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.
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.
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:
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."
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: