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Case History
• Mrs. HA, 33 year old woman with urge incontinence following traumatic delivery.
• Patchy scarring external sphincter in mid anal canal. Internal sphincter intact.
• Pelvic floor exercises helped bladder.
• 4 sessions biofeedback over 5 months.
• Discharged symptom free.
• No symptoms at 3 years
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Urgency with rapid fatigue
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Sustained squeeze with no urgency after exercises
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Fast-twitch to speed reaction
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Home Exercises
• Need to practice a lot
• Attempt 10 times per day
• Start level depends on assessment
• Maximal, sub-maximal and fast-twitch
• Aim for 5 of each
• Often 4-6 weeks before start to benefit
• Up to 4-6 months for maximal benefit
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Urgency• Toilets are not
available in many places
• Anxiety can trigger urgency
• Vicious circle develops: urge panic urgency more panic incontinence panic more next time
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Urge resistance
• Need to re-learn that urge will wear off if resisted
• Practice “holding on” – wait once feel the urge to defaecate
• Behavioural retraining - start on toilet if necessary, gradually increase distance
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Rectal balloon distension
• Increase sensitivity• OR decrease
sensitivity (one report published)
• progressive distension to urge volume
• re-learn that urge wears off if resisted
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RCT of biofeedback for FI(Norton et al, Gastroenterology 2003)
• Consecutive referrals for faecal incontinence biofeedback
• Anorectal physiology tests and ultrasound
• Diary and questionnaires with appointment• 1 hour assessment
(Norton & Chelvanayagam, 2000)
• If consented, allocation to one of four groups
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Groups• Group 1: up to six one hour sessions of
information and advice (teaching, diet, fluids, medication titration, urge resistance, time and attention)
• Group 2: as Group1, add exercises taught digitally + leaflet with home exercises
• Group 3: as Group 2 + computer biofeedback at each session
• Group 4: as Group 3 + home biofeedback machine
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Results
• 171 patients, median age 56 years
• 82% completion, similar between groups
• Median 5 sessions
• No differences detected between the groups on ANY of the outcome measures
• No suggestion of a trend in the direction of hypothesis
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Outcome for all groups
• 80% improved to at least some extent, whatever treatment they were given
• FI, anxiety, depression, quality of life and sphincter function improved in all groups
• 62% patients rated their change as +3 or above (-5 to +5 scale); 18% unchanged or worse.
• Suggests biofeedback and exercises were not the operant for change
• So what DID improve symptoms? (Norton et al, Gastroenterology 2003)
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Patients' rating of change in symptoms(all groups combined)
0 01
2
0
21
9
16
34
21
27
0
5
10
15
20
25
30
35
40
-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5
Rating of change
Nu
mb
er
of
pa
tie
nts
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Patients’ comments on outcome of Biofeedback• We asked patients which aspect of the
treatment helped the most• Most commented in detail
– Knowing I am not the only one with FI– Experimental intervention (whatever they
were asked to do)– Understanding of the problem– Practical advice– Nurse-patient relationship
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• “I felt very involved in understanding what the treatment, symptoms etc are all about. This has helped me to be aware & understand more & take note of what is going on inside me” (Patient 34, Group 2).