Refractory bowel symptoms in quiescent inflammatory bowel disease (IBD) are common but evidence for effective management is limited. The primary aim was to determine whether physiotherapist-led behavioral treatment, including pelvic floor muscle training, decreases the severity of functional gut symptoms in patients with quiescent IBD.  Secondary aims were to evaluate the effect of treatment on quality of life and psychological well-being.

This was a prospective study undertaken in one hospital providing secondary and tertiary care.  Patients with ulcerative colitis (UC), Crohn’s disease or an ileoanal pouch and symptoms of fecal urgency, fecal incontinence, or constipation (reduced defecation frequency or difficulty with evacuation) were referred by gastroenterologists and screened for inclusion. 

Patients included were ≥ 18 years with quiescent IBD, based on a disease activity score and fecal calprotectin, endoscopy, or imaging. Exclusion criteria were significant medical or psychiatric comorbidity, alcohol or drug abuse, inability to understand English, pregnancy, and previous pelvic floor muscle training.

Patients had two to six sessions, at monthly intervals, of physiotherapist-led behavioral treatment which included: education regarding anatomy and function of the bowel and the muscles involved in continence and defecation; specific exercises to improve muscle function and coordination (diaphragm, abdominal, anal and pelvic floor) with or without biofeedback (digital, real-time ultrasound, rectal balloon); modification of maladaptive toileting behavior (prolonged or repeated toileting attempts, straining, digitation); urge control strategies, lifestyle advice on regular eating, stress management and general exercise; practical management strategies including perianal skincare and continence aids, and a home exercise program.

Patient-reported symptom improvement after treatment was rated on a seven-point Likert scale (0 = substantially worse, 7 = substantially better). The primary outcome was the percentage of patients reporting a Likert score of 6 or 7 (moderately or substantially better), post-treatment, considered to indicate significant clinical response [1].

Secondary outcomes, assessed before and at the end of treatment, included the St Mark’s (Vaizey) fecal incontinence score (FIS), the patient assessment of constipation symptoms (PAC-SYM), the inflammatory bowel disease questionnaire (IBDQ) for disease-specific quality of life, and the short-form 36 (SF-36) and EuroQol (EQ-5D) for general quality of life. Psychological factors were assessed with the hospital anxiety and depression scale (HADS), the brief illness perception questionnaire (BIPQ) and the IBD self-efficacy scale (IBD-SES).

Fifty-five of 59 consecutively referred patients were eligible after screening. Thirty-four patients (median age 38 years; 24 female) consented to participate and commenced treatment (18 ulcerative colitis, 13 Crohn’s disease, 3 ileoanal pouch). The median duration of IBD was 7.5 years and current bowel symptoms had been present for a median of 3.5 years. Thirty-eight percent of patients were taking medication for anxiety or depression. Twenty-nine of 34 (85%) patients completed treatment after a median of 4 sessions.  

Twenty-one (62%) of the 34 patients achieved the primary outcome with symptom improvement rated as 6 = moderately or 7 = substantially better.  Five (15%) patients did not complete treatment and were assigned a symptom rating of 4 = no change.  Twenty-one (72%) of the 29 patients who completed treatment achieved the primary outcome. No patients reported worsening symptoms, one reported no change and the remaining seven patients rated improvement as slight (Likert 5 out of 7). IBD medications following treatment were unchanged in 25 patients, decreased in two and ceased in two. 

There were significant improvements in the PAC-SYM, FIS, and IBDQ scores for both intention-to-treat and per-protocol analyses (Table 1).  The SF-36 general health-related quality of life scores improved significantly in the bodily pain and social functioning domains. The HADS and IBD-SES remained stable during treatment and there was a significant improvement in the BIPQ (Table 2).

This prospective study has demonstrated that pelvic floor behavioral treatment is associated with a clear benefit for patients with quiescent IBD and persistent bowel symptoms. The results from this study are comparable to the benefits reported for behavioral treatment in the non-IBD population [2].

Significant improvement occurred in the fecal incontinence, constipation, and disease-specific quality of life measures. Treatment also improved the bodily pain and social functioning domains of the SF-36.  General quality of life and psychological well-being remained stable suggesting that patient-reported improvement was not influenced by patients’ psychological status or overall health status. Illness perception was more positive following treatment suggesting a greater sense of control after learning symptom-reducing strategies.

Significant symptomatic improvement in bowel function occurred in more than two-thirds of the patients with quiescent IBD who completed a median of four sessions of behavioral treatment. Behavioral treatment provides an additional treatment option to existing dietary and pharmacological therapies and should be considered for patients with quiescent IBD and ongoing symptoms of fecal urgency, incontinence and constipation.

Gordon S, Ameen V, Bagby B, et al. Validation of irritable bowel syndrome global improvement scale: An integrated symptom end point for assessing treatment efficacy. Dig Dis Sci 2003; 48:1317-1323.
Wald A, Bharucha AE, Cosman BC, et al. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. 2014; 109:1141-1157