Dyssynergic Defecation and Biofeedback Therapy

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Constipation caused by dyssynergic defecation is common and affects up to one half of patients with this disorder. It is possible to diagnose this problem through history, prospective stool diaries, and anorectal physiologic tests. Randomized controlled trials have now established that biofeedback therapy is not only efficacious but superior to other modalities and that the symptom improvement is caused by a change in underlying pathophysiology. Development of userfriendly approaches to biofeedback therapy and use of home biofeedback programs will significantly enhance the adoption of this treatment by gastroenterologists and colorectal surgeons.

Section snippets

Epidemiology

The prevalence of chronic constipation varies from 2% to 28%.13 It is commonly encountered in primary care. Telephone interviews with 10,018 individuals, aged at least 18 years, produced an estimated prevalence of 14.7%.14 In a questionnaire survey of 5430 households across the United States, functional constipation was reported by 3.6% of responders and difficult defecation by 13.8%.15 Because most patients do not seek health care, its prevalence has been underestimated.15

Constipation is more

Origin

How, when, and why an individual develops dyssynergic defecation is unclear. The authors' prospective survey of 100 patients with dyssynergic suggested that the problem began during childhood in 31% of patients; after a particular event, such as pregnancy, trauma, or back injury in 29% of patients; and no identifiable precipitating cause in 40% of patients.11 Two thirds acquire this condition during adulthood. In this group, 17% reported a history of sexual abuse, 43% the passage of hard stools

Clinical features

Patients with dyssynergic defecation present with a variety of bowel symptoms. Often, patients do not volunteer or misrepresent their symptoms. For example, patients do not readily admit that they use digital maneuvers to disimpact stool or splint their vagina to facilitate defecation. By establishing a trustworthy relationship or through the help of symptom questionnaires or stool diaries, it may be possible to identify the precise nature of their bowel dysfunction. It is essential to

General Issues

The first step in making a diagnosis of dyssynergic defecation is to exclude an underlying metabolic or pathologic disorder. Slow transit constipation may coexist with dyssynergic defecation,1, 35 and hence an assessment of colonic motor function and transit is useful. An evaluation of the distal colonic mucosa through flexible sigmoidoscopy may provide evidence for chronic laxative use and may reveal melanosis coli or other mucosal lesions, such as solitary ulcer syndrome, inflammation, or

Treatment

The treatment of a patient with dyssynergic defecation consists of (1) standard treatment for constipation; (2) specific treatment (ie, neuromuscular training or biofeedback therapy); and (3) other measures including, botulinum toxin injection, myectomy, or ileostomy.

Summary

Constipation caused by dyssynergic defecation is common and affects up to one half of patients with this disorder. This acquired behavioral problem is caused by the inability to coordinate the abdominal and pelvic floor muscles to evacuate stools. Today, it is possible to diagnose this problem through history, prospective stool diaries, and anorectal physiologic tests. Randomized controlled trails have now established that biofeedback therapy is not only efficacious but superior to other

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