Journal
of
Coloproctology
w w w . j c o l . o r g . b r
Original
article
Effectiveness
of
treatment
using
fecal
incontinence
biofeedback
isolated
or
associated
with
electrical
stimulation
夽
Suelen
Melão
a,b,
Doryane
Maria
dos
Reis
Lima
b,c,d,∗,
Raphael
Ferreira
Ratin
a,b,
Gustavo
Kurachi
b,d,
Kelli
Rizzardi
b,
Marcieli
Schuster
b,
Univaldo
Etsuo
Sagae
b,d,e aHospitalSãoLucas,Cascavel,PR,BrazilbGastroclínicaCascavel,Cascavel,PR,Brazil
cUniversidadeFederaldoCeará(UFC),Fortaleza,CE,Brazil
dFaculdadeAssisGurgacz(FAG),Cascavel,PR,Brazil
eUniversidadeEstadualdoOestedoParaná(UNIOESTE),Cascavel,PR,Brazil
a
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t
i
c
l
e
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n
f
o
Articlehistory:
Received24February2014 Accepted11August2014 Availableonline23October2014
Keywords:
Fecalincontinence Biofeedback Anismus
a
b
s
t
r
a
c
t
Introduction:Theprevalenceoffecalincontinence(FI)hasincreasedinrecentdecades,due toanagingpopulation;andresultinnegativeimpactsonqualityoflife.Therefore,itis essentialtosearchforaneffectivetreatmentinordertominimizethemorbiditycausedby incontinence.
Objective:Toevaluatetheeffectofperinealtraininginthetreatmentofpatientswithfecal incontinencebybiofeedback.
Method:Thisisaprospectivestudywhichevaluated85patientswithFIfromJanuary2009 toJanuary2014,attheColoproctologyoutpatientclinicoftheHospitalSãoLucas/Cascavel, Paraná.
Results:Meanagewas47yearsandthedurationoftreatmentrangedfrom5to25sessions (mean,13sessions).Fromthewomeninvolvedinthestudy,70%(50)hadvaginaldeliveries and34(40%)participantsweresubmittedtosomeorificialsurgery.TheFIscoreatbaseline was10.79(6–17)andpost-treatmentFIwas2(0–14)(p<0.001).Inthepopulationstudied, 49.4%(42)ofthepatientshadanassociatedpre-BFTUI;andonly8.2%(7)hadpost-BFTUI (p<0.001).
Conclusions:Thedatapresentedinthisstudyconfirmthatperinealtrainingthrough biofeed-backwaseffectiveinthetreatmentofpatientswithfecalincontinencewithoutimmediate indicationforsurgery,stillensuringforthistechniquetheadvantagesofbeingeffective, painlessandoflowcost.
©2014SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All rightsreserved.
夽
ThisstudywasconductedatColoproctologyOutpatientClinic,HospitalSãoLucas,Cascavel,PR,Brazil.
∗ Correspondingauthor.
E-mail:doryane@gmail.com(D.M.dosReisLima). http://dx.doi.org/10.1016/j.jcol.2014.08.010
Eficácia
do
tratamento
de
incontinência
fecal
utilizando
o
biofeedback
isolado
ou
associado
a
eletroestimulac¸ão
Palavras-chave: IncontinênciaFecal Biofeedback Anismus
r
e
s
u
m
o
Introduc¸ão: Aprevalênciadeincontinênciafecal(IF)vemaumentandonasúltimasdécadas devidoaoenvelhecimentodapopulac¸ão;eresultaemimpactosnegativosnaqualidadede vida.Logo,torna-sefundamentalabuscadeumtratamentoefetivo,afimdeminimizara morbidadeocasionadapelaincontinência.
Objetivo: Avaliaroefeitodotreinamentoperinealnotratamentodepacientesportadores deincontinênciafecalatravésdobiofeedback.
Método:Estudoprospectivo,queavaliou85pacientescomIFnoperíododejaneirode2009a janeirode2014,noambulatóriodeColoproctologiadoHospitalSãoLucas/Cascavel,Paraná. Resultados: Amédiadeidadefoide47anoseadurac¸ãodotratamentovarioude5a25 sessões(médiade13sessões).Dasmulheresenvolvidasnoestudo,70%(50)tiverampartos vaginaise34(40%)indivíduosfizeramalgumacirurgiaorificial.OescoredeIFnaavaliac¸ão inicialfoide10,79(6a17)enopós-tratamentofoide2(0a14)(p<0,001).Napopulac¸ão estudada,49,4%(42)dospacientesapresentaramIUassociadanopré-TBFeapenas8,2%(7) nopós-TBF(p<0,001).
Conclusões: Osdadosdemonstradosnesteestudoconfirmamqueotreinamentoperineal atravésdobiofeedbackmostrou-seeficaznotratamentodepacientescomincontinência fecalsemindicac¸ãoimediatadecirurgia,assegurandoaindaparaessatécnicaasvantagens desereficaz,indoloredebaixocusto.
©2014SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda. Todososdireitosreservados.
Introduction
Fecalincontinence(FI) isaconditionthatresultsin signifi-cantphysicalandpsychologicaldisability,involvingcomplex andmultifactorialmechanisms.1Itisgenerallydefinedasthe
involuntarylossofsolidandliquidfeces,withorwithout emis-sionofflatus.Incontinencereferstoafunctionalchangein theanorectalarea,leadingtoalossofcontrolofthepassage offecalmaterialthroughtheanus.2
Althoughitsprevalenceisgenerallyreportedinfemales, inwhichepidemiologicalstudiesconvergeitsresultsforthe populationover65years,thereisahighprevalenceinboth menandwomen.However,womenappeartobemore sus-ceptible,withthemajorriskfactorsbeingpudendalnerveor analsphincterinjurycausedbyobstetrictrauma.2,3
Regard-lessofitsetiology,theemotionalresultimpactsonqualityof life,exceedingthelimitsofthephysical,social,emotionaland occupationaldomains.4Itishardtoknowtheexactincidence
ofFIin thepopulation, becauseinmany casesthepatient omitsthisfact.However,theeffectdescribedintheliterature rangesfrom0.1%to5%.5
Paradoxicalcontractionofpuborectalmuscles,oranismus, isapathologyofidiopathicorigin,affectingmenandwomen; theanismusdevelopsslowlyandprogressively,beingusually accompanied byconstipation. Clinically, anismus is mani-festedbytheurgetodefecate,withouttheabilitytoeliminate thewholerectalcontent,regardlessofthedegreeofpatient effort.6
Themechanismofanalcontinencedependsonthe inte-grated action of: sphincter muscles; pelvic floor muscles; presenceoftheanorectalinhibitoryreflex;ofrectalcapacity, sensitivityandcompliance;stoolconsistencyandintestinal transittime.7,8Asaresult,anyconditionordisorderthatalters
anyofthesemechanismscancauseincontinence.9Therefore,
itiscriticaltotakeintoaccounttheimportantroleoftheanal sphincters inpreserving the continence,because with this knowledgearehabilitationprogramforpelvicfloor biofeed-backtraining(BFT)canbeestablished.
BFTisatechniquethathasbeenwidespreadsincethelate 70s,through the useofelectronic equipment toinform its user,inacontinuousandinstantaneousway,aboutsomeof his/herinternal(normalandabnormal)physiologicalevents, in the form of visual and/or hearing signals.10 This
tech-niqueallowstheassessmentandmeasurementofthepatient progressthrough monitoringthe tone atrestand the con-tractileabilityofthemusclefiberanditssupport.Thus,BFT iseffectiveinthecourseofthetreatmentofneuromuscular dysfunctions,improvingthemobility,flexibility,andmuscular coordination.11
lifeofthesepatients.12Theaimofthisstudywastoevaluate
theeffectofperinealtraininginthetreatmentofpatientswith fecalincontinencethroughbiofeedback.
Patients
and
methods
ThisisaprospectivestudycarriedoutbetweenJanuary2009 and January2014,involving 85 patients, 71 womenand 14 men (83.5% and 16.4%, respectively), all of them with FI. Thesepatients wereattended attheColoproctology outpa-tient clinic, Hospital São Lucas/Cascavel, Paraná by three colorectal surgeons. Patients were evaluated clinically, and theFecalIncontinenceScoreproposedbyJorge-Wexnerwas applied;theyalsounderwentphysicalexamination.13 Then,
thesepatientswereevaluatedbycolonoscopyandanorectal electromanometry.PatientscomplainingofFIwithand with-outanorectalelectromanometrychangesandwithoutsurgical indicationatthetimewereincludedinthisstudy.The peri-nealtraininginthetreatmentwithBFTwasperformedbytwo physiotherapists(KRandMS).
The protocol consisted of a physiotherapeutic clinical assessment(collectionofpersonaldata,medicalhistoryand physical examination) and perineal training. The physical examinationincludedskininspection,presenceofscars,and anal–vulvar distance; then, adigital palpation of the anus wasperformedtoassess the voluntarycontractilecapacity ofpelvicmuscles,accordingtothetableofOrtiz,graduated from0to5(Table1).14In thetreatmentwithBFT,an
elec-tromyographicapparatusMiotool400(Miotecbiomechanical equipment,Porto Alegre/Brazil)was used.This device con-sistsofa4-channelsystemwithagainofupto8timeseach, with14-bitresolutionandsamplingfrequencyof2000Hzper channel. Onlyone channel wasused, to which two differ-entialsurfacesensorsSDS500wereattachedandconnected withdisposableelectrodes(diameter1.9cm).Thesurface elec-trodeswere appliedinalignmentovertheperineum,and a referenceelectrode(ground)wasfixedovertheanterior supe-rioriliacspine.
Thepatientsfollowedtheinstructionsforthetreatment, whichwasdividedintofourphases:(1)contraction10times the pelvic floor muscles (PFM) with the highest possible
Table1–Functionalclassificationofthepelvicfloor muscles.
AFAscore Clinicalobservation
0 Withoutobjectiveperinealfunction,eventopalpation 1 Absenceofobjectiveperinealfunction,identifiedonly
topalpation
2 Poorobjectiveperinealfunction,identifiedbypalpation 3 Objectiveperinealfunction,withoutopposing
resistancetopalpation
4 Objectiveperinealfunctionandopposingresistancenot heldtopalpation
5 Objectiveperinealfunctionandopposingresistance heldtopalpationduringmorethan5s
AFA,functionalassessmentofthepelvicfloormusclesbydigital palpation(ContrerasOrtizetal.14).
strength and quickness, resting only for 1s between each contraction(5repetitions);(2)contractionofPFMashardas possibleduring5sandrestingfor5s(10reps);(3)contraction ofPFMashardaspossibleduring10s,restingfor10s(5reps); (4) defecationtraining:patientorientationduringthe defe-cationstraining,inordertoincreasetheabdominalpressure (Valsalva),inordertoguideaproperpuborectalisrelaxation. The recommendations for maintaining the joint accessory muscles’(abdominals,gluteiandadductors)non-contraction were followed.Patients were instructed and encouragedto perform home exercisesand recommendations during the treatmentandatitsend.
Alltrainingwasorientedaccordingtotheresultsof anorec-talelectronmanometry:(1)patientswhohadnormotoniaat rest and contraction and anismus: the sessions consisted entirely of BFT (group I);(2) patients presentingwith con-tractionhypotonia:inadditionofBFT,electricalstimulation wasassociatedwiththeuseofNeurodynEvolution(Ibramed), a device which transmits low-amplitude electric current through atrans-analelectrodeatafrequencyof50Hz(the duration of thestimulation rangedfrom 15 to 30min, and itsintensitywasdeterminedintermsofpatientcomfort;the stimulationprocedurewascontinueduntilthepatientshowed contractileabilityofthemusclestostart BFT)(groupII);(3) patientswhopresentedhypotoniaatrest:inadditionofBFT, the patient was submitted to 10 sessions of posterior tib-ial electronstimulation withNeurodyn Evolution(Ibramed), withlow-amplitudecurrentandfrequencyof10Hzandpulse durationof200s.Thestimulationtimewas20minforeach session, with twosurface electrodes: oneapplied over the medialmalleolusandtheother10cmabovethatpoint(group III).
Thetreatmentprotocolconsistedofnineinitialsessions;at thetenthsession,areassessmentoftheinitialsymptomswas performed,asadeterminantfactortoreleasethepatient,or toproceedwiththesessionsuntilhis/herrelease.Thepatient was releasedwhena reportofdecreasedfrequencyand/or intensity,orofabsenceofleakageandotherassociated symp-tomswasobtained.Then,alongwiththepre-andpost-BFT Wexnerscore,thepatientreturnedtotherequesting physi-cian.
TheStudent’sttestwasappliedtoevaluatethe training responseinrelationtoFIandurinaryincontinence(UI).
Patientsrequiringsurgeryforincontinence,patients with-outcognitiveunderstandingandthosewhodidnotagreeto participateinthisstudywereexcluded.Allpatientssigneda freeinformedconsentandagreedtoparticipateinthestudy, whichwasapprovedbytheEthicsCommitteeoftheFaculdade AssisiGurgacz(FAG).
Results
20
10
0
Fig.1–FIscoreoninitialevaluationandonpost-treatment.
IU pre-BFT IU pos-BFT
2
Series 1
1 0
5 10 15 20 25 30 35 40 45
Fig.2–Pre-BFTUIandpost-BFTUI.
ThegroupIwascomposedof34patients(40%);groupII, 11patients(12.9%);andgroupIII,40patients(47.1%).TheFI scoreatbaselinewas10.79(6–17)andafterthetreatmentwas 2(0–14)(p<0.001,Fig.1).WhentheStudent’sttestwasapplied separatelytothesegroups,itwasevidentthatthepre-and post-treatmentresultswerealsostatisticallydifferent.Inthe populationstudied,49.4%(42)ofthepatientshadassociated UIinpre-BFTandonly8.2%(7)exhibitedpost-BFTUI(p<0.001, Fig.2).
Discussion
BFTisawell-establishedmethodforthetreatmentofpatients withFI.15Themostcommontechniquesusedinpelvicfloor
muscle training include: anorectal manometry, displaying sphincterpressures;andelectromyography,whichcandisplay electricalmuscleactivity.16,17
TheresultsofBFTarecontradictoryintheliterature, espe-cially due to the different techniques that can be used.18
A randomized controlled trial, in which BFT was applied inpatientswithFI,suggestedthatthere wasnodifference between conservative treatment and/or BFT exercises.15 A
meta-analysis demonstrated that muscle training was as effectiveasconservativetreatment.19However,arecent
con-trolled study showed that patients with an unsuccessful conservativetreatmentforFIandwhowerereferredtoBFT
showed 76% ofsuccessful responses.20 Other studies have
reportedpositiveresponsesrangingfrom70%to80%.21
In their multicenter study, Schwandner et al. reported that the combination ofelectrical stimulation with a pro-longedmuscletraining(overthreemonths)achievedthebest results.22 Chiarioni et al. reportedthat the benefits ofBFT
lastedforanaverageperiodof12months;thus,itisnecessary that the trainingexercises are performedcontinuously.23,24
Itisnoteworthy,however,thattheAmericanCollegeof Gas-troenterologysuggestedthatBFTisindicatedinpatientswith sphincterhypotoniaand/orimpairedrectalsensitivity.25On
theotherhand,asmallstudyreportedthatBFTwasineffective inpatientswithneurogenicFI.26
Thus,BFT shouldbeofferedtoallpatients whodidnot respondtomedicalinterventionsforFI,becausethisisasafe, cheapandlong-termeffectivetechnique.27
Elderly patients with normal physiology for defecation seemtorespondwell.28
Advancedanorectalphysiologytestssuchasmanometry, pelvicdefecography,MRI,andpudendalnerveterminalmotor latencytestingdonotseemtopredictwhowillrespondbest toBFT.29PatientswithmildtomoderateFIandwhohavenot
respondedwelltomedicaltreatmentsareprobablythebest candidatesforBFT.30
Inthis study,patientswhounderwent treatmentwitha mixedtechnique,chosenfromtheresultsofanorectal elec-tronmanometry,showedafallofFIscore,from10.76to2,with statisticallysignificantdifference.Thetechniquesassociated withbiofeedbackwere:intracavitary(anal)electric stimula-tion andposteriortibialnervestimulation. Andevenwhen thegroupswereseparated,thedifferencewasstatistically sig-nificant.Thesedataallowtheachievementofbetterratesof success than those reportedin the literature.Thismay be duetothefactthatthetechniquewaschosenbecauseofa priorcorrectevaluationofthesphinctericapparatusbythe colorectalsurgeon.
Conclusion
Thedatapresentedinthis study confirmthatthe perineal trainingthroughbiofeedbackwaseffectiveinthetreatment ofpatientswithfecalincontinencewithoutimmediate indi-cationforsurgery,asthisisatechniquewiththeadvantages ofbeingeffective,painlessandoflowcost.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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