Gastroenterology

Gastroenterology

Volume 130, Issue 3, March 2006, Pages 657-664
Gastroenterology

Clinical–alimentary tract
Biofeedback Is Superior to Laxatives for Normal Transit Constipation Due to Pelvic Floor Dyssynergia

https://doi.org/10.1053/j.gastro.2005.11.014Get rights and content

Background & Aims: Uncontrolled trials suggest biofeedback is an effective treatment for pelvic floor dyssynergia (PFD), a type of constipation defined by paradoxical contraction, or inability to relax, pelvic floor muscles during defecation. The aim was to compare biofeedback to laxatives plus education. Methods: Patients with chronic, severe PFD were first treated with 20 g/day fiber plus enemas or suppositories up to twice weekly. Nonresponders were randomized to either 5 weekly biofeedback sessions (n = 54) or polyethylene glycol 14.6–29.2 g/day plus 5 weekly counseling sessions in preventing constipation (n = 55). Satisfaction with treatment, symptoms of constipation, and pelvic floor physiology were assessed 6 and 12 months later. The biofeedback group was also assessed at 24 months. Laxative-treated patients were instructed to increase the dose of polyethylene glycol from 14.6 to 29.2 g/day after 6 months. Results: At 6 months, major improvement was reported by 43 of 54 (80%) biofeedback patients vs 12 of 55 (22%) laxative-treated patients (P < .001). Biofeedback’s benefits were sustained at 12 and 24 months. Biofeedback also produced greater reductions in straining, sensations of incomplete evacuation and anorectal blockage, use of enemas and suppositories, and abdominal pain (all P < .01). Stool frequency increased in both groups. All biofeedback-treated patients reporting major improvement were able to relax the pelvic floor and defecate a 50-mL balloon at 6 and 12 months. Conclusions: Five biofeedback sessions are more effective than continuous polyethylene glycol for treating PFD, and benefits last at least 2 years. Biofeedback should become the treatment of choice for this common and easily diagnosed type of constipation.

Section snippets

Inclusion criteria

  • 1

    Severe constipation present for more than 12 months and unresponsive to standard medical treatment.

  • 2

    Fulfills Rome II4 criteria for chronic constipation, ie, 2 or more of 6 symptoms present for at least 12 weeks of the preceding 12 months: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction/blockage, or manual maneuvers to facilitate defecation on more than one fourth of bowel movements, or less than 3 bowel movements per week.

  • 3

    Paradoxical

Comparability of Treatment Groups

The biofeedback and laxative-treated groups were similar in age (33.3 ± 1.5 vs 35.1 ± 1.4 years, respectively; mean ± standard error) and sex (3 males vs 2 males). All patients were of Italian descent.

Adherence

All patients completed 5 sessions of biofeedback training or medication counseling as prescribed. All laxative-treated patients reported during monthly telephone calls that they took at least 90% of the prescribed dose during the first 6 months, and all reported taking the prescribed 2 packets of

Efficacy Evaluation

This large randomized controlled study showed that biofeedback for pelvic floor relaxation during defecation is more effective than laxatives for the treatment of PFD-type constipation. The differences in outcome were robust (4-fold difference in the proportion reporting major improvement; see Figure 2), and improvements were sustained for 2 years without additional training.

Patients’ ratings of improvement were supported by changes in specific symptoms of constipation reported in diaries: as

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Supported by grants RO1 DK57048 and R24 DK67674.

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