Introduction
Fecal continence depends on the interaction of many factors. Anal sphincters, pelvic floor muscles, anal sensation, rectal sensory-motor activity, and neural integrity all have determinant roles, which together provide a coordinated mechanism of gas and stool continence. The pathophysiology of fecal inconti- nence is, therefore, often multifactorial, and each patient has his or her own specific pathogenetic pro- file as a result of a mix of etiological factors. It is clear that any treatment for fecal incontinence must allow for this fundamental aspect, and each patient thus requires a clinical approach that has been modulated on his or her specific incontinence etiology. This basic fact must be considered when planning therapy for a patient with fecal incontinence.
Rehabilitative treatment using biofeedback and pelvic floor exercises is considered the first-line option in treating fecal incontinence in patients who have not responded to simple dietary advice or med- ication [1]. Understanding when and how to perform rehabilitative treatment is not simple because there are no international agreements on the use of the various rehabilitative techniques. The main prob- lems are related to an absence of standards and guidelines, and the published scientific literature reflects this reality. A systematic review [1] by Nor- ton and Kamm and a consensus conference report [2] by Whitehead et al. mention several negative fac- tors that can be detected in many studies:
– Confusion between biofeedback and pelvic floor exercises
– A wide variety of methods within equipment and training programs
– A wide variety of outcome measures – No predictors of outcome
– Few long-term follow-ups
Significant rehabilitative treatment results may be obtained when the patient experiences (1) perception of sensory signals associated with rectal distension and following stool loss and (2) short external anal sphincter contractions when perceiving rectal disten-
sion [3]. Moreover, the patient prerequisites of reha- bilitative treatment success include motivation, intact cognition, and absence of depression [4]. Last but not least, the nurse–patient interaction is the most important variable that may influence rehabili- tation success rate [3]. The treatment goes on for months, and patients need to have a person as a point of reference who is able to combine technical capaci- ties, patience, and availability.
On these grounds, it is very hard to discuss the topic of rehabilitative fecal incontinence treatment because it will always result in being one sided and incomplete. Thus, the aim of the present study was only to provide an overview of the various approach- es to fecal incontinence rehabilitative treatment. A short description of the various available rehabilita- tive techniques is followed by a description of multi- modal rehabilitation.
Rehabilitative Techniques
The rehabilitative techniques that may be used for treating fecal incontinence are:
– Biofeedback
– Pelviperineal kinesitherapy – Sensory retraining
– Electrostimulation
Biofeedback
Biofeedback therapy is an operant conditioning [5]
that consists of pelvic floor strengthening exercises together with visual/verbal feedback training [6]. It is voluntary, employs a trial-and-error process by which learning takes place, and the subject must be aware of the desired response (signals). Two types of biofeedback training, manometric or electromyo- graphic (EMG), can be used in fecal incontinence, but both techniques work according to the same theoret- ical principles of operant conditioning. Manometric biofeedback is usually performed by monitoring anal
Rehabilitation and Biofeedback
Filippo Pucciani
15
canal pressures coupled to visual/verbal signals pro- portional to the pressure waves. In EMG biofeedback, the EMG sensors are positioned in the anal canal or adjacent to the anus and provide measurements of the averaged EMG activity of the pelvic floor coupled to visual/verbal signals. During their first training session, patients receive instructions on how to con- tract the external anal sphincter and puborectalis muscle in response to or in absence of rectal disten- tion sensation and how to improve muscle strength using modified Kegel exercises. The number of ses- sions is customized for each patient and may be done either in the outpatient unit using a rehabilitative work station or at home using portable devices. The sessions last 1 month, and the use of periodic rein- forcement, at least during the first year of therapy, may help maintain the beneficial effects over a long period [7].
How biofeedback works is debatable, even if it is generally considered a cortical reconditioning method for the defecation reflex [8]. It can influence both the strength of the striated pelvic floor muscles and the threshold of the sphincter contraction [9].
Interestingly, some papers suggested that a marked and significant levator ani strengthening is associat- ed with clinical improvement in response to biofeed- back therapy [10], whereas the external sphincter fails to improve [11]. This could explain why the objective changes in anorectal function seem be related more to improved sensory discrimination than to resting and squeezing anal pressures [4].
Whatever the mechanism of action, about 70% of patients show a decrease in fecal incontinence episodes [12, 13].
Pelviperineal Kinesitherapy
Developed to treat genital prolapse and female uri- nary incontinence [14], pelviperineal kinesitherapy may also be employed in the coloproctology field for rehabilitating fecal disorders [15]. This is a type of muscular training that selectively aims at the levator ani muscles. It is applied in patients with fecal incontinence with the general aim of improving the pelvic viscera bearing and endurance and coordina- tion of pelvic floor muscles and specific targets in order to strengthen the stress abdominal–perineal reflex and reinforce the puborectalis muscle resting tone (with positive effects on the anorectal angle) [16]. Pelviperineal kinesitherapy is useful when descending perineum syndrome [17] or pelvic floor support defects [18] are present in patients with fecal incontinence.
A cycle of pelviperineal kinesitherapy following a standard sequence is performed twice weekly in
some outpatient sessions [19]. Briefly, a sequence carries the patient from a preliminary lesson on relaxed breathing and corporeal consciousness on through intermediate steps (i.e., anteversion and retroversion pelvic movements, puborectalis mus- cle stretch reflexes) to the final lessons, which include abdominopelvic synergy and anal contrac- tion exercises (i.e., bending down, coughing, and Valsalva’s maneuver in supine, upright, and sitting positions).
Sensory Retraining
The aim of sensory retraining is to increase the incontinent patient’s ability to perceive the rectal dis- tension induced by feces or flatus (rectal sensation) [20]. Impaired rectal sensation may be a cause of fecal incontinence. Reduced rectal sensation, with a higher than normal rectal distension conscious threshold, allows the stool to enter the anal canal and, due either to the absence or lateness of the exter- nal anal sphincter reflex contraction, incontinence may occur [4]. Conversely, an exaggerated rectal sen- sation, with a lower conscious threshold, may elicit fecal incontinence because it is associated with reduced rectal compliance, repetitive rectal contrac- tions during rectal distention, and longer simultane- ous sphincter relaxation [21].
In these cases, two types of sensory retraining can be used. The first type partly uses biofeedback train- ing, as sensory retraining is coupled to sphincter strength training. In response to repeated rectal dis- tensions induced by inflation of the catheter-mount- ed balloon with volumes above or below the sensory threshold, the patient contracts the anal sphincter as strongly as possible, with feedback on contraction strength [2]. The second type involves twice–daily administration of a tepid water enema (volumetric rehabilitation) [19] . The initial volume is equal to the maximally tolerated manometric volume. The patient holds the liquid using the strongest possible anal contraction for the longest period of time possi- ble. In the days following, the enema volume is grad- ually either increased or decreased by 30 ml until the patient achieves a normal value of rectal sensation;
the volume is increased if the patient has a resting low–conscious threshold and decreased if the resting conscious threshold is high.
Both techniques act on the above-mentioned points, suggested by Tries [3] as decisive factors in rehabilitation success. Moreover, the program can be managed successfully by advanced-practice nurses in nonhospital settings [22]. If used as an isolated reha- bilitative technique, sensory retraining has the same success rate as biofeedback.
168 F. Pucciani
Chapter 15 Rehabilitation and Biofeedback
Electrostimulation
Electrical stimulation can induce muscle contraction by direct stimulation or indirectly via peripheral nerve stimulation. Anal electrical stimulation can be used to treat fecal incontinence, and the rehabilita- tive cycle is performed daily for some months by the patient in the home environment [19]. Patients are instructed to self-administer electrical stimulation with an anal plug probe. The device delivers a square wave of current alternating between a work period of a few seconds and a double rest period, according to a standard sequence. The daily routine is modulated on a program based on (1) current pulse (width in milliseconds and frequency in hertz) and (2) dura- tion (minutes/day) and frequency (number/day) of sessions.
The therapeutic effects are unpredictable because they depend on current type and intensity, applica- tion time, and tissue impedance. Moreover, some sci- entific papers underline that electrostimulation is not a clinically effective treatment of anal inconti- nence and that passive electrostimulation therapy of the anal sphincter is inferior to active biofeedback training [23, 24]. A Cochrane review [25] and a recent randomized trial [26] did not alleviate these doubts.
Some patients feel better after electrical stimulation, and incontinence may improve, but there is no objec- tive effect on anal sphincter pressures. Positive effects on the anal sphincter may be due to intrinsic muscular factors that are commonly found when the electrostimulation is used in other somatic districts.
Anal electrostimulation, however, could decrease the sphincteric tendency toward fatigue [23], and the compound muscle action potential of the external anal sphincter could be significantly increased by electrical stimulation [27]. After all, as the main pos- sible mechanism of benefit, the improvement of incontinence could be conducive to better anal sen- sory awareness [26, 28].
Multimodal Rehabilitation
Multimodal rehabilitation is the latest news in reha- bilitative treatment of fecal incontinence [19]. The algorithm for this rehabilitation management is based on the manometric reports. Biofeedback and pelviperineal kinesitherapy are indicated by low anal resting pressures or weak maximal voluntary contraction. Volumetric rehabilitation is indicated for disordered rectal sensation or impaired rectal compliance. Electrostimulation is only a prelimi- nary step when patients need to improve sensation of the anoperineal plane. The usual procedure
sequence is (1) volumetric rehabilitation, (2) elec- trostimulation, (3) biofeedback, and (4) pelviper- ineal kinesitherapy. Their combination is suggested by manometric data.
Anorectal manometry is the best diagnostic tech- nique to identify impaired mechanisms of conti- nence and is also a good guide to explain the patho- physiology of fecal incontinence. As stated above, each rehabilitative technique can modify specific aspects of fecal incontinence; therefore, anorectal manometry may suggest when the procedures are indicated. It is a rehabilitative treatment modulated on the incontinence pathophysiology of each patient.
The clinical outcome of multimodal rehabilitation is encouraging. Eighty-nine percent of patients show a significant improvement in incontinence score and 38% become symptom free. The worst results are obtained in patients affected by rectal prolapse and those with sphincter-saving operations. Long-term evaluation as well as prospective studies could con- firm the promising results of the multimodal rehabil- itation model.
Conclusion
In conclusion, the rehabilitative treatment of fecal incontinence is a good therapeutic option. Many patients may be cured and their quality of life much improved. In addition, rehabilitation techniques can be used to screen out the incontinent nonresponders, whose treatment should more appropriately include more expensive and extensive procedures (e.g., sphincteroplasty, sacral neuromodulation, artificial sphincter, dynamic graciloplasty).
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