Review Article

Dyssynergic Defaecation and Biofeedback Therapy in the Pathophysiology and Management of Functional Constipation

G. R. Skardoon; A. J. Khera; A. V. Emmanuel; R. E. Burgell

Disclosures

Aliment Pharmacol Ther. 2017;46(4):410-423. 

In This Article

Abstract and Introduction

Abstract

Background Functional constipation is a common clinical presentation in primary care. Functional defaecation disorders are defined as the paradoxical contraction or inadequate relaxation of the pelvic floor muscles during attempted defaecation (dyssynergic defaecation) and/or inadequate propulsive forces during attempted defaecation. Prompt diagnosis and management of dyssynergic defaecation is hindered by uncertainty regarding nomenclature, diagnostic criteria, pathophysiology and efficacy of management options such as biofeedback therapy.

Aim To review the evidence pertaining to the pathophysiology of functional defaecation disorders and the efficacy of biofeedback therapy in the management of patients with dyssynergic defaecation and functional constipation.

Methods Relevant articles addressing functional defaecation disorders and the efficacy of biofeedback therapy in the management of dyssynergic defaecation and functional constipation were identified from a search of Pubmed, MEDLINE Ovid and the Cochrane Library.

Results The prevalence of dyssynergic defaecation in patients investigated for chronic constipation is as many as 40%. Randomised controlled trials have demonstrated major symptom improvement in 70%-80% of patients undergoing biofeedback therapy for chronic constipation resistant to standard medical therapy and have determined it to be superior to polyethylene glycol laxatives, diazepam or sham therapy. Long-term studies have shown 55%-82% of patients maintain symptom improvement.

Conclusions Dyssynergic defaecation is a common clinical condition in patients with chronic constipation not responding to conservative management. Biofeedback therapy appears to be a safe, successful treatment with sustained results for patients with dyssynergic defaecation. Further studies are required to standardise the diagnosis of dyssynergic defaecation in addition to employing systematic protocols for biofeedback therapy.

Introduction

Functional Constipation. Functional constipation is a common clinical concern, representing approximately eight per cent of patient presentations in a primary care setting.[1] The Rome IV Criteria define functional constipation as at least two of six symptoms; need for straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction and need for manual manoeuvres to facilitate defaecation more than one-fourth of defaecations or less than three defaecations per week for the last 3 months with symptom onset being at least 6 months prior to diagnosis (Table 1) and who do not already meet the criteria for constipation predominant irritable bowel syndrome.[2]

Functional Constipation Subtypes. The true prevalence of subtypes of functional constipation is poorly defined as the studies in this area have generally been undertaken in tertiary or quaternary centers. As a result, the data are difficult to extrapolate to the general population as the majority of patients in the community are not investigated to a similar extent. Nevertheless, functional constipation subtypes are considered to include: (1) functional defaecatory disorders (diagnosed in 12%-24% of patients describing constipation), (2) slow transit constipation (5%-42%), (3) a combination of slow transit constipation and functional defaecatory disorder (2%-25%) and (4) constipation predominant irritable bowel syndrome (IBS), characterised by abdominal pain associated with defaecation, (20%) or normal transit constipation (20%-60%) depending on diagnostic definition and investigative modality.[3–5]

The Rome IV criteria further divides functional defaecatory disorders into those due to paradoxical contraction or inadequate relaxation of the pelvic floor muscles during attempted defaecation (dyssynergic defaecation) and/or inadequate defaecatory propulsion.[6] The prevalence of dyssynergic defaecation in patients investigated for chronic constipation is thought to be as many as 40%,[7] however, evidence from the literature ranges from 13% to 81% depending on patient population and definition.[7] The epidemiological inaccuracy is in large part relating to historical controversy regarding the diagnostic definition of dyssynergic defaecation as well as lack of standardised investigative techniques.

Biofeedback Therapy. Biofeedback was first introduced as a treatment for dyssynergic defaecation in 1987.[8] Since then, biofeedback therapy has demonstrated clinical efficacy in uncontrolled trials and a small number of randomised controlled trials (RCT).[9] Biofeedback is based on "operant conditioning" techniques and uses instruments such as electromyography (EMG) sensors, balloons or manometry to guide the patient to increase intraabdominal pressure effectively and to coordinate relaxation of the pelvic floor and the anal sphincter musculature during defaecation.[10,11]

This review summarises the current evidence regarding (1) the pathophysiology of dyssynergic defaecation, (2) diagnosis of dyssynergic defaecation in chronic constipation and (3) efficacy of managing dyssynergic defaecation with biofeedback therapy.

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