2Manchester Academic Health Sciences Centre, University of Manchester, UK
Methods: Retrospectively we reviewed all IBD cases referred for ano-rectal manometry (ARM) and BFT at our institution between 2009-2014. For each patient, data confirming IBD quiescence (endoscopic, histology, radiography and biochemistry), IBD phenotypes, medication, surgical and obstetric histories, baseline FI frequency, QoL scores (rated 0-10) and results of anorectal investigations were recorded. Patients were classified as responders or non-responders to BFT based on symptoms at follow-up.
Results: Nine quiescent IBD patients (6/9 crohn's and 3/9 ulcerative colitis, median age 53, 7/9 females), with baseline median FI frequency 11.5/week and QoL score 6, had BFT following ARM. Manometrically, all had external anal sphincter weakness, 6/9 internal anal sphincter weakness, 2/9 with co-existing dyssynergic defecation and 8/9 had rectal hypersensitivity. Following a median 2 BFT sessions; 8/9 (89%) patients improved with reduced FI frequency (U=0.5, P=0.003) and 5/9 (56%) became fully continent.
Conclusions: BFT appears to be just as effective for FI in IBD patients as it is in non-IBD populations and may have a role in restoring continence and QoL. This data highlights the importance of anorectal physiology studies in symptomatic patients once active inflammation is excluded.
Keywords: Inflammatory Bowel Disease; Fecal Incontinence; Biofeedback Therapy
Biofeedback therapy: BFT was undertaken using a dedicated software programme (Polygram Net, Medtronic Inc, Watford, and Hertfordshire, UK) and a 4 channel solid state catheter (Gaeltec, Isle of Skye, Scotland, UK). BFT sessions lasted between 45 and 60 minutes. During BFT, the IBD patients received sphincter exercise training using techniques adapted from the Iowa protocol (12) to condition the external anal sphincter muscles. Finally, patients were given an information leaflet on anal sphincter exercises to take home and advised to practice for at least 20 minutes three times a day at home. Additionally, those that met the criteria for dyssynergic defecation (13) received anorectal co-ordination training to relax the puborectalis/anal sphincter using a commode-based approach as described in the Iowa protocol (12).
Patient No |
Gender |
IBD Phenotype (Montreal classification) |
Past Surgical History |
Co-existing Dyssynergic defecation |
No. of BFT sessions |
Response |
Continence Fully restored |
1 |
Female |
Pancolitis (E3) |
Ileo-pan-proctocolectomy Ileo-anal pouch |
Yes |
2 |
Yes |
Yes |
2 |
Male |
Proctitis (E1) |
Nil |
No |
2 |
Yes |
Yes |
3 |
Female |
Procto-sigmoiditis (E2) |
Nil |
No |
2 |
No |
No |
4 |
Female |
Crohns Colitis (L2) |
Nil |
No |
4 |
Yes |
No |
5 |
Male |
Ileal Crohn's (L1) |
Right Hemicolectomy and TI resection |
Yes |
4 |
Yes |
No |
6 |
Female |
Crohn's Colitis (L2) |
Nil |
No |
2 |
Yes |
No |
7 |
Female |
Crohn's Colitis (L2) |
Right Hemicolectomy and anterior resection |
No |
3 |
Yes |
Yes |
8 |
Female |
Crohn's Colitis (L2) |
Nil |
No |
2 |
Yes |
Yes |
9 |
Female |
Ileal Crohn's (L1-p) |
Anal fistula repair |
No |
3 |
Yes |
Yes |
Physiological Test |
Median (IQR) |
Normal range values |
First Sensation volume (ml) |
10 (20) |
15-25 |
Urge to defecate volume (ml) |
70 (70) |
152-218 |
Maximum tolerated volume (ml) |
155 (63) |
223-275 |
Recto-Anal Inhibitory Reflex (ml) |
20 (9) |
9-16 |
Maximum resting pressure (mmHg) |
46 (42) |
56-80 |
Maximum squeeze pressure (mmHg) |
103 (79) |
124-211 |
Whilst detection of abnormalities in anorectal physiology findings was not the primary aim of this retrospective study, our data support previous findings in both UC (9) and CD (7) demonstrating abnormalities in RAIR, which may be suggestive of dysfunction of the enteric nervous system in these patients (7). Our findings of severe rectal hypersensitivity in our quiescent cohort have been reported by some authors previously (8, 15) and are of interest as they may have implications for topical therapies in such patients (5) and may account for urgency symptoms secondary to heightened perception of rectal filling (15).
One of the most striking features in our dataset are the four patients with recognized pre-disposing factors to anorectal dysfunction and FI including; anal fistula surgery and colo-rectal surgeries (2). Surprisingly, all 4 of these patients improved with three regaining full continence post-BFT. Given the observed multitude of sensory and motor abnormalities and likely enteric neuropathic dysfunction one must ask how does BFT restore anorectal function in such patients? Recent studies using cortically evoked potentials before and after therapies, suggest that BFT improves bowel function via neuroplasticity by modulating the brain-gut axis and strengthening transmission in cortico-anal and cortico-rectal neural pathways (16). Trans sacral and Trans lumbar magnetic stimulation are other exciting tools with potential to evaluate damaged neural pathways in patients with FI (17) and may be the subject of future research to unlock the pathophysiology of ano-rectal dysfunction in IBD.
Limitations of this retrospective study include the small sample size which precluded comparisons of physiological parameters between disease sub-types, the limited availability of endoanal ultrasound and the study also pre-dated the availability of fecal calprotectin as a surrogate marker of disease activity and high-resolution manometry at our hospital. Also, due to the retrospective nature of the study and given that all patients were in stable clinical remission, 7/9 patients had mucosal assessments that were between 6-12 months old prior to the baseline visit. Whilst the infrequency of BFT sessions could also be seen as a limitation, we have previously shown that less-intensive BFT regimes have comparable outcomes to more intensive regimes(14) and the data shown here would also support that.
In summary, BFT appears to be effective in quiescent IBD patients with anorectal dysfunction regardless of the disease phenotype, previous surgeries and complications. Symptomatic IBD patients with FI should be referred for ARM once active inflammation is excluded. Further prospective research is now required using modern brain-gut imaging technologies and trans-lumbar/sacral magnetic stimulation to probe the mechanisms of anorectal dysfunction in IBD further to guide novel therapies which may include neuromodulatory techniques. Future prospective studies of BFT in IBD patients with FI may also explore the effects of BFT on correction of physiological parameters such as rectal sensitivity and RAIR.
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