Constipation is defined as the complaint that bowel movements are infrequent and/or incomplete and/or there is a need for frequent straining or manual assistance to defecate, according to the International Continence Society (ICS) and the International Urogynecological Association (IUGA) it can be due to slow transit or by obstructed defecation (inability to relax the external anal sphincter/dyssynergic defecation)1. 

Numerous studies have described the use of biofeedback (BF) therapy for the treatment of pelvic floor dyssynergia, but few describe the combination of BF with electrical stimulation (EST)2. The aims of this study are to demonstrate that biofeedback plus transanal EST can improve bowel symptoms in constipated women with dyssynergic defecation.

The design was a retrospective observational study in a Urogynecology referral clinic. Records from August 2011 to July 2017 were included; of women referred to our hospital with the diagnosis of dyssynergic defecation (the diagnoses were based on symptoms, physiologic and radiologic studies). All of these women had longstanding symptoms unresponsive to laxatives and dietary changes.
History and physical examinations were analyzed to exclude constipation secondary to organic causes.
Exclusion criteria included pregnancy, neurologic diseases and impaired cognizance.

All patients were treated with EMG biofeedback alternated with electrical stimulation (MyoTrac Infiniti™), they underwent a session once a week for six to twelve sessions. The procedure was conducted with the patient in the lithotomy position. The duration of these treatment sessions was 25 minutes and EST was performed using an endoanal probe connected transanally. Stimulatory parameters included a pulse width of 80 msec, a frequency of 10 Hz with the voltage adjusted to each patient´s threshold of pain in response to electrical stimulus. Patients were taught squeeze-relax exercises.
Baseline demographic characteristics included age, parity, vaginal deliveries and BMI. We evaluated the severity of the symptoms with a visual analogue scale (VAS), the number of defecations per week, pain during defecation and use of laxatives, and these parameters were compared before treatment versus session 6, and before treatment versus session 12. Assessment of self-reported improvement was analyzed at the end of each session. All statistical analyses were performed using SPSS version 24.0. Data are expressed as mean ± standard deviation. Student´s t test was used to compare continuous parameters and McNemar test for non-continuous parameters.

We included the records of 34 patients that completed 6 sessions, of these patients 23 had completed 12 sessions. The demographic characteristics are shown on table 1. Results of BF plus transanal EST, baseline versus session 6 and baseline versus session 12 are shown on table 2.

The main endpoint of the study was the improvement of the constipation at session 6 and at session 12. At session 6 the VAS, the self-reported improvement and the defecations per week changed significantly. Al session 12 the VAS, the self-reported improvement, the defecations per week and the pain during defecation changed significantly. We also compared the self-reported improvement session 6 versus session 12 and we found that the percentage didn’t change significantly (p= 0. 089).

BF plus transanal EST is an effective treatment for patients with pelvic floor dyssynergia unresponsive to other treatment options and it should be considered as a first line option treatment.

Sultan AH, Monga A, Lee J, Emmanuel A, Norton C, Santoro G, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction. International Urogynecology Journal. 2016 Oct 24;28(1):5–31.
Cadeddu F, Salis F, De Luca E, Ciangola I, Milito G. Efficacy of biofeedback plus transanal stimulation in the management of pelvic floor dyssynergia: a randomized trial. Techniques in Coloproctology. 2015 Mar 6;19(6):333–8.