PROCEEDINGS
NONPHARMACOLOGIC AND OTC THERAPIES
FOR CHRONIC CONSTIPATION*
—
N
William L. Hasler, MD†
ABSTRACT
Nonpharmacologic and over-the-counter
(OTC) therapies for chronic constipation include
lifestyle measures, such as increased intake of
fluid and fiber, OTC fiber supplements and laxatives, biofeedback, and surgery. Although
lifestyle measures and OTC agents are frequently recommended in clinical practice, a closer
look at the data reveals that most studies show
either no effect, beneficial effects that are often
cancelled out by exacerbation of constipationrelated symptoms, or findings that neither support nor refute the use of these modalities.
Studies examining biofeedback, which is most
commonly used in patients with dyssynergic
defecation, generally demonstrate benefit. This
article reviews the data for each of the 4 modalities and, to illustrate their application in clinical
practice, also includes a ”running” case study of
an actual patient who was treated with 3 of these
4 approaches to therapy.
(Adv Stud Med. 2006;6(2A):S84-S93)
onpharmacologic and over-the-counter
(OTC) therapies for chronic constipation fall into 4 broad categories:
lifestyle measures, such as increased
fluid and fiber intake; OTC fiber-bulking agents, laxatives, and stool softeners; biofeedback;
and surgery. Each plays a role in the management of
constipation, with lifestyle measures and the use of
OTC agents often constituting the initial treatment
approach in the majority of patients.
However, the data regarding these approaches are
variable, with some studies showing little or no effect
and others showing efficacy in some parameters and/or
offsetting side effects. Furthermore, many studies
assessing lifestyle modifications and OTC therapies are
relatively small and poorly designed, making it difficult to glean useful information.
This article reviews the data for all 4 treatment
modalities and, to illustrate their application in clinical practice, includes a “running” case study of a
patient who was treated with 3 of the 4.
LIFESTYLE MEASURES
*Based on a presentation by Dr Hasler at a roundtable
symposium held in Santa Monica, California, on September
22, 2005.
†Associate Professor of Internal Medicine, Division of
Gastroenterology, University of Michigan Medical Center,
Ann Arbor, Michigan.
Address correspondence to: William L. Hasler, MD,
Associate Professor of Internal Medicine, Division of
Gastroenterology, University of Michigan Medical Center,
University Hospital, 1500 East Medical Center Drive, Room
2A341, Ann Arbor, MI 48109. E-mail: [email protected].
S84
As reflected in the case study later in this article,
lifestyle measures are often the initial approach to the
management of constipation. The advantages to this
approach are that it is “natural,” it does not involve
prescription drugs with potentially untoward side
effects, and it puts the patient in charge. However,
studies evaluating the effects of fluid intake, fiber
intake, and exercise on constipation have yielded
mixed findings with regard to their effectiveness.
FLUID INTAKE AND EXERCISE
Although increased fluid intake is often recommended to increase stool output, the literature sug-
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gests that it does not play much of a role. Although 1
small study in healthy volunteers found that reducing
fluid intake from 2500 mL/day to 500 mL/day
reduced stool frequency by 2 bowel movements per
week and stool weight by approximately 20% to 30%,1
another small study in volunteers found that increasing fluid by 1 to 2 L/day increased urine output but
not stool output.2
Similarly, studies of the effects of exercise on constipation have found little or no impact. One small
study of patients with constipation who participated
in an intensive exercise program (1 hour a day, 5 days
a week) found no significant improvement in constipation indices.3 A much larger population study of
more than 1000 employees of the same company
found no difference in physical activity levels among
those who were constipated (n = 140) and those who
were not (n = 929).4
tion have found that bran and ispaghula accelerate
transit,7-10 but that psyllium husk had no effect on
transit or other manometric parameters.11 Findings
from 1 of these studies also suggest that bran is
most beneficial in patients with colonic inertia.7
Several of these studies, in addition to others, also
examined the effects of various fiber supplements on
constipation symptoms. Most found beneficial effects
on stool frequency, weight, and consistency, but not
on abdominal pain or bloating.7,8,12-15 A study by Hotz
and Plein found that psyllium husk and bran
decreased pain, but increased bloating in patients with
constipation-predominant irritable bowel syndrome,16
and a study by Ashraf et al found that psyllium husk
decreased pain.11 The only study to find a decrease in
DIETARY FIBER AND FIBER SUPPLEMENTS
In addition to dietary sources of fiber such as bran,
fruits, and vegetables, there are several fiber supplements
that are available in a number of formulations, such as
pectin, gums, cellulose, and lignins. They work by a variety of mechanisms, including water retention, stool
bulking, stimulation of fermentation, acceleration of
colonic transit, and bile-acid binding.5 Because of the latter, these agents have also been purported to be helpful
in some patients with diarrhea. Pectin and gums form
viscous solutions that delay gastric emptying and nutrient absorption. Cellulose and lignins, which are insoluble, accelerate colonic transit. Commonly available fiber
supplements include psyllium husk (Metamucil; Procter
& Gamble Pharmaceuticals, Inc., Mason, Ohio), calcium polycarbophil, and methylcellulose.
A study evaluating the physiologic effects of fiber
in 20 healthy volunteers who had radiopaque marker
tests before and during consumption of a usual British
diet supplemented by bran 20 g/day found that bran
decreased transit time from 2.75 days to 2.0 days, suggesting an improvement in transit.6 Interestingly, bran
accelerated transit in all 9 subjects with an initial transit time of 3 or more days and slowed transit in all 4
subjects with an initial transit time 1 or less day. A
double-blind crossover trial described in the same
report found that bran significantly accelerated transit,
but oat flakes had no effect.6
Several other studies evaluating the physiologic
effects of various fiber supplements on constipa-
CASE STUDY
Advanced Studies in Medicine
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PRESENTATION
• 46-year-old woman with a 4-year history of
constipation
• Symptoms began gradually; she now has 1 bowel
movement every 6 days with straining and hard,
dry stools, but no bulging, bleeding, or pain
• Her weight is stable
MEDICAL HISTORY
• Caesarean sections
• Migraine headaches
• She takes ibuprofen as needed
PHYSICAL EXAMINATION/EVALUATION FINDINGS
• Physical, anorectal, and pelvic examinations:
normal
• Metabolic studies, including calcium and
thyroid-stimulating hormone determinations:
normal
• Structural tests, including colonoscopy:
normal
INITIAL RECOMMENDATIONS
• Drink 4 glasses of water a day
• Initiate a regular exercise regimen
• Schedule defecation after eating
• Eat plenty of bran cereal, bran muffins, and salads
• Take an OTC bran supplement, if needed
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PROCEEDINGS
pain and bloating was one evaluating ispaghula.10
In a study involving 149 patients at a tertiary care
center who had undergone physiologic testing, the
response to therapy with plantago seeds for 6 weeks
was correlated with the functional abnormality.17
Whereas 85% of patients with normal test results
responded favorably, only 37% of those with abnormal
anorectal manometry and defecography and 20% of
those with abnormal colonic transit had a good
response. This observation suggests that fiber supplements are likely to be beneficial only in those individuals with relatively mild constipation.
and lactulose, and limited evidence for milk of magnesia, senna, bisacodyl, and stool softeners.19
STOOL SOFTENERS
One of the larger studies of stool softeners compared the efficacy of psyllium husk 5 g twice daily versus docusate 100 mg twice daily in 170 patients with
constipation.20 All patients received therapy for 2
weeks after a 2-week baseline run-in period. As shown
in Table 1, psyllium husk was significantly superior to
docusate in all efficacy measures, except stool frequency per week, which was similar in both groups.
OVER-THE-COUNTER LAXATIVES AND
STOOL SOFTENERS
Various types of OTC laxatives and stool softeners
are available, including surface-acting stool softeners,
such as docusate; stimulant laxatives, such as bisacodyl,
castor oil, and the anthraquinones senna, cascara, and
frangula; osmotic agents, such as magnesium and
phosphate salts and sorbitol; and lubricants, such as
mineral oil. Many of the studies evaluating the efficacy of these agents are relatively small and do not provide convincing data to support or refute their use. In
addition, many of these studies are poorly designed,
making it difficult to glean useful information.
META-ANALYSIS AND SYSTEMATIC REVIEW
With the goal of including large placebo-controlled
trials in a meta-analysis of studies on the efficacy of
laxatives in constipation, Jones et al reviewed 250 articles in the literature.18 Of 35 articles that met the
inclusion criteria, only 11 yielded useful data from a
total of 375 patients treated with laxatives and 174
patients receiving placebo. In studies lasting less than 4
weeks, laxatives increased weekly stool frequency by
1.9 (vs 1.0 for placebo) and stool weight by 476 g (vs
434 g for placebo), differences that were not statistically significant. No differences were seen in studies
lasting 5 to 12 weeks. In contrast, a systematic review
of trials evaluating OTC and prescription laxatives and
stool softeners between 1966 and 2003 found good
supporting evidence (Grade A) for the prescription
agents tegaserod (Zelnorm; Novartis Pharmaceuticals,
East Hanover, NJ) and polyethylene glycol (PEG)
3350 (Glycolax; Schwarz Pharma, Inc., Mequon, Wis;
MiraLax; Braintree Laboratories, Inc., Braintree,
Mass), moderate evidence (Grade B) for psyllium husk
S86
Table 1. Efficacy of Psyllium Versus Docusate in
Constipation
Measure
Psyllium
Docusate
Stool water increase
*
2.33%
0.01%
Stool water weight
84.0 g†
71.4 g
Stool weight
359.9 g/week‡
271.9 g/week
Constipation relief score
475.1§
403.9
3.5
2.9
(per bowel movement)
Stool frequency per week
* P = .007; P = .04; P = .005; P = .002.
Data from McRorie et al.20
†
‡
§
FOLLOW-UP ASSESSMENT 1
• No increase in stool frequency or improvement in
stool consistency after increased intake of bran
muffins, bran cereal, salads, and bran supplements
• Straining is still present
• Bran supplements caused significant bloating
RECOMMENDATIONS
• Milk of magnesia; 2 tablespoons at bedtime
• If no response, add senna-based laxative as needed
• If still no response, switch to sorbitol
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STIMULANT LAXATIVES
Studies of stimulant laxatives have shown that they
produce physiologic effects in patients with constipation and in controls. In a study of 18 patients with
slow-transit constipation, bisacodyl elicited pelvic
colon peristaltic waves in 11 patients.21 In another
study, bisacodyl produced more rapid and frequent
high-amplitude propagating contractions in patients
with slow-transit constipation and controls, with the
effect more pronounced in controls.22 A study evaluating the effects of senna in 24 volunteers found that
senna plus fiber was superior to fiber alone in stimulating colonic transit.23 The study also found that
senna reversed constipation induced by loperamide
(Imodium; McNeil Consumer Healthcare, Fort
Washington, Pa).
Other studies assessing the effects of stimulant laxatives on constipation symptoms found that senna
produced additive effects. In a study of 42 nursing
home patients, senna plus dicotylsodium sulfosuccinate with fiber and fluid produced satisfactory defecation in 86%.24 In another study, psyllium husk plus
senna increased stool water and produced an adequate
laxative effect in 63% of patients with constipation
compared to 48% for psyllium husk alone.25
OVER-THE-COUNTER VERSUS PRESCRIPTION LAXATIVES
The prescription laxatives lactulose and PEG are
addressed in detail elsewhere in this monograph, but
are briefly mentioned in this section because they have
been compared to OTC agents or with each other in
various studies.
Results from some studies comparing lactulose
with various fiber supplements or bulking agents have
suggested that fiber and other agents produced more
satisfactory responses than lactulose.26-28 One study
found that lactulose was superior to ispaghula,29
whereas another found no difference between lactulose
and sorbitol in preference and symptomatic relief,
leading the investigators to recommend sorbitol
because of its lower cost.30 An early study (essentially
placebo-controlled because it compared lactulose to
glucose, which has no independent laxative effect)
found that lactulose was very effective in increasing
stool frequency and decreasing constipation-associated
symptoms.31
Results from several studies evaluating PEG have
been favorable. A physiologic study showed that it
increased stool frequency without any adverse effects
Advanced Studies in Medicine
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on standard measures of colonic motor activity,32
whereas placebo-controlled studies demonstrated that
it increased stool frequency and was very effective in
relieving constipation-related symptoms.33,34 In addition, trials comparing PEG to lactulose found that
PEG was more effective in increasing stool frequency
and reducing pain, straining, and flatulence.35-37
METABOLIC COMPLICATIONS OF LAXATIVE THERAPY
Although there has been some concern about
metabolic complications of prescription laxatives,
these complications are also seen with OTC agents,
particularly the osmotic laxatives. For example, laxatives containing magnesium can produce neuromuscular blockade with severe weakness, cardiac dysfunction
with hypotension, and paralytic ileus. Similarly, enemas containing sodium phosphate can cause hyperphosphatemic hypocalcemic coma, hypernatremia,
hypokalemia, metabolic acidosis, and circulatory failure, all of which are significantly exacerbated by coexistent chronic renal insufficiency.
One area of controversy over the years is the role of
anthraquinones in cathartic colon, a condition that
was common 50 or 60 years ago, but is very uncommon today even though senna laxatives are still used
fairly often. The subject is still controversial, as reflected by the findings of 2 of a handful of studies done in
the 1990s. One study, which examined colon biopsy
specimens from patients with constipation treated
with anthraquinones and other laxatives, found no difference between the groups in the number of damaged
neurons or type 1 vesicles.38 However, the other study,
which used barium to assess patients taking
anthraquinones 3 or more times per week and patients
taking other laxatives, found that colon redundancy,
dilation, and loss of haustra were more common in the
former group.39 It was unclear whether the drugs
accounted for the increased prevalence or whether
patients with underlying colonic motility problems
tended to use anthraquinones more often.
Another unresolved issue is whether laxative use
increases the risk of colon cancer. A large populationbased study from Japan found that the relative risk of
colon cancer was significantly higher in constipated
patients who used laxatives frequently than in those
who did not (2.75 vs 1.35 for constipation alone).40
Conversely, a case-control series in North Carolina
found that the odds ratio was higher for constipation
alone than for laxative use, leading the investigators to
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conclude that laxative use did not increase the risk for
colon cancer.41 However, a meta-analysis of 14 series,
which found nearly identical odds ratios for constipation alone and laxative use, questioned whether the
odds ratios reflected dietary alterations and whether
constipation or laxative use played a role in the development of colon cancer.42
in anal pressure. The goal of biofeedback is to train the
patient to relax the anal sphincter during defecation so
that their manometric tracings resemble those shown
in the right panel of the Figure.
A critical review of 38 articles reporting use of
biofeedback in constipation between 1970 and 2000
identified 10 studies with parallel design.43 The review
BIOFEEDBACK
Anorectal function is regulated by the anal sphincters and the pelvic sling muscles that normally relax during defecation. When they fail to relax, as happens in
adult-onset Hirschsprung’s disease, rectocele, intussusception, and rectosphinteric dyssynergia, there is outlet
obstruction that interferes with the passage of stool.
Dyssynergia is the prototypical constipation-related condition for which biofeedback is used, and in
which it has been most extensively studied. Three
types of biofeedback are commonly employed in
patients with dyssynergic defecation: anal pressure/rectal sensation using manometry, anal pressure/rectal
sensation using balloon inflation across the anus, and
electromyography (EMG) using surface electrodes. As
shown in the left panel of the Figure, manometric tracings of dyssynergia reveal normal rectal contraction
with attempted defecation, but a paradoxical increase
FOLLOW-UP ASSESSMENT 2
• No improvement with laxatives, which produced
cramps
• Functional testing revealed:
• Colonic transit: 147 hours, slow in all regions
• Anorectal manometry: paradoxical contraction on
simulated defecation and inability to pass balloon
• Defecography: small rectocele, paradoxical
increase in anorectal angle with defecation
• Referred for biofeedback
Figure. Manometric Tracings in Dyssynergia Before and After Biofeedback Training
Normal
5s
Dyssynergia
5s
Rectum
20 mm Hg
Internal
sphincter
Rectum
External
sphincter
External
and
sphincter
Expulsion
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Expulsion
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of these 10 studies found that pressure biofeedback
with manometry was more successful than EMG
biofeedback (78% vs 70%), that the success rates for
intra-anal and perianal biofeedback were similar (69%
and 72%), and that there was no clear predictor of
who would respond favorably and who would not.
Favorable findings from a study assessing the physiologic effects of biofeedback on anorectal function in
25 patients with obstructive defecation are shown in
Table 2,44 but data regarding long-term benefits are
more variable. In 1 study, 12 of 24 patients with
dyssynergia who responded to biofeedback initially
maintained the benefits of therapy over time, but the
remaining 12 patients did not.45 In another study,
which followed 50 patients for 12 to 24 months,
biofeedback was helpful in 70%, with constipation less
severe in 62.5%.46 However, still another study found
that 19 of 22 patients regressed to prebiofeedback status after 35 months.47
In contrast to the critical review that found no clear
predictors of response43 and a study finding that neither diet, pelvic exercise, manometry, EMG, nor rectal
sensation predicted response,47 some studies have identified factors that are predictive.48-50 For example, one
study found that lack of anal relaxation and inability
to pass a 1-mL balloon were associated with failure,48
whereas another found that biofeedback was more
effective in patients with normal anorectal physiology.49 A third study identified the number of biofeedback sessions as a predictor of outcome, with success in
18% of patients attending 2 to 4 sessions compared to
44% in those attending 5 or more sessions.50
Biofeedback has also been shown to be helpful in
constipation that is not caused by dyssynergia. A study
of 100 patients who received biofeedback more than 1
year earlier found that although 65% had slow-transit
constipation and 59% had dyssynergia, 55% of the
group as a whole found biofeedback to be helpful at 1
year, with equal responses in those with slow and normal transit, with or without paradoxical contraction.51
SURGERY
Subtotal colectomy with ileorectal anastomosis is
considered the therapy of last resort for refractory
slow-transit constipation. Several reports have been
published on the procedure and its variations.
Responses were similar in the 8 reports published since
2000, with approximately 60% to 90% of patients
Advanced Studies in Medicine
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having good results.52-59 However, there was significant
postoperative morbidity in many of the reported
series, including pain, incontinence, diarrhea, ileus,
and small bowel obstructions. In 1 of the studies,
which involved colectomy and the placement of
ileostomy, stomal retractions developed in 25% of the
patients, hernia in 8%, sepsis in 3%, and persistence of
difficult evacuation in 4%.59
Colectomy has also been examined in mixed patterns of constipation. In a series of 16 patients with
slow-transit constipation plus dyssynergia, colectomy
resolved symptoms in 7.60 However, 2 patients had
severe incomplete evacuation that was unresponsive to
FINAL CASE ASSESSMENT
• Patient now has 1 bowel movement every 2 to 3
days on PEG and low-dose colchicines
• She has received 5 sessions of biofeedback
• No surgery is planned
Table 2. Physiologic Effects of Biofeedback
Parameter
Percentage anal relaxation
Response
Increased
Intrarectal pressure
Increased
Defecation index
Increased
Balloon expulsion time
Decreased
Straining effort
Decreased
Rectal sensation
Improved
Satisfaction with bowel movement
Improved in 60%
Laxative use
Decreased
Digital disimpaction
Markedly decreased (94%)
Data from Rao et al.44
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additional sessions of biofeedback, 3 had diarrhea, and
only 9 were satisfied with the surgery.
Other conditions associated with constipation that
may be treated surgically are rectocele and rectal intussusception. Studies involving surgical closure of the
rectocele have generally shown response rates of 70%
to 80%.61-65 However, as demonstrated in 3 of these
studies,63-65 patients with slow-transit constipation,
dyssynergia, or reduced rectal sensation do not
respond as well to rectocele repair.
Data on retropexy with or without resection for
rectal intussusception are limited, but available studies
show a high degree of patient satisfaction,66 good to
excellent response rates at 1 year, with a low incidence
of complications,67 and a reduction in constipation
and transit time.68
Other therapies for constipation include anal dilation, botulinum toxin, and electrogalvanic stimulation
to relieve outlet obstruction, and various surgical
approaches to specific conditions underlying constipation. These include endorectal pull-through, the
Duhamel procedure, ileocolic anastomosis, and
myomectomy for Hirschsprung’s disease; reduction rectoplasty for megarectum; division of the puborectalis for
dyssynergia; and antegrade enema, colonic pacing, and
sacral nerve stimulation for slow-transit constipation.
CONCLUSIONS
Nonpharmacologic and OTC therapies for chronic constipation include alterations in fluid and fiber
intake, OTC fiber supplements and laxatives, biofeedback, and surgery.
Data on lifestyle measures have shown that
increased fluid intake and exercise have little or no
effect on constipation. Studies examining the effect of
OTC fiber supplements have found beneficial effects
on colonic transit for some agents in some patients,
but they have also found no effect on or exacerbation
of symptoms, such as abdominal pain or bloating.
A similar situation exists with OTC laxatives, in
which many studies evaluating efficacy are relatively
small and do not provide convincing data to support or
refute their use. Biofeedback data are more consistent in
demonstrating benefit, with some studies identifying
subsets of patients who are more likely and less likely to
respond. Surgery, which is considered the option of last
resort, provides reasonably good results, but it is also
associated with considerable postoperative morbidity.
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DISCUSSION
Dr Lee: How many biofeedback sessions over what
period of time are typical for patients with constipation? How well do patients comply?
Dr Hasler: That varies from center to center. At
our center, we typically schedule patients for 3 consecutive sessions, separated by 3 to 4 weeks in most cases.
Then we re-evaluate to see if they’ve had any sort of
response in terms of symptoms. Our institution
switched from manometry-based biofeedback to
EMG, thus we also like to see EMG evidence of success. If there’s a response, we will use biofeedback again
as needed, but if there’s absolutely no response, we
usually discontinue it.
In terms of compliance, our rates have been pretty
good, approximately 70% or better, because our
patients tend to be at the end of their rope. Most have
failed all laxative therapy, and they’re ready to try anything.
Dr Rao: That’s similar to what we do, although we
tailor the number of sessions to the needs of the patient.
There is no fixed number, but 6 is fairly typical.
The number of sessions for a given patient depends
on many factors, including the patient, the level of
understanding of the instruments and the equipment,
the willingness to work on some of the initial issues,
and the ability to learn and master a new technique.
It’s a question of trial and error. It takes a lot of learning. Some patients are quick learners, some are slow
learners, and some are not well motivated. Our program includes a 1-hour education and training session,
and then we schedule biweekly sessions thereafter. We
rarely go beyond 6 sessions. If they haven’t responded
by then, I usually make a determination that it’s not
working and I discontinue biofeedback.
If they do respond, I offer 3 more sessions over the
next year—at 6 weeks, 3 months, and 6 months—as
reinforcement. That’s an important component, even
though we have not assessed it in a prospective or controlled fashion. It’s important in ensuring the longterm beneficial effects of biofeedback.
Dr Lembo: What if the manometry pattern normalizes after the first or second session? Do you stop
them or do you still have them come back?
Dr Rao: If the manometry pattern normalizes, it
often goes hand-in-hand with the ability to expel the
balloon easily, within a few seconds perhaps, and with
symptomatic improvement. However, that rarely hap-
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pens after only 2 sessions. Even if it does, there may be
some persistent straining or hard stools.
In addition, there are some people who continue to
do digital disimpaction, despite normalization of the
manometry pattern. We try to address all of their
symptoms and try to get them back to more normal
physiologic behavior. We address why they have to use
digital maneuvers and how they can overcome it.
Dr Lembo: Ones of the issues that comes up is the
lack of sensitivity of any one test, or even all the tests,
used in diagnosis. Even patients with normal test findings seem to get better with biofeedback. Do you really need to do any tests? If you have a high degree of
clinical suspicion, based on symptoms or the physical
examination, why can’t you just send the patient for
biofeedback without a lot of testing that doesn’t have
very good sensitivity or specificity?
Dr Rao: St Mark’s group is moving towards that
kind of strategy, and Michael Kamm thinks that may
be a way to go. He sends all patients in his practice,
whether they have fecal incontinence or constipation,
for biofeedback first. If they fail, he does the evaluation and testing. That approach is acceptable at St
Mark’s, but it won’t serve well at my institution.
I believe in testing first because it gives me a much
better understanding of what the problem is before I
embark on treatment. Some patients probably don’t
need any biofeedback training, which is labor intensive
and requires a lot of motivation. If a patient’s ability to
relax the pelvic floor is normal, or if an incontinent
patient has a normal manometric profile, you can’t
make them better physiologically. They are already
normal.
You can send patients for anorectal manometry to
identify abnormalities and then go ahead with
biofeedback; that’s a reasonable argument. However, if
they don’t have abnormalities, you then have to have a
consult and find out what’s going on. I still think
biofeedback should be preceded by testing to identify
pelvic floor dysfunction. If it’s present, then proceed
with appropriate management or behavioral therapy.
Another important point about biofeedback is that
it is a holistic approach. It comprises several interventions in addition to the physiologic conditioning.
You’re probably changing their laxatives, you’re changing their lifestyle, and you’re teaching them timed toileting and maybe even coping strategies. Patients find
all of these to be helpful. That is why we performed
controlled studies to see if these factors were responsi-
Advanced Studies in Medicine
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ble for improvement rather than the physiologic conditioning. Our studies clearly showed that physiologic
conditioning truly makes a difference.69
Dr Bharucha: There was a paper by Chiarioni et al
in Gastroenterology earlier this year showing that an
abnormal balloon expulsion test predicts a positive
response to biofeedback therapy in constipated
patients.70
Dr Lembo: That’s something you can do in your
office.
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