improved, I/wk 1/wk for 28 yrs decresed dirrhoe /wk No + + No 5/5 Cholestyrmine Not improved 1/wk 1-2/wk imodium /dy Occ. + + Ant. resection No / Metmucil Not improved -1/dy Colostomy for rectl imodium prolpse Dily + + Yes 5/4 Metmucil Not improved, Dily Dily imodium decresed dirrhoe I/wk Stress only 3/3 Metmucil Not improved l/wk I/wk 1395 Gut: first published s /gut on 1 December 199. Downloded from on 13 August 218 by guest. Protected by copyright.

2 1396 Loening-Bucke TABLE II Chrcteristics ofconventionlly treted incontinent ptients nd results of three month nd oneyerfollow up I yer follow Incontinent of 3 month follow up P Age Incontinence Frequency Formed rinry Grv! Subjective Frequency Frequency Ptient (yrs) (yrs) ofsoiling stool Dirrhoe Gs Pst history incontinence pr Medictions outcome ofsoiling ofsoiling /wk No + + Lifelong Yes 3/3 Imodium Cured None None constiption metmucil Dily Severe No 1/1 Lomotil Improved 2-3/mth 2-3/mth constiption metmucil /dy Stress only 3/3 Lomotil psyllium Improved 6/mth 6/mth /dy Low nt. No 7/7 Improved 3/wk 3/wk resection nstomosis 1 cm bove nus /dy Bypss for Yes 5/5 Improved 1/dy 1/dy morbid obesity /wk Stress only 3/3 Not improved 2-3/wk 2-3/wk /mth + + Subtotl Yes / Codeine Not improved 6-7/mth 6-7/mth colectomy metmucil for imodium diverticulitis /dy + + Cervicl 3/3 Metmucil Not improved 4/dy 5/dy cncer nd irrdition 3 yrs go /dy Cervicl No 1/1 Cholestyrmine Not improved 2/dy Colostomy cncer nd irrdition 6 yrs go to two yer follow up. The mechnisms for the improved continence re not known, since only few studies reported norectl mnometric mesurements before nd fter biofeedbck. The ims of the present study were to evlute: (1) the efficcy of biofeedbck () by evluting outcome in ptients with fecl incontinence treted with biofeedbck trining nd medicl therpy nd (b) by compring the outcome of the biofeedbck treted ptients to tht in consecutive group of fecl incontinent ptients treted with medicl therpy lone; nd (2) the effects of biofeedbck on norectl function by compring norectl mnometric mesurements before nd fter biofeedbck. Methods SBJECTS The study popultion consisted of 17 women ged yers (men 64 yers) who complined of fecl incontinence. All experienced incontinence with dirrhoel stools nd 59% lso with formed stools (see Tbles I nd II). Eight women with fecl incontinence (ged 35 to 78 yers, men 63 yers) received biofeedbck consisting of three one hour trining sessions, nd performed dily nl exercises (Kegle exercises) for three months. In ddition, these eight received medicl to improve stool consistency. One control group consisted of nine femle ptients with fecl incontinence (ged 47 to 84 yers, men 66 yers) who recieved only medicl therpy to improve stool consistncy nd fecl incontinence. All ptients with fecl incontinence were seen in the Gstroenterology nd Gstrointestinl Surgery Clinics t the niversity of Iow. Ptients receiving biofeedbck were evluted from September 1983 to August 1985, nd the control group were consecutively evluted from September 1985 to June Ptients were enrolled if they experienced fecl incontinence t lest once week. Ptients with disruption of the nl sphincter due to birth trum or surgery to the nl cnl (fissurectomy or fistulectomy) nd ptients with generlised neurologicl or musculr disese were not enrolled. Four dditionl incontinent women were excluded. They elected not to return for second nd third biofeedbck session for the following resons: one felt unble to trvel becuse of 1 incontinent episodes per dy, one did not think biofeedbck trining would help, nd two ptients with Crohn's disese of the colon underwent colectomy nd ileostomy (even so one experienced improvement fter the first session). Some of the ptients included in the fecl incontinent control group suffered from gstrointestinl disese cusing dirrhoe, but hd no involvement of the nl cnl. The chrcteristics of the fecl incontinent ptients re presented in Tbles I nd II. The norectl physiologicl dt obtined on the biofeedbck group were lso compred with those of 11 helthy control women (3 to 81 yers of ge, men 64 yers). These 11 were selected becuse of ge from group of 18 helthy women who were studied previously.12 They hd two bowel movements per dy to one every other dy. They hd no history of previous gstrointestinl disese nd their physicl exmintion yielded norml results. The study ws pproved by the Institutionl Humn Reserch Review Committee. Written informed consent ws obtined from ll biofeedbck subjects nd. STDY DESIGN A complete history nd physicl exmintion were performed on ll subjects nd the frequency nd consistency of bowel movements nd soiling episodes were determined from the stool recordings of the pst month. Ptients kept diries of fecl soiling nd bowel movements for n dditionl three months. Anorectl mnometry nd sline continence test were performed t Gut: first published s /gut on 1 December 199. Downloded from on 13 August 218 by guest. Protected by copyright.

3 Efficcy ofbiofeedbck trining in improvingfecl incontinence nd norectl physiologicfunction 1397 Figure 1: Intrluminl pressure recordings from the nl cnl during rectl blloon distension with 6 ml irfor 1-2 seconds. A helthy person is ble to voluntrily contrct the externl nl sphincter (A), hs reflex contrction ofthe externl nl sphincter before the reflex relxtion ofthe internl nl sphincter fter blloon distension (C), nd cn override the reflex relxtion when blloon distension is perceived (E). A ptient with wek nl sphincter cn ccomplish only wek nd short voluntry contrction ofthe externl nl sphincter (B), hs no reflex contrction ofthe externl nl sphincter fter blloon distension (D), nd is unble to override the reflex relxtion when told to squeeze s soon s rectl distension is perceived (F). the beginning of the study in ll subjects nd repeted n verge two months lter in ptients doing dily nl exercises nd receiving the three biofeedbck sessions. Three months nd 12 months fter the initil norectl evlution ll ptients were sked to fill out follow up questionnire which included questions on mediction use, stooling ptterns, nd frequency of soiling. BIOFEEDBACK TREATMENT Three one hour long biofeedbck sessions were given using three blloon system developed by Schuster et l."3 involved mesuring internl sphincter relxtion nd externl sphincter contrction by recording pressure chnges in two intr-nl blloons nd using third blloon for rectl distension. incorported three seprte nd potentilly effective components: exercise of the externl sphincter muscle; trining in discrimintion of rectl senstions; nd trining synchrony of the internl nd externl sphincter responses to rectl distension.6 During biofeedbck the ptient ws mde wre of the bnorml -wek or bsent pressure increse during voluntry nl sphincter contrction, of rectl senstions during distension, nd of bsent or wek externl sphincter contrction before internl sphincter relxtion. All this ws visulised during the norectl mnometric recording. The ptients were lso shown trcing from norml person (Fig 1(A), (C), (E)) to demonstrte the missing or wek voluntry externl sphincter/ pelvic floor contrction (Fig 1(B)), the missing reflex contrction during rectl distension (Fig 1(D)), nd the inbility to override reflex relxtion of the internl sphincter with externl sphincter squeeze (Figure 1(F)). The ptients were instructed to contrct the voluntry nl sphincter (vrying muscles in the nl re which surround the nl cnl, such s the externl nl sphincter, puborectlis muscle, nd the muscles of the pelvic floor. Constnt visul (by recording) nd verbl (by the technicin) reinforcements were given when correct responses were mde, nd the ptients were encourged to try hrder or to modify their efforts in order to produce trcings similr to norml trcings in pproximtely 5 trining trils per session. In ddition, rectl blloon distension volumes lrge enough to be felt by the ptients were used in n effort to trin the ptients to recognise smller nd smller distension volumes nd to synchronise voluntry nl sphincter contrction with blloon distension. The ptients were encourged to increse the mplitude nd durtion of the voluntry nl sphincter response. In some ptients n bnorml increse in intr-bdominl pressure during ttempted nl squeeze ws recorded. These ptients were instructed to inhibit the intr-bdominl pressure increse. As trining proceeded, trils in which control ws tested in the bsence of biofeedbck were introduced to encourge the development of utonomous self control. CONVENTIONAL THERAPY Conventionl medicl consisted of fibre, psyllium, lopermide (Imodium), diphenoxylte hydrochloride with tropine sulphte (Lomotil), cholestyrmine, etc (see Tbles I nd II). Mny ptients were receiving conventionl medicl t the time of their first evlution. Conventionl ws djusted during the follow up visits to further improve consistency nd frequency of stooling by the ptient's personl physicin. MEASREMENTS Subjective mesurement. Subjective mesurement of continence ws obtined from the stool diries nd pre nd follow up questionnires. A good response (improvement nd cure of incontinence) ws defined s the disppernce of soiling or.75% improvement in the frequency of soiling three nd 12 months fter the study begn.7 14 Objective mesurements. Objective mesurements were obtined through norectl mnometric evlution nd sline continence test, done once in helthy nd fecl incontinent nd twice in the biofeedbck treted fecl incdntinent ptients. These ptients were re-evluted on the dy of the third biofeedbck trining session. The bttery of Gut: first published s /gut on 1 December 199. Downloded from on 13 August 218 by guest. Protected by copyright.

4 1398 Loening-Bucke norectl tests ws repeted four or more hours fter the biofeedbck session so tht the nl muscles hd time to recover from the trining in the morning. The instrument used for the norectl mnometric evlution ws motility probe (model P31-D3, Sndhill Scientific, Littleton, Colordo, SA).'5 16 This ws flexible, silicone rubber tube (5 mm in dimeter) tht contined three intrluminl trnsducers spced 5 cm prt t the distl end. A ltex blloon ws ttched to the end of thin polyethylene tube nd ws tied to the tip of the motility probe, 5 cm bove the distl end. Pressure from the ltex blloon ws trnsmitted vi the polyethylene tube to pressure trnsducer (Stthm PDS, Stthm Instruments, Oxford, Cliforni, SA). The output of ll four trnsducers were fed into dynogrph recorder (R611, SensorMedics, Anheim, Cliforni, SA). The mnometric studies were performed with the subjects lying on their left side nd the hips nd knees flexed. The nl resting pressure nd mximl squeeze pressure were determined during step wise retrction of 1 cm every two minutes of one intrluminl pressure trnsducer of the motility probe from the rectum through the nl cnl. The nl resting pressure ws defined s the pressure (mmhg) t the troughs of the wves. The highest nl resting pressure ws locted 2 cm bove the nl verge. The mximl squeeze pressure (mmhg) ws the highest pressure mesured bove nl resting pressure. We defined squeeze s pressure increse in the nl cnl without intr-bdominl pressure increse. Anl pullthrough pressure ws mesured by rpidly pulling (1 cm/i second) the three intrluminl trnsducers from the rectum through the nl cnl while the subject ws resting nd lso during voluntry squeeze. The nl pullthrough pressure ws defined s the pressure difference in mmhg between the pek of the curve on the pressure trcing nd tmospheric pressure, nd ws clculted for ech subject s the verge of six mesurements t rest nd s the verge of the three highest mesurements during voluntry squeeze. The effect of rectl distension on nl pressure ws ssessed with the bse of the ltex blloon lying 12 cm bove the nl verge nd the pressure trnsducer lying in the nl cnl in the re with the highest pressure (pproximtely 2 cm bove the nl verge). The threshold of the rectosphincteric reflex nd the threshold of rectl senstion (ml ir) were determined three times by inflting the blloon trnsiently for 1 second in rndom order with 6, 5, 4, 3, 25, 2, 15, 1, nd 5 ml of ir with grduted syringe, strting ech time t. The threshold of the rectosphincteric reflex ws the smllest ir volume tht produced 5 mmhg or greter decrese in nl pressure. The ir volume when two ofthe three infltions were felt ws defined s the threshold of rectl senstion. The criticl volume, the miniml mount of ir (ml) felt s lsting urge to defecte nd the volume of constnt relxtion, the rectl distension volume which produced sustined complete relxtion of the internl nd externl nl sphincter were determined by step wise dding 3 ml ir ech 2 seconds into the rectl blloon. When the criticl volume hd been reched, but constnt relxtion hd not occurred, the next highest volume ws used s the volume of constnt relxtion. For objective mesurement of overll continence the sline continence test'7 ws done immeditely fter the mnometric evlution. A smll ctheter ws plced into the distl bowel with its tip positioned 1 cm from the nl verge. Sline mintined t 37 C ws infused into the distl bowel t rte of 6 ml/minute up to 78 ml, while the subjects st upright in specilly designed chir with centrl round perture. Any lekge ws collected by mens of funnel nd collecting cylinder which st on top of weight trnsducer. The signl from the weight trnsducer ws fed into the dynogrph recorder. The volume infused into the rectum when lekge of -1 ml sline first occurred ws mesured (lek volume). In subjects with no lekge vlue of 78 ml sline ws used for the nlysis. Sttisticl nlysis. The Wilcoxon non-pired rnk sum test, Wilcoxon signed rnk sum test, nd Fisher's exct probbility test were used. Results The clinicl chrcteristics of ptients treted with biofeedbck, dily nl exercises, nd medicl therpy cn be seen in Tble I, nd those of ptients treted with medicl therpy lone re listed in Tble II. All eight ptients in the biofeedbck treted group experienced fecl incontinence with dirrhoe, four of six complined of incontinence with formed stools, while two ptients hd no formed bowel movements. All nine ptients in the fecl incontinent conventionlly treted group experienced fecl incontinence with dirrhoe, six of seven complined of incontinence with formed stools, nd two ptients hd no formed bowel movements. Ptients in both groups were similr in ge. EFFICACY OF BIOFEEDBACK FOR FAECAL INCONTINENCE Three month follow up (Tbles I nd II). None of the eight ptients who hd received biofeedbck were free of soiling; four ptients (5%) reported improvement nd four (5%) reported no chnge in the frequency of soiling one month fter biofeedbck trining ws completed. Three months fter the initil mnometric evlution one of the nine conventionlly treted ptients ws free of soiling nd four reported improvement (56%), while four ptients (44%) reported no chnge in the frequency of soiling. Three months fter the initil mnometric evlution biofeedbck plus conventionl treted ptients did not differ in improvement in soiling frequency to ptients receiving conventionl therpy lone. One yer follow up (Tbles I nd II). One yer fter the initil evlution only one of the eight biofeedbck treted ptients hd no soiling nd two hd improved (38%), four hd no reduction in the frequency of soiling, nd one ptient hd undergone colostomy to obtin relief from soiling. One of the conventionlly treted ptients Gut: first published s /gut on 1 December 199. Downloded from on 13 August 218 by guest. Protected by copyright.

5 Efficcy ofbiofeedbck triningin improvingfecl incontinence nd norectlphysiologicfunction 1399 Figure 2: Highest nl resting pressure, mximl nl squeeze pressure, nd nl pullthrough pressures t rest nd during squeeze in ptients before nd fter biofeedbck, in comprison with helthy control subjects nd conventionlly treted fecl incontinent control subjects. mm Hg 7, mm Hg Highest nl pressure 181 I Anl pull through prssure t rest 121. I I -. * * - Good clinicl response --- Poor clinicl response Incontinent * Good clinicl response O Poor clinicl response continued to be free of soiling, four were improved (56%), three hd no reduction in the frequency of soiling, nd one hd undergone colostomy. This ptient hd developed sigmoid stricture becuse of irrdition. One yer fter the initil mnometric norectl evlution ptients who hd received biofeedbck trining in ddition to conventionl hd no better outcome thn ptients treted with conventionl therpy lone. EFFECTS OF BIOFEEDBACK TREATMENT ON ANORECTAL FNCTION Anl pressures (Tble III nd Fig 2). A or II -( mm Hg S Incontinent Anl pull through presure during squee ] mmhg* Ij 'I - - -,-- treted ptients hd no improvement in men (SD) highest nl resting pressure (before 4 (15), fterwrds 41 (13) mmhg), mximl squeeze pressure (before 34 (46), fterwrds 28 (23) mmhg), nd nl pullthrough pressure t rest (before 62 (26), fterwrds 57 (14) mmhg) nd during squeeze (before 91 (42), fterwrds 89 (35) mmhg) fter biofeedbck nd dily nl exercises. There ws no significnt difference for these nl pressure mesurements before nd fter biofeedbck trining in the four ptients who improved nd the four ptients who did not (see Fig 2 nd Tble III). treted ptients hd significntly lower mximl squeeze pressures so A Incontinent Gut: first published s /gut on 1 December 199. Downloded from on 13 August 218 by guest. Protected by copyright.

6 14 Loening-Bucke TABLE III Men (SD) nl mesurements in helthy nd improved nd unimproved ptients before nd fter biofeedbck trining nd fecl incontinent treted ptients Fecl incontinent Improved Not improved Not Improved improved (n=ll) (n=4) (n=4) (n=4) (n=4) (n=s) (n=4) Highest nl resting tone (mmhg) 49 (14) 37 (6) 35 (9) 42 (21) 47 (15) 26 (18) 33 (14) Mximl squeeze pressure (mmhg) 56 (17) 42 (64) 33 (27) 25 (25) 22 (21) 22 (8) 45 (4) Anl pullthrough pressure t rest (mmhg) 11 (22) 53 (17) 51 (4) 74 (35) 63 (18) Not done Not done Anl pullthrough pressure during squeeze (mmhg) 148 (29) 82 (32) 71 (2) 12 (57) 16 (41) Not done Not done mm Hg mm Ht A 121w Hietnlpreure Al /,\/' -. Good clinicl response ---O Poor clinicl response Incontinent * Good clinicl response o Poor clinicl response S Incontinent mm Hg 14-i mm Hg I 18- Mximl squeeze o'o 15o ---] 121 I 91 \ o *C7T * _- so Incontinent Gut: first published s /gut on 1 December 199. Downloded from on 13 August 218 by guest. Protected by copyright. Figure 3: Threshold ofrectl senstion, criticl volume, volume ofconstnt relxtion, nd sline volume when 21 ml leked in ptients before nd fter biofeedbck, in comprison with helthy control subjects nd conventionlly tretedfecl incontinent control subjects.

7 Efficcy ofbiofeedbck trining in improvingfecl incontinence nd norectl physiologic function 141 TABLE IV Effects ofrectl blloon distension nd sline continence test in helthy nd improved nd not improved ptients before nd fter biofeedbck trining ndfecl incontinent (men (SEM)) treted ptients Fecl incontinent Improved Not improved Not Improved improved (n= 11) (n=4) (n=4) (n=4) (n=4) (n=5) (n=4) Rectl distension volume (ml ir) Rectosphincteric reflex 18 (8) 1 (4) 13 (6) 2 (14) 24 (24) 25 (17) 23 (3) Threshold senstion 14 (9) 21 (5) 21 (13) 2 (5) 28 (1) 27 (8) 31 (19) Criticl volume 157 (78) 12 (49) 95 (33) 93 (4) 1 (42) 16 (67) 15 (17) Volume of constnt relxtion 192 (8) 83 (45) 85 (29) 55 (26) 113 (62) 18 (86) 88 (57) Lek volume (ml sline) 553 (235) 113 (19) 135 (15) 115 (12) 98 (75) 78 (63) 79 (48) nd nl pullthrough pressures t rest nd during squeeze thn the helthy (p< 5). treted ptients were not significntly different from conventionlly treted ptients in men nl resting pressure or mximl squeeze pressure. Anl pullthrough pressures t rest nd during squeeze were not mesured in the conventionlly treted ptients. Effects ofrectl blloon distension (Tble IV nd Fig 3). treted ptients hd no improvement in the miniml rectl distension volumes required to produce rectosphincteric reflex (before 15 (11), fterwrds 18 (18) ml), threshold of rectl senstion (before 21 (4), fterwrds 24 (11) ml), n urge to defecte (criticl volume (before 16 (44), fterwrds 98 (35) ml), or complete sustined inhibition ofboth the internl nd externl nl sphincters (before 69 (37), fterwrds 99 (47) ml). There ws no significnt difference in these distension tests before nd fter biofeedbck trining in the four ptients who improved nd the four who did not (Fig 3 nd Tble IV). treted ptients were not significntly different from conventionlly treted ptients in these distension volumes. The volume t which constnt relxtion of both sphincters occurred ws significntly reduced in the eight biofeedbck treted ptients (before 69 (37), fterwrds 99 (47) ml) nd the fecl incontinent control subjects (99 (71) ml) s compred with (192 (8) ml) (p< 5). In none of the helthy control subjects did constnt relxtion occur before feeling strong urge to defecte, while constnt relxtion occurred in five of eight ptients in the biofeedbck group (p<1) nd in four of nine ptients in the conventionlly treted group (p<3) before feeling strong urge. Sline continence test (Tble IV nd Fig 3). treted ptients were not ble to retin significntly lrger men volume of sline without lekge fter biofeedbck trining. There ws no significnt difference for the lek volume before nd fter biofeedbck trining in the four ptients who improved nd the four who did not improve (Fig 3 nd Tble IV). treted ptients (before 114 (16) ml, fterwrds 116 (87) ml) nd fecl incontinent control subjects (78 (53) ml) leked t significntly lower men sline volumes thn control subjects (553 (235) ml) (p< 1). Discussion This study did not show tht biofeedbck is effective in our ptients with fecl incontinence. Three month nd one yer follow up showed tht fecl incontinent ptients treted with biofeedbck, sphincter exercises, nd conventionl therpy did not differ in improvement of soiling from incontinent ptients treted with conventionl therpy lone. did not improve bnorml norectl physiologic function including nl pressure t rest, squeeze pressure, sustined relxtion of the internl nd externl sphincter with decresed volumes of rectl distension, nd continence to rectlly infused sline in those ptients who improved with biofeedbck. A ptient with fecl incontinence often will seek t time of incresed frequency of soiling, nd mesurement of the intensity of the symptoms t this point does not reflect the true stte over time. In most cses, if untreted, the symptom tends to recede (regression to the men). In ddition, simple comprison of prend post frequency of soiling cn be misleding, in prticulr, if is stopped when the symptoms hve disppered or gretly lessened. To overcome this problem we evluted control ptient group nd evluted both ptient groups t preset times. Idelly, ptients with fecl incontinence should hve been rndomly ssigned to conventionl therpy or biofeedbck plus conventionl therpy insted of the consecutive enrolment in our study. We defined our ptient popultion to llow ssessment of the efficcy of these s on fecl incontinence. We excluded ptients with fecl incontinence cused by meningomyelocele or disruption of the sphincter (birth trum or surgicl intervention) becuse these underlying problems hve been reported to relte to poor outcome, prticulrly in the presence of dirrhoe. Whitehed et l" reported results in 13 geritric ptients with incontinence to solid stools. Dily sphincter exercises for one month in 5% of them did not produce clinicl improvement nd did not significntly increse the strength of sphincter contrctions. trining did significntly ugment sphincter strength; 6% of ptients were improved t six months nd 42% t one yer. Our biofeedbck trining technique ws Gut: first published s /gut on 1 December 199. Downloded from on 13 August 218 by guest. Protected by copyright.

8 142 Loening-Bucke similr to tht in other studies,5` but our study popultion my hve been different from those in number of uncontrolled biofeedbck trining studies which hve reported tht 7-83% of ptients chieved continence or considerbly reduced frequency of incontinence.5-1 In some of these studies, ptients hd incontinence to solid stools only,611 but some ptients were lso incontinent of liquid stool' "-1 or liquid stool only.7 The different success rte my be due to our different ptient popultion. Our ptients ll complined of fecl incontinence with liquid stools. Four ptients in the biofeedbck group nd six in the conventionlly treted group lso hd stool incontinence with formed stools. therpy is often combined with dditionl s nd it my be these tht re responsible for the decrese in the frequency of soiling through improvement or resolution of dirrhoe. In support of our findings, smll controlled studies in fecl incontinent dults92 nd children with fecl incontinence due to meningomyelocelel82l showed tht biofeedbck ws not significntly better thn sphincter exercises,'9 dietry djustment,'9 expectncy of improvement, conventionl therpy including regulting bowel hbits by frequent toilet use fter mels, djusting stool consistency with drugs, nd follow up ttention2' or behviour modifiction therpy.'8 There re t lest three components to biofeedbck : exercise of the externl sphincter muscle; trining in discrimintion of rectl senstions; nd trining synchrony of the internl nd externl sphincter responses during rectl distension. Ech of these components my be effective for some ptients. It is possible, for exmple, tht ptients who hve n impired externl sphincter muscle (perhps due to previous injury t childbirth or surgery) nd norml rectl senstion will respond to exercise so tht reflexive response to rectl distension will be dequte. On the other hnd, ptients with rised sensory threshold to rectl distension (perhps due to multiple sclerosis or other neurologicl disorders) my respond by lerning to sense smller volumes of rectl distension. There re still other ptients who hve dequte senstion nd musculr strength, but no pproprite synchrony of the sphincteric response. The use of objective nd sensitive ssessment instruments is essentil in the evlution of biofeedbck results. Only few studies reported norectl mnometric mesurements before nd fter biofeedbck. Wld7 used the three blloon system'3 for norectl mnometric ssessment nd found no significnt difference fter biofeedbck trining in the thresholds of rectl senstion nd internl sphincter relxtion between fecl incontinent ptients with good nd poor outcome. The threshold of reflexive externl sphincter contrction decresed significntly in ptients with good nd poor outcome. Riboli et l' used n hour-glss shped device consisting of continuous wter perfused ctheters for norectl evlution. In ptients with good outcome, the nl resting pressure incresed from 15 (9) to 4 (12) mmhg (norml 52 (5)), the voluntry externl sphincter squeeze incresed from 32 (9) to 67 (28) mmhg (norml 11 (1)), nd the threshold of rectl senstion decresed from 65 (4) to 28 (7) ml ir (norml 6 (5)). Ptients with unstisfctory outcome lso hd incresed nl resting pressure nd voluntry externl sphincter squeeze, nd decresed threshold of rectl senstion."' Ltimer et l2 found tht fter biofeedbck the rectosphincteric reflexes remined bnorml despite chievement of continence. Our study did not show better clinicl outcome fter biofeedbck. No improvement ofnorectl function ws observed. Therefore, the improved continence observed in some of our ptients my be the result of medicl intervention or spontneous regression of symptoms, or both, nd not of biofeedbck trining. Ptients with incontinence nd dirrhoe did not seem to benefit from biofeedbck trining. Prt of this work ws presented t the Americn Motility Society Meeting in October 1986 t Houston, Texs, SA nd ws published in bstrct form in Gstroenterology 1986; 91: 16. The uthor thnks Ms Molly Wiese nd Mrs Cssie Svge for excellent technicl ssistnce. 1 Penninckx FM, Elliot MS, Hnke E, et l. Fecl incontinence. IntJ Colorect Dis 1987; 2: Swsh M. The neuropthology of idiopthic fecl incontinence. In: Thoms Smith W, Cvngh JB, eds. Recent dvnces in neuropthology. Edinburgh: Churchill Livingstone, 1982: Prks AG. Anorectl incontinence. Proc R Soc Med 1975; 68: Beersiek F, Prks AG, Swsh M. Pthogenesis of no-rectl incontinence: histometric study of the nl sphincter musculture. J Neurol Sci 1979; 42: S Cerulli MA, Nikoomnesh P, Schuster MM. Progress in biofeedbck conditioning for fecl incontinence. Gstroenterology 1979; 76: Engel BT, Nikoomnesh P, Schuster MM. Opernt conditioning of rectosphincteric responses in the of fecl incontinence. N EnglJ Med 1974; 29: Wld A. therpy for fecl incontinence. Ann Intern Med 1981; 95: Wld A, Tunuguntl AK. Anorectl sensorimotor dysfunction in fecl incontinence nd dibetes mellitus: modifiction with biofeedbck therpy. N EnglJ Med 1984; 31: Goldenberg DA, Hodges K, Hersh T, Jinich H. therpy for fecl incontinence. AmJ Gstroenterol 198; 74: Riboli EB, Frscio M, Pitto G, Rebo G, Znoll R. conditioning for fecl incontinence. Arch Phys Med Rehbil 1988; 69: Whitehed WE, Burgio KL, Engel BT. of fecl incontinence in geritric ptients. J7 Am GeritrSoc 1985; 33: Loening-Bucke V, Anurs S. Effects of ge nd sex on norectl mnometry. AmJ Gstroenterol 1985; 8: Schuster MM, Hookmn P, Hendrix TR, Mendeloff A. Simultneous mnometric recording of internl nd externl nl sphincteric reflexes. BullJohns HopAinsHosp 1965; 116: Wld A. se of biofeedbck in of fecl incontinence in ptients with meningomyelocele. Peditrics 1981; 68: Loening-Bucke V. Sensitivity of the sigmoid colon nd rectum in children treted for chronic constiption. J Peditr Gstroenterol Nutr 1984; 3: Loening-Bucke V. Abnorml rectonl function in children recovered from chronic constiption nd encopresis. Gstroenterology 1984; 87: Hynes WG, Red NW. Ano-rectl ctivity in mn during rectl infusion of sline: dynmic ssessment of the nl continence mechnism. J Physiol 1982; 33: Whitehed WE, Prker L, Bosmiin L, et l. Tretment of fecl incontinence in children with spin bifid: Comprison of biofeedbck nd behvior modifiction. Arch Phys Med Rehbil 1986; 67: McHugh 5, Wlm K, Dimnt NE. Fecl incontinence: controlled tril of biofeedbck. Gstroenterology 1986; 9: Ltimer PR, Cmpbell D, Ksperski J. A component nlysis of biofeedbck in the of fecl incontinence. SelfRegul 1984; 9: Loening-Bucke V, Desch L, Wolrich M. trlning in ptients with meningomyelocele nd fecl incontinence. Dev Med Child Neurol 1988; 3: Gut: first published s /gut on 1 December 199. Downloded from on 13 August 218 by guest. Protected by copyright.