incontinence Effects of biofeedback in the treatment of femalefecal Coloproctology Journal of

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w w w . j c o l . o r g . b r

Journal of

Coloproctology

Original Article

Effects of biofeedback in the treatment of female fecal incontinence

Kertulem Larissa Aparecida Silverio dos Santos

^∗

, Simone Cavenaghi,

Ana Elisa Rosselli Folchine, Lais Helena Carvalho, Priscila Martins, Lucas Lima Ferreira, João Gomes Netinho

SchoolofMedicineofSãoJosédoRioPreto(FAMERP),SãoJosédoRioPreto,SP,Brazil

a r t i c l e i n f o

Articlehistory:

Received27February2018 Accepted25March2018 Availableonline30April2018

Keywords:

Biofeedback Physicaltherapy Fecalincontinence

a bs t r a c t

Introduction:Fecalincontinenceistheinvoluntarylossofstoolsandgases,characterizedby theinabilitytokeepphysiologicalcontrolofbowelcontents.Itcannegativelyaffectpatients’

qualityoflife.Biofeedbackisatherapeutictoolusedinthetreatment,throughthetraining ofthepelvicﬂoormusclesfromvisualandsoundstimuli.

Objective:Toevaluatetheeffectsofbiofeedbackinthetreatmentoffemalefecalinconti- nence.

Methods:Twenty-threepatientswithfecalincontinence,diagnosedbyclinicalevaluation andmanometry,andreferredforbiofeedbacktreatment,participatedrespondingtothe ClevelandClinicIncontinenceAssessmentscale,andtheFecalIncontinenceQualityofLife Questionnairetoobtainpersonaldata,clinicalcomplaintsandincontinencecharacteristics.

Fourbiofeedbacksessionswereheldonceaweek.Aftertheprotocol,theywerereevaluated withanorectalmanometryandquestionnaires,andtheywereinstructedtodailyperform thesphinctericcontractionexercisesathome.

Results:ThecomparisonoftheClevelandClinicFloridaScoringSystemandFIQLscores beforeandafterthebiofeedbackprotocolshowedasigniﬁcantdecrease(p=0.0001)infecal incontinence.Themeananalpressureatrestwas33.3mmHgbeforeand49.65mmHgafter biofeedback,whilethemeananalpressureofmaximalvoluntarycontractionwas85mmHg beforetreatmentand136.65mmHgafterit.

Conclusion:Biofeedbackisaneffectivemethodforthetreatmentoffecalincontinence,with increasedsphincterstrengthandimprovedqualityoflife.

creativecommons.org/licenses/by-nc-nd/4.0/).

∗ Correspondingauthor.

E-mail:keerlari@hotmail.com(K.L.Santos).

https://doi.org/10.1016/j.jcol.2018.03.008

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Efeitosdobiofeedbacknotratamentodaincontinênciaanalfeminina

Palavras-chave:

Biofeedback Fisioterapia Incontinênciafecal

r e s u mo

Introduc¸ão: Aincontinênciaanaléaperdainvoluntáriadefezesegases,caracterizadapela incapacidadedemanterocontroleﬁsiológicodoconteúdointestinal.Podeinterferirneg- ativamentenaqualidadedevidadospacientes.Biofeedbackéumaferramentaterapêutica utilizadanotratamento,atravésdotreinamentodosmúsculosdoassoalhopélvico,apartir deestímulovisualesonoro.

Objetivo: Avaliarosefeitosdobiofeedbacknotratamentodaincontinênciaanalfeminina.

Metódos: Participaram23pacientesportadorasdeincontinênciaanal,diagnosticadaspela avaliaçãoclínica,manométricaeencaminhadasparatratamentocombiofeedback,respon- deramumquestionárioparaobtençãodosdadospessoais,queixasclínicasecaracterísticas daincontinência,aescaladeAvaliaçãodaIncontinênciadaClevelandCliniceoquestionário FecalIncontinenceQualityoflife.Foramrealizadasquatrosessõesdebiofeedback,umavezpor semana.Apósoprotocoloforamnovamentereavaliadascomexamedemanometriaanor- retalequestionários,foramorientadasarealizarosexercíciosdecontraçãoesfincteriana diariamenteemcasa.

Resultados: NacomparaçãodosescoresdosquestionáriosClevelandClinicFloridaScoringSys- temeFIQLanteseapósoprotocolodebiofeedbackpode-seobservardiminuiçãosignificativa (p=0,0001)daincontinênciaanal.Asmediasdepressãoanalderepousofoide33,3mmHg antese49,65mmHgapósobiofeedback,enquantoqueamédiadapressãoanaldecontração voluntáriamáximafoide85mmHgantesdotratamentoe136,65mmHgapósomesmo.

Conclusão: ObiofeedbackéummétodoefetivonotratamentodaIncontinênciaanal,com aumentodaforc¸aesﬁncterianaemelhoradaqualidadedevida.

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Fecal incontinence (AI) is deﬁned by the involuntary loss offecesand gases,and ischaracterizedbythe inability to keepthephysiologicalcontroloftheintestinalcontents.¹The symptomsleadtoembarrassingsituationstothepatients,and tosocialandprofessionalisolation.²

ItisestimatedthatAIaffects 1.9%to21.3% ofthepop- ulation, and its prevalence varies according tothe sample investigated,buttheactualprevalenceisnotfullyestimated duetotheembarrassmentpatientsfeelforpresentingsuch conditions.^3,4

Analcontinencecontrolphysiologyiscomplex,andrelies ontheintegratedactionofseveralevents,suchastheaction ofthesphinctermusclesandpelvicﬂoormuscles,presence ofthe rectal-anal inhibitoryreﬂex, rectal-anal angle,rectal capacity,sensory-motor functionoftheanorectalanatomi- calregion,patient’sneurologicstatus,stoolconsistency,and intestinaltransittime.^5,6

Several factors contribute to the appearance of female fecalincontinence,withpredominanceofobstetrictrauma;

asphinctericlesion may occur in35% ofwomenwho had normal deliveries, which can progress to incontinence or not, along with diabetes mellitus, multiple sclerosis and dementia.⁷Inﬂammatoryboweldiseases,postoperativehem- orrhoidaldisease,andresectionofcolonandrectumarealso conditionsassociatedwithAI.⁸

It can negatively interfere withpatients’ quality oflife, causing social and familial concomitant disorders, being consideredapublichealthissue.Individualswhosufferfrom thediseasedelayseekforcare,ordonotseekit,thusworsen- ingthesymptomspresentedandhavinganegativeimpacton theirlives.⁹

Severalcomplementaryexamsarecurrentlyusedtoaidin theunderstandingoftheetiology,detectionandclassiﬁcation ofAI,suchasendoanalultrasound,pudendalnervelatency time,perineometry,andanorectalmanometry.Thelattercon- sistsofastudythatallowsthemeasurementofrestingand contractionpressures,thesizeoftheanalcanal,thesynchro- nizationofsensoryandmotorcomponentsofthischannel, aswellastherecto-analcapacity,complianceandinhibitory reﬂex.^10,11

Thetreatmentforfecalincontinencecanbeconservative orsurgical,andeventhecombinationofboth.Theconserva- tivetreatment,whenindicated,involvesthemultidisciplinary team withdietary andpharmacologicalactions,psycholog- ical support, and physical therapy through resources for awareness and strengthening of the pelvic ﬂoor muscles.

Following it, whether a surgical approach is necessary is evaluated.¹²

Biofeedbackisanimportanttherapeutictoolusedinthe treatmentofthiscondition,throughthetrainingofthepelvic ﬂoormuscles,fromvisualand/orsoundstimulation,inorder to obtain a more adequate, less invasive, and less costly response.¹³

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Thus,thisstudyaimedtoevaluatetheeffectsofbiofeed- backinthetreatmentoffemalefecalincontinence.

Patients and methods

Twenty-threepatientswithfecalincontinencediagnosedby clinical and manometric evaluation by the Coloproctology team,andreferredforphysicaltherapywithbiofeedbackat theColoproctologicalPhysiotherapyClinicofaUniversityHos- pitalparticipatedinthestudy.Theyansweredaquestionnaire thatwas previouslydevelopedfor obtainingpersonaldata, clinicalcomplaints,andcharacteristicsofincontinence,the Cleveland Clinic Incontinence Rating Scale, and the Fecal IncontinenceQualityofLifequestionnaire,validatedforthe Portugueselanguage.

Patientswhorefusedtoparticipate,thosewithneurologi- calconditions,orwhoforanyreasondidnotunderstandthe biofeedbacktreatment,patientswhomissedatreatmentses- sion,orwhodidnotattendmanometrywereexcludedfrom thestudy.

Theselectedpatientsunderwentfourconsecutivebiofeed- back sessions once a week and were instructed to daily performthesphinctericcontractionexercisesathome.After thefoursessions,theyunderwentanorectalmanometryagain forevaluationand comparisonofthe pressure values,and answeredthequestionnairesofclinicalevaluationandquality oflifeagain.

Dataweredescriptivelyanalyzed,andpresentedinaver- ages,standarddeviations,percentages,absoluteandrelative frequencies.Inferentialstatistics wasalsoperformedusing theShapiro–Wilktesttocheckdatanormalityandthepaired t testor Wilcoxon test tocompare the outcomes analyzed beforeandaftertreatmentwithbiofeedback,dependingon thenormalityofdata.Thelevelofsigniﬁcancewasconsidered asp≤0.0001.StatisticalanalysiswasconductedbyGraphPad Instatsoftware,version3.0.

Results

Themeanageofthepatientswas68years(SD=8),with73.90%

being married and working with general services. Regard- ing the period of onset of incontinence symptoms, most (30.4%)patientsreported thatthe symptomsstarted 1to2 years before; 26%, 2 to 5 years before; and 17.4%,5 years before.

Althoughthereare severalcauses forthe appearanceof fecalincontinence, 52% ofthe patientsreport noapparent reasonfortheonsetofsymptoms,and26%reportasurgical procedure.

In 23 patients, the number ofvaginaldeliveries ranged fromnonetosixwithameanof2.69births(SD=2.20),while cesareansectionsrangedfromnonetotwowithameanof 0.56(SD=0.84).

Regarding the characteristics of fecalincontinence, 57%

reported evacuation urgency, 57% reported feeling loss of feces,78%hadfecalleakageduringtheday,and61%reported lossofasmallamountoffeces(Table1).

Table2presentsdatacomparingthescoresoftheCleve- land Clinic Florida Scoring System before and after the

Table1–Distributionofpatientsregardingthe characteristicsoffecalincontinence.

n %

Characteristics

Evacuatingurgency 13 57%

Feelingofstoolsloss 13 57%

PresenceofUI 10 44%

Periodsoffecalleakage

Onlyduringtheday 18 78%

Duringthedayandnight 5 22%

Onlyatnight 0 0%

Amountofstoolslost

Small 14 61%

Moderate 5 22%

Large 4 17%

Table2–LevelofincontinenceaccordingtotheCleveland ClinicFloridaScoringSystem(IICCF)questionnairebefore andaftertreatmentwithBiofeedback.

Variable Before After pvalue^a

IICCFScore 14.56±4.02 6.82±2.81 <0.0001^b

a Pairedttest.

b p≤0.0001.

Table3–QualityoflifeaccordingtotheFecalIncontinence QualityofLifequestionnaire.

Variable Before After pvalue^a

Lifestyle 21.30±7.59 33.04±8.48 <0.0001^b Behavior 15.39±7.54 25.13±7.77 <0.0001 Depression 18.60±5.06 23.91±4.35 <0.0001 Embarrassment 5.43±2.55 9.65±2.85 <0.0001

a Pairedttest.

b Wilcoxontest.

Table4–Comparisonofanalpressuresatrestandpre- andposttreatmentmaximumcontraction.

Pre(mean±SD) Post(mean±SD) pvalue^a

PAR 33.30±14.19 49.65±18.68 0.0001^b

PACVM 85±24.87 136.65±25.40 0.0001^b

a Pairedttest.

b p≤0.0001.

application of biofeedback sessions. A statistically signif- icant decrease (p=0.0001) in fecal incontinence can be observed.

In the comparisonof FecalIncontinence Qualityof Life scores,beforeandaftertheapplicationofbiofeedback,asta- tistically signiﬁcant increase was observed in all domains evaluated(p≤0.0001)(Table3).

Therewasasigniﬁcantincrease(p≤0.0001)inmeananal restingpressuresandmaximalvoluntarycontractionafterthe endoftreatment(Table4).

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Discussion

TheprevalenceoffecalincontinenceinBrazilhasbeenscarce uptothepresentmoment,butitisknownthattheproblem affectstheindividual’spersonalandprofessionallife,causing socialisolation,embarrassment,andworseningofthequality oflife.⁴

Thedefecationprocessattheappropriatetimeandplace demandsabalancebetweenthemusclesofthepelvicﬂoor and thenervous system. Any irregularityinthesesystems canleadtoanorectaldysfunctionand fecalincontinence.¹⁴ Several factors contribute to fecal incontinence, such as age, overweight, depression, chronic diarrhea and urinary incontinence.¹⁰However,inthepresentstudy,mostreported nospeciﬁcreasonfortheonsetofsymptoms.

Inthe presentstudy,most womenhadvaginaldelivery, whichisconsidered tobeanother riskfactor forAIdue to sphincterinjury,¹⁵and3%ofwomenmayhavefecalinconti- nenceafternormaldelivery.

Whenitcomestotheamountoffeceslost,asurveyshowed that76%ofthepatientsdescribeditassmall,and24%asmod- erateorlarge,possiblyduetothetypeofstools.³Inthepresent study,mostpatientsdescribedthatfecalleakageoccurredina smallamountduringtheday,andtheobservedcharacteristic wasdefecationurgency,whichcoulddirectlyaffectproductiv- ityatworkandthusqualityoflife.

In a study carried out in Porto Alegre, in 2017, a microprocessor-controlled device capable of recording the analpressurewavesconsistentwiththeexercisesperformed by the patient at home was developed. Participants were femalepatients, older than 30years,presentingAI andno previoustreatmenthistory;anevaluationwasperformed,and theWexnerscale,andFIQLquestionnaireswereapplied.The patientsperformed28sessionsathome,andaftertreatment showedsignificantimprovementinsymptomatology,param- etersofmanometry,andqualityoflife.Theauthorpointsout thatthepatientshadnodifficultyinhandlingthedeviceor performingthetreatmentathome,andalthoughthemethod wasconsiderednew,itobtainedsatisfactoryresults,¹⁶corrob- oratingwiththe presentstudy,whichreachedindiceswith significantimprovement.

Biofeedbacktreatmentshowedtobeeffectivebecauseit improvestheawarenessandmotorresponseoftheexternal anal sphincterand the pelvic floormuscles. However, it is amethodthatrequires aqualifiedprofessional foritsexe- cution,and time and commitment ofthe individual to be successful.^16,17Inthepresentstudy,significantimprovement wasobservedincomparisontothemanometricvaluesbefore andaftertreatment(p=0.0001).

Incontrast,arandomizedcontrolledstudywasconducted from 2011 to 2012 at the Shahi Faghihi Hospital in Iran, where27 women withfecal incontinencecomplaints after delivery were evaluated. The patients were submitted to surgical treatment and were divided into three groups. In theﬁrstgroup,womenunderwent biofeedbacktreatment3 monthsbeforesurgeryand6monthsaftersurgery.Inthesec- ondgroup,biofeedbacktreatmentwasperformed6months aftersurgery,andinthethirdgrouponlythesurgicaltreat- mentwasperformed.Wexner’squestionnaireandmanometry

examinationwere used tocompare preoperativeand post- operative results.There was asigniﬁcant difference in the incontinencescoresassessedbytheWexnerquestionnairein all groups,but thethirdgrouppresentedworseresults.No differencewasobservedbetweenthethreegroupsregarding theresultsobtainedinmanometry.Thestudydidnotshow signiﬁcantresultsinmanometry,howeverWexner’squestion- naire was anindicator ofsatisfactionafter treatmentwith biofeedback.¹⁸

Inanotherstudy,theresultsobtainedin52patientswith fecalincontinencewhoreceivedbiofeedbacktreatmentwere analyzed; questionnaires for evaluating the level of fecal incontinence,suchasFISI(FecalIncontinenceSeverityIndex), and thequality ofliferelatedtofecal incontinence(FIQL– FecalIncontinenceQualityoflifeScale)wereused.Therewas asigniﬁcantimprovementintheFIQLquestionnaire,mainly inthedomainsofbehaviorandembarrassment(p=0.008)after treatmentwithbiofeedback.¹⁹

Similarly, in the present study, using the FIQL ques- tionnaire, it was observed that, in the presence of fecal incontinence,thepatientsfeltembarrassed,andhadlowself- esteem,whichcausesagreatchangeinthequalityoflifeand inthesocialscenario.Afterthetreatment,anewevaluation showedgreatimprovementinpatients’sociallifeandwell- being,withasigniﬁcantincreaseofthescoresinalldomains evaluatedbeingachieved.

Conclusion

Biofeedbackisaneffectivemethodfortreatingfecalincon- tinence,withincreaseofsphinctercontractionstrength,and improvementofqualityoflife.

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

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