Most health professionals are aware that anal incontinence is a widespread problem that increases with aging and an aging population. But according to Dr. Richard Nelson of the University of Illinois Medical School, it may also be one of the most costly problems. Nelson observes that more health care dollars are spent on anal incontinence each year than on cancer. The reason is simple; anal incontinence is widely regarded as the leading cause of removal of individuals from their homes to nursing homes.[1]

One consequence is that most people don’t actually see any incontinent individuals during the course of the day. And by most estimates, fewer than 50% of patients spontaneously admit to the problem or seek professional help. They incorrectly assume it is an inevitable consequence of aging, when in fact it is a highly treatable condition.

The extent, nature and treatment of anal incontinence was recently the topic of a Consensus Conference in Milwaukee, jointly sponsored by International Foundation for Functional Gastrointestinal Disorders (IFFGD)[2] and the Office of Continuing Medical Education of the University of Wisconsin Medical School. Recently the American Gastroenterological Association (AGA) issued new guidelines for the evaluation of fecal incontinence.[3]

New Treatments for Incontinence
A common theme to both reports is new optimism about non-invasive treatments available for most patients, and new techniques and instruments for the more complex problems. The AGA guidelines advocated several tests primarily on the basis of their ability to predict success with biofeedback training. But many specific anatomical defects are still treated best by various surgical interventions, or a combination of surgery and biofeedback.

A wide variety of causes have been described in the literature, from obstetrical injuries to the changes in mass, strength, and fatigability of all skeletal muscles in the elderly. Other specific causes include pudendal nerve neuropathy, spinal cord lesions, diabetes mellitus, multiple sclerosis, Parkinson’s and Alzheimer’s disease, and strokes.

A comprehensive History and Physical is the basis for an accurate diagnosis of fecal incontinence and selection of appropriate therapy. Specialized tests have been developed to pin-point causes. Traditionally, fine-wire needle electrodes were used for electromyographic assessment of the anal sphincter, but their use has fallen into disfavor because of the invasiveness and painfulness of the technique.

Needle EMG has largely been replace by new endosonographic (ultrasound) techniques, which create images that provide a good morphological information regarding the intactness of the internal and external anal sphincter muscle, and the overlap of muscle fibers.[4] But technologically advanced techniques, such as MRI, have not been shown to be cost effective for clinical purposes, although they are useful in research.[5]

In recent years the measurement of pudendal nerve terminal motor latency (PNTML) has been popular, but the AGA has now recommended against the routine use of this diagnostic test as unnecessary. Some experts, such as Satish Rao of Iowa City, still consider it of value in predicting therapeutic outcomes.

Most Gastroenterologists still use one of the several varieties of ano-rectal manometry to assess the anal sphincters. These include “large” and “small” balloons, and water infusion techniques, to evaluate precisely the holding capacity of the sphincters.

A major consideration in the changing diagnostic techniques has been the increasing utilization of biofeedback instruments in the treatment fecal incontinence. Biofeedback has proved widely useful in restoring sphincter control, regardless of the precise nature of the defect, deformity, or weakness. Diagnostic tests are now evaluated in large part on their ability to predict the outcome of biofeedback treatment, as in the recent AGA guideline.

Behavioral Techniques from NIA
Early techniques were pioneered by the behavioral sciences labs at the National Institute of Aging. Marvin Schuster[6], Bernard Engel, and William Whitehead developed feedback methods using “large balloon manometry” with mechanical polygraph displays to help patients recover sphincter function through repetitive exercises. Other scientists, such as Arnold Wald of Pittsburgh, have focused on the role of sensation in the rectum as a factor in fecal control.

Despite substantial success - typically three quarters of patients improve - manometry has been limited by the high cost and relative complexity of the instrumentation, the discomfort or even pain of the “large balloons”, and the lack of an isomorphic “home trainer” for patient practice. Progress was further hampered by the use of a traditional “operant conditioning” conceptual model, similar to drug research models, in the early research. Emphasis was placed on standardization of conditions and treatments, rather than exploiting the particular methods and advantages of biofeedback.

Two changes - one in theory, the other in instrumentation - have led to a renewed interest in and enthusiasm for biofeedback techniques on the part of colorectal specialists. In 1986, Robert Shellenberger and Judith Green published “From the Ghost in the Box to Successful Biofeedback Training”[7] “Ghost” revolutionized thinking about biofeedback by providing a “training” or “mastery” model, not unlike athletic or other skills development, as an theoretical alternative to the traditional drug model.

Incontinence pioneer Whitehead (among others) has now adopted this viewpoint. At the recent Consensus Conference, he used a learning skills model to describe biofeedback:

  “the patient attempts to perform some action and uses feedback from the success or failure of his/her attempt to learn how to refine their performance. A good example is learning to throw a basketball: the individual throws repeatedly and learns from their successful shots how to throw the ball more accurately.”[8]

Advocates of the “training” model note that basketball teams are evaluated on their performance in competition against teams trained by other coaches and methods. They argue that the “test” of a training method is shown by the number of successful “shots”. In a similar manner, the success of a biofeedback method is based on the “successful days” without fecal incontinence incidents. The concept of a control group has no meaning in evaluating the training of athletic teams or biofeedback therapy.

Unfortunately, even Whitehead reverts to drug model of random assignments and control groups when evaluating biofeedback outcome research. He faults a biofeedback study for “a major design flaw”, in that patients were allowed to select the treatment group they preferred”. While patients obviously can’t choose between “active ingredient” and “placebo”, enthusiasm for the training is considered a virtue and motivator in biofeedback practice.

On the instrumentation front, there has been a revolution in the selection of electrodes to use for EMG evaluation and training. In 1991, Scottish researchers[9] showed that inserted sensors with longitudinal electrodes (but not with circular electrodes) were virtually equivalent to the more invasive fine-wire needle electrodes in assessing resting, contraction, and push-out muscle activity levels.

Inserted EMG sensors are called “probes” in urology, “plugs” in Gastroenterology, and “sensors” in the biofeedback field. Currently these new devices are manufactured and distributed by several companies, including SRS Medical, Sandhill Scientific, Verimed, Prometheus, and Lifetech. In addition, all of these manufacturers have developed structured computerized testing programs, which collect sphincter muscle data in a standardized format and thus facilitate comparisons between patients to evaluate progress.

Early biofeedback studies (and some recent ones) have relied on general-purpose paper strip chart recorders, which provide a very crude analog feedback of muscle performance based on ink tracings of muscle activity over time. The new computerized systems feature vivid computer graphic displays, and summarize the results digitally. They also include matching portable home trainers, so that patients are able to get additional feedback at home on a comparable instrument.

Biofeedback Outcome Studies
Outcome studies of biofeedback therapy have consistently shown significant positive results, typically “overall patient improvement” rates of about 80%, including both elderly patients and younger ones recovering from surgical intervention to remedy birth defects.

A German researcher, Paul Enck[10] summarized 13 studies and found a range of improved patients of between 50 and 90%. Rao, Enck and Loening-Baucke[11] reported an even greater range of 40 to 100% in a group of 14 studies. Most recently, Whitehead[12] summarized 22 biofeedback studies of adults with a range of 53 to 100% improved patients, and an average of 75%.

In general, smaller studies, which include more homogeneous treatment conditions, tend to show better results, which are not fully sustained in larger multi-center studies. But most of the larger studies include variations in treatment methods and a greater range of patient pre-treatment conditions. A notable exception, which is also the largest biofeedback study to date, had 77 patients, treated at several centers in Florida. Six clinicians used the same packaged EMG incontinence treatment system and obtained an 85% “improved patients” rate and an 83% “overall symptom reduction rate[13].
References

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_{[1] Nelson RL. Epidemiology and the incidence of anal incontinence: The magnitude of the problem. Consensus Conference on Fecal Incontinence, IFFGD, Milwaukee, April 1999; p. 3.}

[2] Contact: IFFGD, P. O. Box 17864, Milwaukee, WI 53217; http://www.iffgd.org.

[3] Diamant et al, AGA position statement on anorectal function testing. Gastroenterology, 1988; 116 (3): 745-757.

[4] Rao SC. Electrophysiological evaluation of Fecal Incontinence, Consensus Conference on Fecal Incontinence, IFFGD, Milwaukee, April 1999; p. 39-41.

[5] Enck P. Transrectal Ultrasound and Other Imaging Studies. Consensus Conference on Fecal Incontinence, IFFGD, Milwaukee, April 1999; p. 42.

[6] Schuster M, Hookman P, Hendrix T & Mendeloff A. Simultaneous manometric recording of internal and external anal sphincter reflexes. Bulletin of the Johns Hopkins Hospital, 1965; 116, 79-88.

[7] Greeley, CO: Health Psychology Publications, 1986.

[8] Whitehead W. Biofeedback Treatment of Fecal Incontinence. Consensus Conference on Fecal Incontinence, IFFGD, Milwaukee, 1999, p. 45.

[9] Binnie NR, Kawimbe BM, Papachrysostomou M, Clare N, & Smith AN The importance of the orientation of the electrode plates in recording the external anal sphincter by non-invasive plug electrodes. Int. J. Colorectal Disease, 1991, 6:5-8.

[10] Enck P. Biofeedback training in disordered defecation: A critical review. Dig Dis Sci 1993; 1953-1960

[11] Rao SS, Enck P, Loening-Bauche V. Biofeedback therapy for defecation disorders. Dig Dis Sci 1997; 15 (Suppl. 1); 78-92.

[12] Whitehead W. Biofeedback Treatment of Fecal Incontinence. Consensus Conference on Fecal Incontinence, Milwaukee, 1999, p. 45.

[13] Patanker SK, Ferrara A, Levy JR, Larach SW, et al Biofeedback in colorectal practice: A multicenter, statewide, three-year experience. Dis Colon Rectum 1997; 40:827-31.


About the authors:

John D. Perry, PhD, is a retired psychologist who has specialized in biofeedback for over 25 years. He now masters a popular professional website called “Incontinence on the Internet”, at http://www. incontinet.com. Lesley M. Perry, MS, RNC, is currently Director of the Acute Psychiatric Unit at North Coast Health Care Centers in Santa Rosa, CA. For many years they treated patients at the Behavioral Medicine Institute in Bryn Mawr, PA.

By John D. Perry, PhD and Lesley M. Perry, MS, RNC