Physiotherapeutic Approaches to Treat Anal Incontinence in Women after Obstetric Trauma

Mayanna Machado Freitas Lara Elma Franco Moura Denise Saquetto Iane Castro Rodrigues Valéria Conceição Passos de Carvalho Silvana Maria Macedo Uchôa About the authors

Abstract

Introduction

Anal incontinence is defined as the loss of voluntary control of fecal matter or gases with a recurrence period longer than 3 months in individuals aged ≥ 4 years; it has a female predominance. Among the treatment modalities is pelvic physiotherapy, the second line of treatment, which promotes the reeducation, coordination, and strengthening of the muscles of the pelvic floor to enable patients to return to their regular activities of daily living.

Objective

To perform a systematic review on the physiotherapeutic treatments used in women between the ages of 18 and 65 years with a diagnosis of anal incontinence.

Material and methods

Clinical studies written in Portuguese, Spanish and English were searched on the the following databases: Science Direct, Medical Literature Analysis and Retrieval System Online (Medline) via PubMed, Physiotherapy Evidence Database (PEDro), Scientific Electronic Library Online (SciELO), and Scopus.

Results

Of the 998 articles found, only 4 studies met the inclusion criteria of the present systematic review. The physiotherapeutic approaches to treat women with anal incontinence are biofeedback, Kegel exercises, electrostimulation, and training of the pelvic floor muscles. The average score on the PEDro scale was of 6.25, which indicates that the methodological quality was good.

Conclusion

Although pelvic physiotherapy is effective to treat anal incontinence, it must be promoted through the performance of evidence-based scientific research.

Keywords:
fecal incontinence; rehabilitation; physiotherapy modalities

Introduction

Fecal incontinence (FI) is defined as the loss of voluntary control of stool with a recurrence period longer than 3 months in individuals aged ≥ 4 years.11 Barroso AMF, Arruda e Sá MTM, Nunes EFC, Latorre GFS. Abordagem fisioterapêutica na incontinência fecal: revisão de literatura. Fisioterapia Ser. 2018;13(04):426-430 When there is gas leakage, associated or not with the loss of feces, the term anal incontinence (AI) is used.22 Lumi CM, Muñoz JP, La Rosa L. Neuromodulación sacra para el tratamiento de la incontinencia anal. Técnica y presentación de la primera experiencia nacional / Sacral neuromodulation for the treatment of anal incontinence. Technique and presentation of the first national experience Rev Argent Coloproctología. 2006;17 (02):104-109 33 Barbosa JMM, Dias RC, Pereira LSM. Qualidade de vida e estratégias de enfrentamento em idosos com incontinência fecal: uma revisão da literatura. Rev Bras Geriatr Gerontol 2007;10(03): 383-400. Doi: 10.1590/1809-9823.2007.100310 [Internet]
https://doi.org/10.1590/1809-9823.2007.1...

It is a health condition that affects ∼ 7% of the general population, with a female predominance44 Nelson R, Norton N, Cautley E, Furner S. Community-based prevalence of anal incontinence. JAMA 1995;274(07):559-561 55 Lumi CM, Miravalle OR, La Rosa L, et al. Ecografía anorrectal y manometría en el estudio de pacientes con incontinencia fecal. Acta Gastroenterol Latinoam 2012;42(03):193-198 and a multifactorial etiology, including traumatic, neurological, congenital and iatrogenic factors. Among the causes mentioned, the most common are obstetric trauma and unsuccessful anorectal surgery.66 Hayden DM, Weiss EG. Fecal incontinence: etiology, evaluation, and treatment. Clin Colon Rectal Surg 2011;24(01):64-70. Doi: 10.1055/s-0031-1272825
https://doi.org/10.1055/s-0031-1272825...

There are 3 subtypes of FI: passive incontinence, in which there is an unnoticed (involuntary) loss of feces or gas; urge incontinence, characterized by the unsuccessful attempt to retain stool, which indicates an injury to the external sphincter; and soiling, which is defined as the involuntary loss of rectal contents after evacuation due to an injury to the internal sphincter, with soiling of the perianal area and underwear.11 Barroso AMF, Arruda e Sá MTM, Nunes EFC, Latorre GFS. Abordagem fisioterapêutica na incontinência fecal: revisão de literatura. Fisioterapia Ser. 2018;13(04):426-430 77 Muñoz-Duyos A, Montero J, Navarro A, Del Río C, García-Domingo MI, Marco C. Incontinencia fecal: Neurofisiología y neuromodulación. Cir Esp 2004;76:65-70. Doi: 10.1016/S0009-739X(04) 72362-3
https://doi.org/10.1016/S0009-739X(04)...
88 Leite J, Poças F. TRATAMENTO DA INCONTINÊNCIA FECAL. Rev Port Coloproct. 2010;7(02):68-72

In the affected patients, this clinical condition triggers a series of consequences such as embarrassment, social isolation, low self-esteem, and changes in lifestyle and quality of life (QOL).99 Meyer I, Richter HE. Impact of fecal incontinence and its treatment on quality of life inwomen.Womens Health (Lond) 2015;11 (02):225-238. Doi: 10.2217/whe.14.66
https://doi.org/10.2217/whe.14.66...
As the perception of QOL is very subjective, some scales help to measure the impact of FI on it, such as the Fecal Incontinence Quality of Life (FIQOL) index, which assesses lifestyle, coping/behavior, self-perception, and embarrassment,1010 Rockwood TH, Church JM, Fleshman JW, et al. Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 2000;43(01):9-16, discussion 16-17. Doi: 10.1007/BF02237236
https://doi.org/10.1007/BF02237236...
and the Manchester Health Questionnaire (MHQ), which measures eight domains: impact of the incontinence, role, physical function, social function, personal relationships, emotions, sleep and energy, and the severity of the incontinence.1111 Kwon S, Visco AG, Fitzgerald MP, Ye W, Whitehead WEPelvic Floor Disorders Network (PFDN) Validity and reliability of the Modified Manchester Health Questionnaire in assessing patients with fecal incontinence. Dis Colon Rectum 2005;48 (02):323-331, discussion 331-334. Doi: 10.1007/s10350-004- 0899-y
https://doi.org/10.1007/s10350-004-...

Theere are multiple treatment modalities for AI, which can be conservative and/or surgical. Conservative therapy is usually chosen as the first-line treatment, with no initial need for invasive methods in these patients. Only when the proposed treatment is not effective patients are submitted to surgical procedures (sphincter repair, overlapping repair, muscle transposition, prosthesis implantation, sacral neuromodulation, and ostomies).1212 Lumi CM, Muñoz JP. Tratamiento quirúrgico de la incontinencia anal. ECirugía Digestiva. 2009;III-368:1-1 1313 Vergara MT, Suárez JM, Orellana HG, et al. Incontinencia fecal del adulto. Rev Chil Cir 2011;63(03):320-326. Doi: 10.4067/S0718- 40262011000300016 [Internet]
https://doi.org/10.4067/S0718-...
1414 Duelund-Jakobsen J, Worsoe J, Lundby L, Christensen P, Krogh K. Management of patients with faecal incontinence. Therap Adv Gastroenterol 2016;9(01):86-97. Doi: 10.1177/1756283X15614516
https://doi.org/10.1177/1756283X15614516...

Changing eating habits, controlling the diet, and drinking fluids are the first steps to help these individuals in the formation of a consistent stool, thus avoiding frequent bowel movements. In addition, constipating agents such as loperamide are also prescribed to increase the time of intestinal transit through the small intestine and colon to form more consistent stools.1515 Nakano K, Takahashi T, Tsunoda A, Shimizu Y. Effects of Dietary Guidance without Dietary Fiber Supplements on the Symptoms, Quality of Life, and Dietary Intake in Patients with Fecal Incontinence. J Anus RectumColon 2020;4(03):128-136. Doi: 10.23922/ jarc.2020-008
https://doi.org/10.23922/...

Currently, pelvic physiotherapy stands out as a possible line of treatment, since its techniques promote reeducation, coordination, and strengthening of the pelvic floor muscles (PFMs) to restore the QOL of these individuals and to enable them to return to their daily life activities (DLAs).11 Barroso AMF, Arruda e Sá MTM, Nunes EFC, Latorre GFS. Abordagem fisioterapêutica na incontinência fecal: revisão de literatura. Fisioterapia Ser. 2018;13(04):426-430

Among the techniques used biofeedback is a therapeutic approach that helps to create a sensitive biological response, and, as a consequence, the patient improves their perception and voluntary contraction of the PFMs.1616 Guerra-Mora JR, Buenrostro-Acebes JM, Erciga-Vergara N, et al. Efectividad del biofeedback en pacientes con incontinencia fecal. Rev Med Inst Mex Seguro Soc 2015;53(04):472-475 Training with a rectal balloon aims to improve the thresholds for sensory perception and rectal capacity.1717 Murad-Regadas SM, Regadas FSP, Regadas Filho FSP, Mendonça Filho JJ, Andrade Filho RS, Vilarinho ADS. Predictors of unsuccessful of treatment for fecal incontinence biofeedback for fecal incontinence in female. Arq Gastroenterol 2019;56(01):61-65 cited2021May09. Doi: 10.1590/s0004-2803.201900000-17 [Internet]
https://doi.org/10.1590/s0004-2803.20190...
Functional electrical stimulation is a type of excitomotor electrical current which aims to recruit nerve fibers to promote muscle strengthening and/or resistance, depending on the parameters used.1818 Yik YI, Stathopoulos L, Hutson JM, Southwell BR. Home Transcutaneous Electrical Stimulation Therapy to Treat Children With Anorectal Retention: A Pilot Study. Neuromodulation 2016;19 (05):515-521. Doi: 10.1111/ner.12451
https://doi.org/10.1111/ner.12451...
Kinesiotherapy, on the other hand, helps to increase the muscle tone of both type-I and type-II fibers to recover continence, coordination, and strength.11 Barroso AMF, Arruda e Sá MTM, Nunes EFC, Latorre GFS. Abordagem fisioterapêutica na incontinência fecal: revisão de literatura. Fisioterapia Ser. 2018;13(04):426-430

These approaches, isolated or combined, can be effective in the partial or total recovery of the functional diagnosis of these patients. Thus, the objective of the present article was to conduct a systematic review to learn about the physiotherapeutic treatments that have been used in women aged 18 to 65 years with a diagnosis of AI.

Materials and Methods

The present is a systematic review guided by a question based on the Patient, Intervention, Comparison, Outcome, Study Design (PICOs) stategy (Chart 1): “What are the physiotherapeutic approaches to women aged between 18 and 65 years with a diagnosis of AI?”.

Chart 1
Representation of the Patient, Intervention, Comparison, Outcome, Study Design (PICOs) search strategy

The Health Sciences Descriptors (Descritores em Ciências da Saúde, DeCS, in Portuguese) and the Medical Subject Headings (MeSH) were consulted and combined as follows: Modalidades de Fisioterapia AND Incontinência Fecal; Fisioterapia AND Incontinência Fecal; Reabilitação AND Incontinência Fecal; Modalidades de Fisioterapia AND Incontinência Anal; Fisioterapia AND Incontinência Anal; Reabilitação AND Incontinência Anal; Modalidades de Fisioterapia AND Incontinencia Fecal; Fisioterapia AND Incontinencia Fecal; Rehabilitación AND Incontinencia Fecal; Modalidades de Fisioterapia AND Incontinencia Anal; Fisioterapia AND Incontinencia Anal; Rehabilitación AND Incontinencia Anal Physical Therapy Modalities AND Fecal Incontinence; Physical Therapy Specialty AND Fecal Incontinence; Rehabilitation AND Fecal Incontinence; Physical Therapy Modalities AND Anal Incontinence; Physical Therapy Speciality AND Anal Incontinence; Rehabilitation AND Anal Incontinence; Physiotherapy AND Fecal Incontinence: Physiotherapy AND Anal Incontinence Electricalstimulation AND Fecal Incontinence; Electrical stimulation AND Anal Incontinence; Neurostimulation AND Fecal Incontinence; Neurostimulation AND Anal Incontinence; Biofeedback AND Fecal Incontinence; Biofeedback AND Anal Incontinence; Pelvic Floor Muscle Training AND Fecal Incontinence; and Pelvic Floor Muscle Training AND Anal Incontinence.

The search was conducted on the the following databases: Science Direct, Medical Literature Analysis and Retrieval System Online (Medline) via PubMed, Physiotherapy Evidence Database (PEDro), Scientific Electronic Library Online (SciELO), and Scopus. The search and selection ofe articles was conducted by two independent researchers, with a third evaluator available in case of discrepancies.

The inclusion criteria were: clinical studies that addressed physical therapy treatments in women aged 18 to 65 years with AI. And the exclusion criteria were: articles that did not focus on physiotherapeutic treatment in female patients diagnosed with AI; articles not written in Portuguese, Spanish or English; articles with neurological patients and/or pregnant patients; and duplicates, review articles, editorials, letters, comments, dissertations or theses.

The articles were submitted to the Relevance Test I (RTI), by reading the titles and abstracts. Then, those that were selected were submitted to the Relevance Test II (RTII), in which the full texts of the articles were read (Table 1).

Table 1
Application form for the Relevance Tests I and II

Using the PEDro scale, two independent authors assessed the methodological quality, and any disparities weresolved through discussion, with the involvement of a third person if necessary. The results of this assessment are presented in Chart 2.

Chart 2
Quality assessment of the included studies (n = 4) according to the Physiotherapy Evidence Database (PEDro) scale

Results

A total of 998 articles were identified, and 478 were discarded because they were duplicates. Of the 520 articles left, 472 were excluded for the following reasons: 20 did not meet the language requirements; 55 were not primary studies; 383 did not present outcomes related to the proposed topic; 13 evaluated patients with neurological diseases; and 1 study was excluded because it was on a physiotherapy treatment for AI in pregnant women (Fig. 1)

Fig. 1
Flowchart as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement summarizing the selection of articles.

Regarding the number of articles found by database, the Scopus and Science Direct databases obtained the highest percentages: 45.7% and 25% respectively (Table 2). As for the combined descriptors, Rehabilitation AND Fecal Incontinence, Biofeedback AND Fecal Incontinence, and Electrical Stimulation AND Anal Incontinence were the most found, with percentages of 13.4%, 13.3% and 10.1% respectively (Table 3).

Table 2
Percentage of scientific articles found in each database

Table 3
Percentage of articles found according to the combined descriptors searched

Of the 998 articles found, only 42828 Naimy N, Lindam AT, Bakka A, et al. Biofeedback vs. electrostimulation in the treatment of postdelivery anal incontinence: a randomized, clinical trial. Dis Colon Rectum 2007;50(12):2040- -2046. Doi: 10.1007/s10350-007-9075-5
https://doi.org/10.1007/s10350-007-9075-...
2929 Mahony RT, Malone PA, Nalty J, Behan M, O'connell PR, O'herlihy C. Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in the early treatment of postpartum fecal incontinence. Am J Obstet Gynecol 2004;191(03):885-890. Doi: 10.1016/j.ajog.2004.07.006
https://doi.org/10.1016/j.ajog.2004.07.0...
3030 Fynes MM, Marshall K, Cassidy M, et al. A prospective, randomized study comparing the effect of augmented biofeedback with sensory biofeedback alone on fecal incontinence after obstetric trauma. Dis Colon Rectum 1999;42(06):753-758, discussion 758-761. Doi: 10.1007/BF02236930
https://doi.org/10.1007/BF02236930...
3636 Johannessen HH, Wibe A, Stordahl A, Sandvik L, Mørkved S. Do pelvic floor muscle exercises reduce postpartum anal incontinence? A randomised controlled trial. BJOG 2017;124(04): 686-694. Doi: 10.1111/1471-0528.14145
https://doi.org/10.1111/1471-0528.14145...
studies met the inclusion criteria, and Table 4 presents their results.

Table 4
Comparative effectiveness of physiotherapeutic treatments for anal incontinence in women

The average score of 6.25 on the PEDro scale shows that, in general, the included studies are of methodological good quality. All of them used methods of random distribution (100%); the groups were similar with regard to the most important prognostic indicators (100%); measurements of at least one key result were obtained in more than 85% of the individuals initially distributed among the groups (100%); and intergroup comparisons (100%) were performed and presented the average and variability of the data regarding the results (100%). In all studies the allocation of individuals was secret; only in 1 survey (25%) there was blinding of the therapists, and in none of them there was blinding of individuals, blinding of the evaluators, and an analysis by intention to treat (Chart 2).

Discussion

Fecal incontinence is a condition that significantly affects QOL, with high social and psychological impacts.1919 Jelovsek JE, Markland AD,WhiteheadWE, et al; National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Controlling faecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomised clinical trial. Lancet Gastroenterol Hepatol 2019;4(09):698-710. Doi: 10.1016/S2468-1253(19)30193-1
https://doi.org/10.1016/S2468-1253(19)30...
According to Freeman and Menees (2016),2020 Freeman A, Menees S. Fecal Incontinence and Pelvic Floor Dysfunction inWomen: A Review. Gastroenterol Clin NorthAm2016; 45(02):217-237. Doi: 10.1016/j.gtc.2016.02.002
https://doi.org/10.1016/j.gtc.2016.02.00...
the prevalence in women ranges from 2% to 25%, depending on age and socioeconomic status. This data often underestimate the true prevalence, as many women avoid commenting on symptoms due to embarrassment, some doctors fail to ask about this topic during consultations, and women often avoid seeking medical attention.

The present review included 4 studies2828 Naimy N, Lindam AT, Bakka A, et al. Biofeedback vs. electrostimulation in the treatment of postdelivery anal incontinence: a randomized, clinical trial. Dis Colon Rectum 2007;50(12):2040- -2046. Doi: 10.1007/s10350-007-9075-5
https://doi.org/10.1007/s10350-007-9075-...
2929 Mahony RT, Malone PA, Nalty J, Behan M, O'connell PR, O'herlihy C. Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in the early treatment of postpartum fecal incontinence. Am J Obstet Gynecol 2004;191(03):885-890. Doi: 10.1016/j.ajog.2004.07.006
https://doi.org/10.1016/j.ajog.2004.07.0...
3030 Fynes MM, Marshall K, Cassidy M, et al. A prospective, randomized study comparing the effect of augmented biofeedback with sensory biofeedback alone on fecal incontinence after obstetric trauma. Dis Colon Rectum 1999;42(06):753-758, discussion 758-761. Doi: 10.1007/BF02236930
https://doi.org/10.1007/BF02236930...
3636 Johannessen HH, Wibe A, Stordahl A, Sandvik L, Mørkved S. Do pelvic floor muscle exercises reduce postpartum anal incontinence? A randomised controlled trial. BJOG 2017;124(04): 686-694. Doi: 10.1111/1471-0528.14145
https://doi.org/10.1111/1471-0528.14145...
regarding the effectiveness of physiotherapy treatments on the symptoms of AI in adult women (aged between 18 and 65 years) after obstetric trauma, with a total population of 242 patients. The literature provides little guidance for physiotherapists and patients on rehabilitation for AI, and few studies have examined the same treatment-result combination within similar timeframes, making it impossible to perform a meta-analysis.

Regarding the initial number of articles found, most did not present titles related to the proposed topic. This is due to the lack of practice in searching for suitable descriptors using the keywords query registered in the DeCS and MeSH.2121 Brandau R, Monteiro R, Braile DM. Importância do uso correto dos descritores nos artigos científicos. Rev Bras Cir Cardiovasc 2005;20 (01):VII-IX. Doi: 10.1590/S0102-76382005000100004 [Internet]
https://doi.org/10.1590/S0102-7638200500...

Andalia et al. (2010)2222 Andalia RC, Rodríguez-Labrada R, Castells MM. Scopus: la mayor base de datos de literatura científica arbitrada al alcance de los países subdesarrollados. Acimed 2010;21:270-282 performed a review on the Scopus database and showed that it contains the highest number of citations and high-quality studies related mainly to the clinical sciences. These findings corroborate those of the present study, since the Scopus yielded the highest percentage of scientific articles found (45.7%).

Of the four articles2828 Naimy N, Lindam AT, Bakka A, et al. Biofeedback vs. electrostimulation in the treatment of postdelivery anal incontinence: a randomized, clinical trial. Dis Colon Rectum 2007;50(12):2040- -2046. Doi: 10.1007/s10350-007-9075-5
https://doi.org/10.1007/s10350-007-9075-...
2929 Mahony RT, Malone PA, Nalty J, Behan M, O'connell PR, O'herlihy C. Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in the early treatment of postpartum fecal incontinence. Am J Obstet Gynecol 2004;191(03):885-890. Doi: 10.1016/j.ajog.2004.07.006
https://doi.org/10.1016/j.ajog.2004.07.0...
3030 Fynes MM, Marshall K, Cassidy M, et al. A prospective, randomized study comparing the effect of augmented biofeedback with sensory biofeedback alone on fecal incontinence after obstetric trauma. Dis Colon Rectum 1999;42(06):753-758, discussion 758-761. Doi: 10.1007/BF02236930
https://doi.org/10.1007/BF02236930...
3636 Johannessen HH, Wibe A, Stordahl A, Sandvik L, Mørkved S. Do pelvic floor muscle exercises reduce postpartum anal incontinence? A randomised controlled trial. BJOG 2017;124(04): 686-694. Doi: 10.1111/1471-0528.14145
https://doi.org/10.1111/1471-0528.14145...
included in the present review, three performed biofeedback training using different modalities (sensory biofeedback, audiovisual biofeedback, and intraanal electromyographic biofeedback). Biofeedback is a treatment to monitor physiological activities based on visual or auditory signals.2323 Bertotto A, Schvartzman R, Uchôa S, Wender MCO. Effect of electromyographic biofeedback as an add-on to pelvic floor muscle exercises on neuromuscular outcomes and quality of life in postmenopausal women with stress urinary incontinence: A randomized controlled trial. Neurourol Urodyn 2017;36(08): 2142-2147. Doi: 10.1002/nau.23258
https://doi.org/10.1002/nau.23258...
According to Damin et al. (2017),2424 Damin DC, Hommerding F, Schirmer D, et al. Patient-Controlled Biofeedback Device for the Treatment of Fecal Incontinence: A Pilot Study. Appl Psychophysiol Biofeedback 2017;42(02): 133-137. Doi: 10.1007/s10484-017-9352-6
https://doi.org/10.1007/s10484-017-9352-...
it is recommended as the first-line treatment for patients with AI. It acts to improve the contraction of the external anal sphincter and the PFMs, increasing the perception and response capacity to rectal distension. According to Norton and Cody (2012)2525 Norton C, Cody JD. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev 2012;7(7, CD002111):CD002111. Doi: 10.1002/14651858. CD002111.pub3
https://doi.org/10.1002/14651858. CD0021...
and Van Koughnett and Wexner (2013),2626 Van Koughnett JA, Wexner SD. Current management of fecal incontinence: choosing amongst treatment options to optimize outcomes. World J Gastroenterol 2013;19(48):9216-9230. Doi: 10.3748/wjg.v19.i48.9216
https://doi.org/10.3748/wjg.v19.i48.9216...
biofeedback has a variable efficiency, ranging from 0% to 80%, which justifies the choice of this treatment by most authors of this study.

Although there are two different devices to perform biofeedback, the objectives of both include sensory training and compliance, strength training, coordination, and resistance of the pelvic floor and sphincters.2020 Freeman A, Menees S. Fecal Incontinence and Pelvic Floor Dysfunction inWomen: A Review. Gastroenterol Clin NorthAm2016; 45(02):217-237. Doi: 10.1016/j.gtc.2016.02.002
https://doi.org/10.1016/j.gtc.2016.02.00...
One is the manometer, in which it is possible to record the contraction of the external anal sphincter with pressure sensors applied to the anal canal; and the electromyographic device, which uses sensors near the anal region to detect the electromyographic activity of the pelvic floor.2727 Heymen S, Jones KR, Ringel Y, Scarlett Y, Whitehead WE, Whitehead WE. Biofeedback treatment of fecal incontinence: a critical review. Dis Colon Rectum 2001;44(05):728-736. Doi: 10.1007/ BF02234575
https://doi.org/10.1007/...

Most of the articles included in the present review used electromyographic biofeedback. Heymen et al. (2001),2727 Heymen S, Jones KR, Ringel Y, Scarlett Y, Whitehead WE, Whitehead WE. Biofeedback treatment of fecal incontinence: a critical review. Dis Colon Rectum 2001;44(05):728-736. Doi: 10.1007/ BF02234575
https://doi.org/10.1007/...
in a comparative study on the effectiveness of types of biofeedback, found an improvement in 74% of the patients undergoing treatment with electromyographic biofeedback, and 64% among those who used the manometer, contrary to the findings of Naimy et al. (2007),2828 Naimy N, Lindam AT, Bakka A, et al. Biofeedback vs. electrostimulation in the treatment of postdelivery anal incontinence: a randomized, clinical trial. Dis Colon Rectum 2007;50(12):2040- -2046. Doi: 10.1007/s10350-007-9075-5
https://doi.org/10.1007/s10350-007-9075-...
in who only observed a subjective improvement in the control of incontinence, without significant results. The multicenter study performed by Van Koughnett and Wexner (2013)2626 Van Koughnett JA, Wexner SD. Current management of fecal incontinence: choosing amongst treatment options to optimize outcomes. World J Gastroenterol 2013;19(48):9216-9230. Doi: 10.3748/wjg.v19.i48.9216
https://doi.org/10.3748/wjg.v19.i48.9216...
showed better results from biofeedback when associated with electromyography and electrostimulation for a period longer than 3 months, which is in agreement with the studies by Mahony et al. (2004)2929 Mahony RT, Malone PA, Nalty J, Behan M, O'connell PR, O'herlihy C. Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in the early treatment of postpartum fecal incontinence. Am J Obstet Gynecol 2004;191(03):885-890. Doi: 10.1016/j.ajog.2004.07.006
https://doi.org/10.1016/j.ajog.2004.07.0...
and Fynes et al. (1999).3030 Fynes MM, Marshall K, Cassidy M, et al. A prospective, randomized study comparing the effect of augmented biofeedback with sensory biofeedback alone on fecal incontinence after obstetric trauma. Dis Colon Rectum 1999;42(06):753-758, discussion 758-761. Doi: 10.1007/BF02236930
https://doi.org/10.1007/BF02236930...

Of the three studies involving biofeedback, those by Fynes et al. (1999)3030 Fynes MM, Marshall K, Cassidy M, et al. A prospective, randomized study comparing the effect of augmented biofeedback with sensory biofeedback alone on fecal incontinence after obstetric trauma. Dis Colon Rectum 1999;42(06):753-758, discussion 758-761. Doi: 10.1007/BF02236930
https://doi.org/10.1007/BF02236930...
and Mahony et al. (2004)2929 Mahony RT, Malone PA, Nalty J, Behan M, O'connell PR, O'herlihy C. Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in the early treatment of postpartum fecal incontinence. Am J Obstet Gynecol 2004;191(03):885-890. Doi: 10.1016/j.ajog.2004.07.006
https://doi.org/10.1016/j.ajog.2004.07.0...
associated rehabilitation with perianal exercises, showing significant improvement in fecal continence scores and increased average sphincter pressure respectively. For Jelovsek et al. (2015),1919 Jelovsek JE, Markland AD,WhiteheadWE, et al; National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Controlling faecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomised clinical trial. Lancet Gastroenterol Hepatol 2019;4(09):698-710. Doi: 10.1016/S2468-1253(19)30193-1
https://doi.org/10.1016/S2468-1253(19)30...
anal sphincter exercises with biofeedback increase the compression strength of the anal sphincter through strength training and, when combined with sensory training, may increase sensory thresholds in patients with urge incontinence (hypersensitivity).

Electrical stimulation is another therapeutic approach for the treatment of AI, which aims to provide sensorimotor stimuli for the PFMs. The application of excitomotor currents improves muscle tone and motor awareness, enabling an increase in the contraction capacity of the anal canal.3131 Longo GJ, Fuirini N. Correntes de alta freqüência: ondas curtas. São Paulo: KLD biossistemas equipamentos eletrônicos. LTDA, 2000 This modality was applied intracavitaryly by Naimy et al. (2007)2828 Naimy N, Lindam AT, Bakka A, et al. Biofeedback vs. electrostimulation in the treatment of postdelivery anal incontinence: a randomized, clinical trial. Dis Colon Rectum 2007;50(12):2040- -2046. Doi: 10.1007/s10350-007-9075-5
https://doi.org/10.1007/s10350-007-9075-...
in isolation, and by Fynes et al. (1999)3030 Fynes MM, Marshall K, Cassidy M, et al. A prospective, randomized study comparing the effect of augmented biofeedback with sensory biofeedback alone on fecal incontinence after obstetric trauma. Dis Colon Rectum 1999;42(06):753-758, discussion 758-761. Doi: 10.1007/BF02236930
https://doi.org/10.1007/BF02236930...
and Mahony et al. (2004)2929 Mahony RT, Malone PA, Nalty J, Behan M, O'connell PR, O'herlihy C. Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in the early treatment of postpartum fecal incontinence. Am J Obstet Gynecol 2004;191(03):885-890. Doi: 10.1016/j.ajog.2004.07.006
https://doi.org/10.1016/j.ajog.2004.07.0...
combined with audiovisual and electromyographic biofeedback respectively.

Regarding the choice of intracavitary electrical stimulation, it is noted that, unlike electrostimulation of the sacrum nerve and percutaneous tibial nerve, the sphincter is directly stimulated, improving the stability of the pelvic floor, which facilitates and can promote a better voluntary muscle contraction, avoiding the use of accessory muscles.3232 JostWH, Loch EG,Müller-Lobeck H. [Electrophysiologic studies of fecal incontinence in the woman]. Zentralbl Gynäkol 1998;120 (04):153-159

There is little scientific evidence to prove the therapeutic potential of electrical stimulation in AI, which makes it difficult to apply it in isolation, as was the case of the study by Naimy et al. (2007),2828 Naimy N, Lindam AT, Bakka A, et al. Biofeedback vs. electrostimulation in the treatment of postdelivery anal incontinence: a randomized, clinical trial. Dis Colon Rectum 2007;50(12):2040- -2046. Doi: 10.1007/s10350-007-9075-5
https://doi.org/10.1007/s10350-007-9075-...
in which there was no significant improvement after the isolated application in the group treated by endo-anal electrical stimulation. However, Mahony et al. (2004)2929 Mahony RT, Malone PA, Nalty J, Behan M, O'connell PR, O'herlihy C. Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in the early treatment of postpartum fecal incontinence. Am J Obstet Gynecol 2004;191(03):885-890. Doi: 10.1016/j.ajog.2004.07.006
https://doi.org/10.1016/j.ajog.2004.07.0...
and Naimy et al. (2007)2828 Naimy N, Lindam AT, Bakka A, et al. Biofeedback vs. electrostimulation in the treatment of postdelivery anal incontinence: a randomized, clinical trial. Dis Colon Rectum 2007;50(12):2040- -2046. Doi: 10.1007/s10350-007-9075-5
https://doi.org/10.1007/s10350-007-9075-...
showed significant improvement associating biofeedback with electrostimulation, corroborating the review by Hosker et al. (2000),3333 Hosker G, Norton C, Brazzelli M. Electrical stimulation for faecal incontinence in adults. Cochrane Database Syst Rev 2000;1(2, CD001310):CD001310. Doi: 10.1002/14651858.CD001310
https://doi.org/10.1002/14651858.CD00131...
who reported benefits of both treatments together in the short term in cases of AI after obstetric trauma.

Rehabilitation of the PFMs is a term that incorporates different approaches, including PFM training performed under the guidance of a pelvic physiotherapist. Physiotherapy aims to improve strength, tone, resistance, and muscle coordination, in addition to promoting perineal awareness and improving sensitivity.3434 Lunniss PJ, Gladman MA, Hetzer FH, Williams NS, Scott SM. Risk factors in acquired faecal incontinence. J R Soc Med 2004;97(03): 111-116 García López (2002)3535 García López AJ. Incontinencia anal. Iatreia [Internet] 2002;15 (03):190-199 reported that perianal exercises improve the coordination and strength of the pelvic floor, as well as the functional tone in the voluntary contraction of the external anal sphincter and muscle mass of the pelvic floor, without interfering with the internal anal sphincter.

Exercises for the PFMs are effective in preventing and treating AI in pregnant women and in those in the postpartum period, as evidenced by Johannessen et al. (2017),3636 Johannessen HH, Wibe A, Stordahl A, Sandvik L, Mørkved S. Do pelvic floor muscle exercises reduce postpartum anal incontinence? A randomised controlled trial. BJOG 2017;124(04): 686-694. Doi: 10.1111/1471-0528.14145
https://doi.org/10.1111/1471-0528.14145...
with a significant reduction in the incontinence score, gas leakage and fecal urgency. In addition, one of the fundamental factors for the success of rehabilitation is the sensorymotor awareness of the pelvic region and a good patient-therapist relationship to provide information and instructions on the treatment. This could also be observed in the study by Johannessen et al. (2017),3636 Johannessen HH, Wibe A, Stordahl A, Sandvik L, Mørkved S. Do pelvic floor muscle exercises reduce postpartum anal incontinence? A randomised controlled trial. BJOG 2017;124(04): 686-694. Doi: 10.1111/1471-0528.14145
https://doi.org/10.1111/1471-0528.14145...
in which the control group, who received only written information by the physiotherapist about exercises for the PFMs, did not achieve any significant improvement.

Conclusion

In the present review, we recorded the following techniques for the treatment of AI and FI: pelvic floor exercises; muscle strength and endurance training guided by biofeedback; rectal sensitivity guided by biofeedback; and coordination and electrical stimulation training. The average score on the PEDro scale of the four articles included in the present study was of 6.25; therefore, it was not possible to assess the real cost-benefit ratio in relation to the techniques used. However, it is necessary to emphasize that the results of the application of these techniques were promising regarding the improvement of the symptomatic framework. There is an evident need for studies with better frameworks to validate the effectiveness of the techniques used in the treatment of AI and IF.

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Publication Dates

  • Publication in this collection
    03 June 2022
  • Date of issue
    Jan-Mar 2022

History

  • Received
    23 May 2021
  • Accepted
    06 Aug 2021
  • Published
    14 Feb 2022
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