How is Dyssynergic Defecation Treated?
Dyssynergic defecation can be effectively treated with education and pelvic floor biofeedback therapy. The healthcare provider will begin by reviewing past strategies, which may have been used by the patient in trying to treat their constipation. The future treatment plan will depend on what underlying factors may now be contributing to the chronic constipation.
Standard Treatment
Different remedies may have been tried, with little success, to relieve symptoms prior to being diagnosed with dyssynergic defecation. Coexisting issues that are present in addition to the dyssynergic defecation still need to be addressed to move forward with successful treatment. For example, a review of all medicines and supplements being taken is important to identify any that may be constipating.
There is little evidence that changes in diet and exercise will improve chronic constipation. However, a balanced diet, adequate fiber (20 to 30 grams per day), and regular exercise promote good health in general.
When and how often to attempt bowel movements are important issues.
- Whenever possible, one should always respond to the urge to have a bowel movement, rather than hold it back.
- The body has internal mechanisms that naturally stimulate the bowel after waking and after meals. One can take advantage of this by attempting bowel movements, at least twice a day, about 30 minutes after meals.
- When attempting a bowel movement, it is important not to strain too long (no more than 5 minutes) nor push too much (no more than about one-half effort).
- Digital or manual maneuvers to empty BMs from the rectum should be stopped. Bowel re-training involves sitting on the toilet for 10 minutes at the same time each day, preferably 30 minutes after meals, so the gut can get reprogrammed into the habit of having regular bowel movements.
A healthcare provider may recommend laxatives in order to help change bowel movement consistency or increase movement through the bowel. Several types of laxatives are available. Bulk forming laxatives (fiber supplements), along with stool softeners and osmotic laxatives such as magnesium compounds or senna or polyethylene glycol (Miralax, Glycolax), change stool consistency. Stimulant laxatives cause rhythmic muscle contractions in the bowel to propel stool. All are available without prescription, but for chronic constipation, should be taken under a doctor’s guidance. Today, several other prescriptions drugs are available for treatment of chronic constispation and this includes lubiprostone (Amitiza®), linaclotide®, plecanatide (Trulance®), prucalopride (Motegrity®), and a non-pharmacological capsule device called the Vibrant Capsule (Vibrant®).
Specific Treatment
When muscles under voluntary control in the pelvic floor fail to relax in the way needed for a normal pattern of defecation, their function is best improved through various learning procedures. Neuromuscular training using biofeedback techniques has been shown to be beneficial. Symptom improvement has been reported in more than two-thirds of patients.
The goal of biofeedback therapy is to restore a normal pattern of defecation. Biofeedback therapy is an instrument-based learning process. In biofeedback, special sensors and a computer are used to painlessly monitor muscle and sensory responses. Bowel training additionally may involve special devices used to practice having a bowel movement. Working with a knowledgeable therapist, the patient learns to change abnormal responses to more normal patterns. In patients with dyssynergic defecation, there are usually two goals for biofeedback therapy.
- To correct the abnormal coordination (dyssynergia) of the abdominal, rectal and anal sphincter muscles in order to achieve a normal pattern and complete evacuation.
- To improve rectal sensory perception if rectal sensation is abnormal.
The patient will undergo repeated sessions (typically 6) of biofeedback therapy training. During training, the individual will learn several things:
- How the muscles of the pelvic floor work during defecation
- How to use abdominal muscles and diaphragmatic breathing to improve push effort
- How to relax the pelvic floor during a bowel movement
- How to be more aware of the sensation of rectal fullness or desire to defecate
The number and length of neuromuscular training sessions varies depending on individual needs. Typically, each training session takes one hour. On average, 6 training sessions, performed once every week or two weeks. After completion of biofeedback therapy training, periodic reinforcements at six weeks, three months, six months, and twelve months may provide additional benefit, and also improve the long-term outcome.
There are several means and methods available to perform biofeedback therapy for pelvic floor dyssynergia. Effective therapy requires a specially trained therapist working closely with a willing patient and a multi-disciplinary approach. The therapy has no adverse effects.
There are several means and methods available to perform biofeedback therapy for dyssynergia defecation. Effective therapy requires a specially trained therapist working closely with a willing patient and a multi-disciplinary approach. The therapy has no adverse effects. This treatment is scientifically proven. However, effective biofeedback therapy to treat dyssynergic defecation is only offered in a few centers.
This lack of availability is in part due to lack of insurance payment for this simple, yet effective therapy and lack of standardized and dedicated equipment and protocol. Hopefully, through public awareness and education of insurance payors, and improved instruments including home biofeedback therapy this treatment program can become more widely available.
How effective is Biofeedback Therapy?
In the last few years, several research studies in adults with dyssynergic defecation have been reported. While they differ significantly in the way in which they were conducted, the studies all concluded that biofeedback therapy is superior to controlled treatment approaches such as diet, exercise, laxatives, and several other methods.
In order to treat the large number of constipated patients in the community, development of a home based, self-training program will be essential. Recently, research has shown that home biofeedback therapy worked just as well in patients with dyssynergic defecation as in-office therapy. Newer, user friendly home biofeedback devices may be available in the near future.
Summary
Dyssynergic defecation is common and affects up to one-half of patients with chronic constipation. Unfortunately, it is not well recognized and on average it takes 5-10 years of constipation symptoms before patients are identified with this condition. It is due to an inability to coordinate the abdominal and pelvic floor muscles to evacuate bowel movements. It is possible to diagnose this problem through a medical history, physical examination, and specialized tests of anorectal function. Randomized controlled trials have now shown that biofeedback therapy is effective and superior to other treatment approaches. The symptom improvement is due to a change in underlying function of the muscles and nerves involved with defecation. Wider availability of biofeedback therapy including the use of home biofeedback therapy devices, could result in significant improvement of symptoms for patients with this disorder.
Adapted from IFFGD Publication #237 by Satish S.C. Rao, MD, PhD, FRCP(LON), AGAF, Chief, Section of Gastroenterology/Hepatology and Director, Digestive Health Center, Medical College of Georgia, Georgia Regents University, Augusta, GA.
