Long-term efficacy and safety of transanal irrigation in multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) is the commonest disabling neurological disease in young adults. A majority of patients experience bowel dysfunction, reporting a wide spectrum of bowel symptoms that significantly negatively impact social activities and emotional state. Transanal irrigation (TAI) is a method of managing such bowel symptoms. We aimed to investigate long-term efficacy of TAI, to measure health status-related quality of life and identify factors predictive of TAI outcome. METHODS: Forty-nine consecutive MS patients (37 female; mean age 51, range 26-80) were studied. We investigated predominant symptoms, reason for beginning TAI and medical comorbidity. All patients underwent anorectal physiology testing. They completed Neurogenic Bowel Dysfunction and EQ-5D questionnaires at baseline and annual follow-up. KEY RESULTS: Mean follow-up was 40 months, at which there was 55% rate of continuation of TAI. Severe bowel dysfunction was present in 47% at baseline, falling to 18%. The EQ-5D scores at latest follow-up were not statistically significant, but 42% had improved visual analog scores. The only predictive factor for successful therapy was impaired anal electrosensitivity (p = 0.008). CONCLUSIONS & INFERENCES: Long-term continuation of TAI, with improved bowel symptomatology, is seen in the majority of patients. The EQ-5D is insufficiently sensitive to show change in MS patients that using TAI.

Treatment of constipation in adults associated with idiopathic megarectum by behavioural retraining including biofeedback.

BACKGROUND: Constipation in adults associated with a grossly dilated rectum and recurrent faecal impaction, idiopathic megarectum, is rare. The aetiology of idiopathic megarectum is unknown, but may involve neuromuscular or behavioural factors. It is unknown whether the condition is reversible. This study aimed to determine the efficacy of behavioural therapy, including biofeedback, in such patients. METHODS: Six patients (4 female; median age 27) with a history of rectal faecal impaction and a grossly dilated rectum on radiological examination were evaluated by structured questionnaire before, immediately after biofeedback therapy, and on follow-up. Physiological testing was performed before treatment, and 2 patients were evaluated by repeat physiological testing and contrast radiology on follow-up. RESULTS: On median follow-up of 18 months (range 11-27), five patients felt major and one patient minor improvement in symptoms, including two with complete symptom relief. Four patients came off laxatives without recurrent faecal impaction. In the 2 studied patients rectal size did not appear to decrease. CONCLUSION: Behavioural retraining, including biofeedback, improved symptoms in most patients with idiopathic megarectum. In some patients symptoms completely resolved, without the need for laxatives. Although further studies are necessary in terms of both larger number of patients and longer follow-up period, behavioural treatment may be useful for such patients.

Treatment of impaired defecation associated with rectocele by behavorial retraining (biofeedback).

PURPOSE: Large rectoceles have been associated with symptoms of impaired rectal evacuation, often leading to rectocele repair. However, these symptoms, or the anatomic abnormality, may be caused, at least in part, by a primary disturbance of rectoanal coordination. This study aimed to determine the efficacy of biofeedback therapy in such patients. METHODS: Thirty-two female patients (median age, 52 years) complaining of impaired rectal evacuation and with a rectocele greater than 2 cm at proctography were evaluated by structured questionnaire before, immediately after treatment, and at follow-up. Physiologic and proctographic findings were related to outcome. RESULTS: Immediate results were available in 32 patients and medium-term follow-up (median, 10; range, 2-30 months) in 25 patients. At follow-up 14 (56 percent) patients felt a little and 4 (16 percent) patients felt major improvement in symptoms, including 3 (12 percent) with complete symptom relief. Immediately after biofeedback there was a modest reduction in need to strain (from 72 to 50 percent), feeling of incomplete evacuation (from 78 to 59 percent), need to assist defecation digitally (from 84 to 63 percent), and need to use an evacuant (from 47 to 28 percent), and this was maintained at follow-up. Bowel frequency was significantly normalized at follow-up (P = 0.02). Pretreatment presence of symptoms of digitally assisting defecation, pelvic floor incoordination, and proctographic rectocele size and contrast trapping, did not predict outcome. CONCLUSIONS: Behavioral therapy, including biofeedback, leads to major symptom relief in a minority, and partial symptom relief in a majority, of patients with a feeling of impaired defecation and the presence of a large rectocele. Residual symptoms are common. Biofeedback may be a reasonable first-line treatment for such patients.

Gut focused behavioural treatment (biofeedback) for constipation and faecal incontinence in multiple sclerosis.

OBJECTIVES: To determine whether gut focused behavioural treatment (biofeedback) is a useful therapy in multiple sclerosis patients referred for constipation, incontinence, or a combination of these symptoms. Most patients with multiple sclerosis complain of constipation, faecal incontinence, or a combination of the two. Patients rate these bowel symptoms as having a major impact on their life. Until now the management of these problems has been empirical, with a lack of evaluated therapeutic regimes. METHODS: Thirteen patients (eight women, median age 38 years, median duration of multiple sclerosis 10 years) complaining of constipation, with or without faecal incontinence underwent a median of four sessions of behavioural treatment. Anorectal physiological tests were performed before therapy. Impairment and disability were rated with the Kurtzke score and the Cambridge multiple sclerosis basic score (CAMBS). Patients were contacted a median of 14 months after completion of treatment. RESULTS: A beneficial effect was attributed to biofeedback in five patients. Mild to moderate disability, quiescent and non-relapsing disease, and absence of progression of multiple sclerosis over the year before biofeedback were predictive of symptom improvement. No physiological test predicted the response to therapy. CONCLUSION: Biofeedback retraining is an effective treatment in some patients with multiple sclerosis complaining of constipation or faecal incontinence. A response is more likely in patients with limited disability and a non-progressive disease course.

Behavioural treatment (biofeedback) for constipation following hysterectomy.

BACKGROUND: Constipation after hysterectomy has been postulated to be due to pelvic nerve damage, but there may be emotional or reversible physical factors of pathophysiological relevance. The aim of this study was to determine whether such constipation is responsive to behavioural treatment. METHODS: Three groups of patients who had completed a course of biofeedback treatment were compared: women with no history of abdominal or pelvic surgery (n = 25), women for whom a hysterectomy had led to no change in bowel function (n = 27) and women who stated that their constipation was precipitated (n = 18) or severely worsened (n = 8) by hysterectomy. Pretreatment and post-treatment details about bowel function and symptoms were assessed using structured interview, and pretreatment whole-gut transit time and anorectal physiology testing were assessed for prognostic relevance. RESULTS: Follow-up after completing treatment was a median of 28 (range 12-44) months. Forty-eight of 78 patients considered that their constipation had improved with treatment; the proportion in each group was similar (P = 0.73). Biofeedback reduced the need to strain, reduced abdominal pain, improved bowel frequency, and reduced laxative use to a similar degree in all three groups. Thirty-three of 53 patients with slow transit considered there was an improvement, compared with 15 of 22 with measured normal transit. Physiological testing did not predict outcome and did not differ between the three groups. CONCLUSION: The majority of patients complaining of constipation induced or worsened by hysterectomy respond subjectively to behavioural treatment, in a similar proportion to those with idiopathic constipation. In contrast to the widely held view that nerve damage is responsible for symptoms, reversible factors are likely to be important in many patients.

Biofeedback provides long-term benefit for patients with intractable, slow and normal transit constipation.

BACKGROUND: Many patients with idiopathic constipation do not respond to conventional medical treatments. Recently biofeedback has been proposed as an alternative treatment but the long-term results, and which patients benefit, are unknown. Treatment has usually been restricted to patients with normal colonic transit and impaired pelvic floor coordination on straining. AIMS: To determine the efficacy and long-term outcome of biofeedback treatment in idiopathic constipation. METHODS: One hundred consecutive contactable patients who had completed a course of biofeedback more than 12 months previously were identified. Pretreatment details of bowel function and symptoms, whole gut transit time, and anorectal physiological testing, which had been previously prospectively collected, were collated. Follow up consisted of structured interview. Sixty five per cent had slow transit and 59% had paradoxical pelvic floor contraction on straining. RESULTS: Median follow up was 23 months (range 12-44). On long-term follow up 55% felt that biofeedback had helped and 57% felt their constipation was improved. There was a significant reduction in need to strain, abdominal pain, bloating, and oral laxative use. Spontaneous bowel frequency was significantly improved by treatment. Patients with slow and normal transit, males and females, and those with and without paradoxical contraction of the anal sphincter on straining, benefited equally from treatment. Anorectal testing did not predict outcome. CONCLUSION: This study suggests that biofeedback is an effective long term treatment for the majority of patients with idiopathic constipation unresponsive to traditional treatments. Pelvic floor abnormalities and transit time should not form selection criteria for treatment.

Biofeedback: a first-line treatment for idiopathic constipation.

This article defines the various types of defecatory problems which could be termed idiopathic constipation, and outlines the main diagnostic tests used to identify its origins. It highlights the limited role that laxatives, increased dietary fibre, and surgery can play in the management of this condition. It suggests the use of biofeedback and associated non-invasive strategies as the treatment of first choice in idiopathic constipation. The article stresses that as there is often a significant psychological cause or contribution to this condition, the counselling, discussion, and listening which biofeedback therapy entails are just as important as training patients to coordinate their defecatory muscles during straining.