Retraining Pelvic Floor Muscles to Correct Chronic Constipation

Up to 50% of patients with chronic constipation have pelvic floor dysfunction (PFD, or dyssynergia). This condition is characterized by impaired coordination between pelvic floor (e.g., puborectalis) relaxation and abdominal wall motion, which is necessary for normal defecation. However, PFD is not widely recognized as a possible cause of chronic constipation. As a result, many patients with medically refractory constipation do not receive optimal therapies that enable them to recover normal bowel habits.

Biofeedback therapy and the bowel

When mechanical, anatomic, and disease- and diet-related causes of constipation have been ruled out, clinical suspicion should be raised to the possibility that PFD is causing or contributing to constipation. Informed by an understanding of PFD, best-practices treatment of medically refractory chronic constipation due to PFD includes retraining the pelvic floor muscles with biofeedback.

Based on the principle of operant conditioning, biofeedback helps patients modify bowel habits by restoring defecation, which normally entails propulsive forces coordinated with relaxation.

"Many patients with refractory chronic constipation have unrecognized PFD, which improves with biofeedback therapy. PFD is an under-recognized cause of chronic constipation. Patients are most likely to be evaluated for PFD when they seek care at an advanced multidisciplinary center and to receive biofeedback therapy in this setting," explains Adil E. Bharucha, M.B.B.S., M.D., a gastroenterologist and specialist in PFD at Mayo Clinic in Rochester, Minnesota.

Anorectal manometry topographic plots

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Multidisciplinary approach

Mayo Clinic gastroenterologists address chronic constipation through an integrated, multidisciplinary approach. When chronic constipation is a presenting symptom, a careful digital rectal examination is indicated. Its purpose is to evaluate such features as high anal resting tone and inability to relax the puborectalis muscles.

Depending on digital exam findings, patient evaluation may also include:

• Anorectal manometry with 12 circumferential sensors for high-resolution output to assess anorectal pressures
• Pelvic MRI to visualize pathologic pelvic floor motion and anal sphincter anatomy
• Evacuation proctography (defecography) to provide a video recording of pelvic floor motion and anorectal anatomy under various patient conditions (at rest, during coughing, squeezing and straining to expel barium from the rectum)

The methods used to conduct these tests were developed, in part, at Mayo Clinic. Interpretation is guided by an extensive database of normal values, which is important since anorectal functions are influenced by patient age and sex. Test results also are interpreted in the context of each patient's clinical features.

Absent other pathologies, data showing lack of coordination of propulsion and relaxation due to inability to relax pelvic floor and abdominal muscles are generally the basis for initiating biofeedback therapy. Notes Dr. Bharucha: "A majority of patients are delighted with the improvement in symptoms after retraining, which is conservative and safe. Many have suffered for months or years through inappropriate treatments because the central role of PFD in chronic constipation was not recognized and treated."

Pelvic floor muscles help support internal organs

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Normal pelvic floor musculature

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Puborectalis muscle at rest and during defecation

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Outpatient program

Biofeedback Treatment of Constipation

Biofeedback treatment for constipation at Mayo Clinic consists of an intensive 2-week outpatient program to teach patients how to coordinate the abdominal muscles with those of the pelvic floor for successful evacuation.

Treatment sessions are held Monday-Friday for 2 weeks, during which patients meet with Mayo physical medicine and rehabilitation specialists as follows:

Week 1

• Average of 3 sessions lasting 30 to 45 minutes every day.
• Insertion of a rectal sensor that monitors muscle tension through electromyography (EMG). The EMG activity is visually displayed for the patient to indicate tension and relaxation of the pelvic floor.
• Verbal explanation and cueing from the therapist on what pelvic floor relaxation feels like and how to relax these muscles. Simultaneous visual feedback strengthens learning by showing improvements in relaxation.
• Learning to identify the internal sensations associated with day-to-day relaxation (baseline relaxation) and how to sustain that point.
• Education on the negative effects of both pelvic floor and general tension. Relaxation training may be augmented with the help from occupational therapists who teach diaphragmatic breathing.

Week 2

• Average of 2 sessions each day.
• Insertion of a rectal balloon inflated with varying volumes of water to simulate a bowel movement. The patient learns to sustain relaxation with rectal volume present, to coordinate abdominal activation with dynamic pelvic floor relaxation, and to avoid habit co-contraction of the pelvic floor. The goal is unpressured release of the rectal balloon to simulate normal defecation.
• Teaching long-term skills and exercises for home use to maintain pelvic floor relaxation.
• Education regarding normal bowel function, identification of problematic toileting habits, and behavioral modification.