Biofeedback Mastery

Biofeedback Mastery

Have you ever wondered what Biofeedback is all about? Uncover these unique information on Biofeedback! Are you in constant pain? Do you wish you could ever just find some relief? If so, you are not alone. Relieving chronic pain can be difficult and frustrating.

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Manometry for Biofeedback

Manometry can be utilized for the performance of biofeedback techniques in the treatment of fecal incontinence and constipation. The most Despite the lack of objective data favoring biofeedback therapy for the treatment of defecation disorders, the clinical improvement and impact on the quality of life obtained by more than 60 of the patients justify its use. In addition, this method is safe and may be performed as self-training with a special home equipment apparatus. The experience of Gilliland et al38 with selected constipated patients and a medium of four sessions of biofeedback using anal manometry demonstrated a clinical improvement in these patients. As previously demonstrated in the literature,38,39 the number of sessions completed is the only predictable factor for the success of biofeedback therapy.

Biofeedback for Constipation

Anismus, also termed pelvic floor dyssyner-gia, spastic pelvic floor syndrome, paradoxical puborectalis contraction, and nonrelaxing pub-orectalis syndrome, accounts for an estimated 50 of patients with symptoms of chronic constipation.6 Rome II diagnostic criteria for a diagnosis of pelvic floor dyssynergia are specified in Table 13.2.3 This disorder of unknown etiology is characterized by failure of the puborectalis muscle to relax during defecation. Invasive surgical therapy or injection of botulinum neurotoxin7 are associated with an unacceptable incidence of incontinence. In 1993, Enck's8 critical review found that biofeedback has become widely accepted as the treatment of choice for anismus.

Practical Aspects of Biofeedback Therapy for Constipation

Practical aspects of using biofeedback therapy for pelvic floor muscle (PFM) dysfunction to treat symptoms of constipation and fecal incontinence include the technical, therapeutic, behavioral, and the pelvic muscle rehabilitation (PMR) components. The technical component involves the instrumentation used to provide meaningful information or feedback to the user. There are several technical systems available, and the advantages of any one device have not been scientifically tested. Devices include surface electromyography (sEMG), water-perfused manometry systems, and the solid-state manometry systems with a latex balloon. Although each system has inherent advantages and disadvantages, most systems provide reproducible and useful measurements. The choice of any one system depends on many factors, including cost incontinence.13 Patients with fecal incontinence may complain of multiple daily bowel movements and a feeling of incomplete evacuation resulting in postdefecation seepage.9 Many...


Biofeedback focuses on the biological systems that are beyond conscious control but are acting in a way that impairs the individual's performance, thereby contributing to stress-related diseases. In the biofeedback process, the individual first becomes aware of any faulty response, then is guided by the feedback signal to control the response, and learns to transfer this control to everyday situations. Biofeedback is used to teach people how to relax in stress management programs and for the control of hypertension, anxiety, insomnia, and other stress-related disorders (Kaplan, Sallis, & Patterson, 1993).

Biofeedback Defined

Schwartz et al9 define the biofeedback process as a group of therapeutic procedures which utilize electronic instruments to accurately measure, process, and feed back to persons and their therapists, meaningful physiological information with educational and reinforcing properties about their neuromuscular and autonomic activity, both normal and abnormal, in the form of analog, binary, auditory and or visual feedback signals. This process helps patients develop a greater awareness of, confidence in, and an increase in voluntary control over physiologic processes. This result is best achieved with a competent biofeedback professional. Employing biofeedback instruments without proper cognitive preparation,instruction, and guidance is not appropriate biofeedback therapy. As with all forms of therapy, the therapist's skill, personality and attention to the patient affect the outcome.9 It has been suggested that when researchers understand the essential components of biofeedback training,...

Biofeedback Sessions

Darstellung Datenlogger Linien

Verbal and written instructions are simplified for easy comprehension using layman's terminology. This is followed by a description of the biofeedback process, instrumentation, and PMR exercises. Patients should be aware that physicians cannot make muscles stronger or change muscle behavior. However, patients can learn to improve symptoms and quality of life by active participation and commitment to making changes. Results are not immediate as with any exercise program, muscle improvement requires time and effort. Beginning goals of isolated pelvic muscle contractions are established and an example of sEMG tracing showing efficient muscle function is reviewed. Patients are given instructions on proper insertion of the internal sensor and remain fully clothed during the session. They are placed in a comfortable semi-recumbent position for training however, internal sensors work in a variety of positions for functional maneuvers such as

Studies in MS and Other Conditions

Biofeedback may have applications for multiple sclerosis (MS)-related symptoms. For anxiety and insomnia, which may be significant problems in MS, biofeedback may be beneficial by promoting relaxation. It also may be helpful in treating some types of pain, including tension headaches, migraines, and low back pain. However, the use of biofeedback to treat MS-associated pain has not been formally studied. Some research suggests that biofeedback may be helpful for people with urinary incontinence, a problem that may occur in MS. Medications and pelvic exercises are available for incontinence. These approaches may not be fully effective, however, and the medications may have undesirable side effects. Studies for biofeedback treatment of urinary incontinence have reported mixed results. Biofeedback may be especially effective for people who have difficulty knowing which muscles to contract during the performance of pelvic exercises. Studies must be done to more fully evaluate biofeedback...

Practical Information

Biofeedback should be obtained from a trained therapist. Self-operated biofeedback devices are available, but biofeedback monitoring is a complex process that is most likely to be helpful when it is performed by a qualified practitioner. Biofeedback sessions typically last 30 to 60 minutes. The number of sessions required ranges from a few to 30 or 40. Health insurance sometimes provides coverage for this therapy. Many trained biofeedback therapists are psychologists. Certification is provided by the Biofeedback Certification Institute of America. Biofeedback practitioners can be found in the telephone directory under psychologists or by obtaining a directory of biofeedback therapists from the Biofeedback Certification Institute of America (, 10200 W. 44th Avenue, Suite 310, Wheat Ridge, CO 80033 (303-420-2902). An organization that provides biofeedback information and is involved in biofeedback research is the Association for Applied Psychophysiology and Biofeedback...

Additional Readings Books

Biofeedback in the neurologic disorders. In Weintraub MI, Micozzi MS, eds. Alternative and Complementary Treatment in Neurologic Illness. New York Churchill Livingstone. 2001, pp. 156-165. Klarskov P, Heely E, Nyholdt I, et al. Biofeedback treatment of bladder dysfunction in multiple sclerosis. A randomized trial. Scand J Urol Nephrol Suppl 1994 157 61-65. Norton C, Hosker G, Brazzelli M. Biofeedback and or sphincter exercises for the treatment of faecal incontinence in adults (Cochrane review). In The Cochrane Library, Issue 2, 2000. Oxford Update Software. Wiesel PH, Norton C, Roy AJ, et al. Gut focused behavioural treatment (biofeedback) for constipation and faecal incontinence in multiple sclerosis. J Neurol Neurosurg Psychiatry 2000 69 240-243.

Primary Nursing Diagnosis

A variety of treatments have been used for IC, including dietary and fluid management, time and stress management, and behavioral modification. Certain foods such as coffee, alcohol, tomatoes, vinegar, and chocolate may aggravate symptoms of IC. Other interventions that have been used with varying success are biofeedback and pelvic floor rehabilitation such as Kegel exercises, and bladder training programs. Generally, treatments are initiated in a progressively more invasive fashion until symptomatic relief is obtained.

Adjunctive Treatment Method Balloon Expulsion

Various adjunctive biofeedback treatment methods have been employed throughout the years. Balloon expulsion has been used as an objective diagnostic tool and reportedly enhances sensory awareness in patients with outlet obstruction. This training technique involves inserting a balloon into the rectum and inflating with 50 mL of air so that the patient has the sensation of the need to defecate. Adherent perianal placement of surface electrodes allows the patient to see the resultant sEMG pattern made by voluntary sphincter contraction. The patient is then asked to expel the balloon and if there is increased, rather than decreased, sphincter activity, the patient is instructed on straining without increasing sphincter activity.22

Treatment of Constipation

In nature.27 Furthermore, diagnostic data from physiologic testing beyond confirmation of spastic pelvic floor syndrome is often not reported. Patient's concomitant conditions disclose a significant variance in inclusion criteria (e.g., presence of rectoceles, rectal sensory thresholds, previous surgery), which presumably contribute to the success of treatment.27 Park et al28 described two varieties of anismus, anal canal hypertonia, and nonrelaxation of the pub-orectalis muscle that appear to correlate with the success of biofeedback specifically, anal canal hypertonia may be responsible for failure of biofeedback therapy. McKee et al29 concluded that biofeedback for outlet obstruction constipation is more likely to be successful in patients without evidence of severe pelvic floor damage. Biofeedback is a conservative treatment option for patients with idiopathic constipation, although some studies have had less favorable results. The most recent study, by Emmanuel and Kamm22 in...

Treatment of Combined Colonic Inertia and Obstructed Defecation

We have observed a poor correlation between preoperative rectal evacuation as demonstrated by proctography and postoperative clinical obstructed defecation.9 A total of 34 patients undergoing colectomy had preoperative evacuation proctography. Normal preoperative proctography was found in only 10 of 23 patients who had normal postoperative evacuation and four of 11 patients with postoperative evacuation difficulties. Of the 34 patients undergoing proc-tography, 20 had preoperative obstructed defecation, and 13 of these 20 could defecate normally postoperatively. Of the remaining seven patients, three were improved with postoperative biofeedback. We have not found preoperative pelvic floor retraining with biofeedback to be helpful or indeed necessary in the majority of patients with obstructed defecation and colonic inertia. Our preferred treatment is to offer biofeedback to those patients with persisting postoperative symptoms of obstructed defecation. Other studies have shown a poor...

Fluid Filled and Air Filled Balloon Systems

Rectoanal Inhibitory Reflex

This device is inserted into the anus and positioned where the inner balloon lies attached to the internal anal sphincter and the pear-shaped balloon to the outer bundle of the external anal sphincter. Thus, theoretically, the pressures of the internal and external sphincter can be independently measured however, the overlap of these two portions is too wide to allow adequate differentiation. Normally, recording is performed with an aneroid manometer. The advantage is that recording is done from a larger surface reflecting overall pressures of a large area of the sphincters. Furthermore, the technique is simple and cost-effective, and the balloon stays fixed in place, thereby requiring only one operator. The disadvantage is that larger balloons create more artifacts during recording therefore, this method is better for evaluating pressure changes than for evaluating actual pressures. Balloons and cylinders are available in three sizes infant, pediatric, and adult. Although the device...

Solitary Rectal Ulcer Syndrome

Defecography can clarify anatomic changes that contribute to the pathogenesis of solitary rectal ulcer syndrome and accordingly may be used to direct therapy. Kuijpers et al41 determined that, among 19 patients with histologic features of solitary rectal ulcer syndrome, 12 had intussusception and five patients had inappropriate pub-orectalis muscle contraction on defecography exam. Intussusception can cause stretching of the submucosal vessels, ischemia, and ulceration. Straining against a nonrelaxing puborec-talis muscle can cause internal prolapse, ischemia and ulceration.26 Patients with solitary rectal ulcer syndrome and inappropriate puborectalis muscle contraction may be offered biofeedback, with surgery reserved for those with significant intussusception.42 Goei and Baeten22 studied pre- and postoperative defecograms in 11 patients with solitary rectal ulcers who were treated with a rectopexy. In nine patients the intussusception and rectal lesions were cured, and in two the...

Classification Schemes

Ommended following pelvic reconstructive procedures. Biofeedback therapy may be necessary to instruct patients how to adequately isolate and contract their pelvic floor muscles. Poorly estrogenized thin vaginal mucosa should be treated with local estrogen prior to surgical therapy, as well as postoperatively to enhance mucosal strength.

Surgical Treatment of Rectocele Colorectal Approaches

Rectocele Measurement Defecography

Johansson et al16 and Mellgren et al17 pointed out the possibility that some rectoceles may be the result of a paradoxical sphincter response (paradoxical puborectalis contraction) leading to an outlet obstruction and subsequently disappointing surgical results. To rule out this possibility, concentric needle electromyography should be performed to evaluate the recruitment of motor unit potentials (MUPs)18 during an evacuatory effort generally MUP recruitment should be equal to or less than at rest. If MUP recruitment is increased compared to rest, a paradoxical muscle response can be suspected and preoperative biofeedback therapy is advisable. Mimura et al19 and Johansson et al16 have suggested that biofeedback should be taken into account to ensure better surgical results. Response to medical therapy leads to symptomatic relief in only a minor percentage of patients with paradoxical puborectalis response and rectocele.

Sacral Nerve Stimulation

Pelvic causes of abnormal evacuation include rectal aganglionosis, rectal intussusception or complete rectal prolapse, and anterior rectal wall hernia (rectocele), and they may sometimes be cured with surgery. Many patients with rectal constipation lack coordination of the rectum and the anal sphincters (outlet constipation),which is not amenable to simple surgical treatments. While biofeedback, stool softeners, and laxatives help some patients, these agents are often not a satisfactory long-term solution. Moreover some patients with colonic inertia are unresponsive to medical therapy, and the results of a subtotal colectomy are not always predictable.

Postoperative Outcome

A prolonged history of constipation prior to the operation would suggest colonic inertia, possibly mandating bowel resection in combination or without rectopexy. Conversely there are not enough data to support preservation of the lateral stalks, although there is a sound theoretical basis to support it. When addressing incontinence in these patients, there is a 50 to 75 postoperative improvement.15 It is generally accepted that in patients suffering from significant incontinence, rectopexy without resection should be preferred. If continence is not improved postoperatively there are a range of treatments that can be offered to the patients such as biofeedback and sphincter repairs.

Antegrade Continent Colonic Conduit

The successful treatment of intractable constipation remains challenging. Standard conservative therapies such as oral laxatives, suppositories, retrograde enema techniques, and bowel retraining programs incorporating biofeedback techniques may fail to achieve adequate bowel emptying and resolution of symptoms in some patients, who may therefore seek a surgical solution. Although surgery has a role in the management of selected patients with severe constipation, some procedures have suboptimal long-term success rates.1,2 Nevertheless, antegrade colonic irrigation, in which water or saline, with or without added aperients, is instilled via a catheter introduced into the proximal colon, may, in highly selected cases, provide an alternative method to improve rectal evacuation. This technique also promotes continence by ensuring regular bowel emptying, and thus is particularly useful in constipated patients with associated fecal (overflow) incontinence. This chapter outlines the evolution...

Constipation Caused by Dysfunction of the Pelvic Floor Muscles

In another study, Joo and colleagues14 demonstrated some success in using botulinum toxin to treat four patients with obstructed defecation who had failed to respond to conventional biofeedback treatment. They used between 6 and 15 U of botulinum toxin injected into the puborectalis muscle or external anal sphincter under EMG guidance. They found that although all four patients showed both subjective and objective (EMG results) improvement initially, long-term benefits were seen in only two of the four patients after 3 months.

Surgical Treatment of Puborectalis Hypertrophy

Good Defecation Dynamics

Jorge et al6 reported that the mean success rate for biofeedback for constipation was 68.5 , attributable to paradoxical puborectalis syndrome. Other nonsurgical methods, such as bot-ulinum toxin injection and anal dilation, can also offer improvement to some patients with PPC who do not respond to biofeedback.7,8 Another, often neglected cause of puborectalis syndrome is PH. The etiology of PH is unclear. The most common cause may be due to inflammation around the puborectalis, which causes puborectalis edema and stimulates hypertrophy. Gradually, the puborectalis loses its elasticity and cannot contract and relax func-tionally.9,10 The authors reviewed 200 cases of PH and found sepsis around the puborectalis in 15 to 30 .9 Other factors such as congenital trauma and chronic diarrhea may also play a role in the development of PH. The structure of the pub-orectalis is abnormal among patients with PH. Successful treatment cannot rely on biofeedback and other conservative methods, but...

Surface Electromyography Evaluation

Semg Biofeedback For Pelvic Floor

The abdominal and pelvic floor,the two channels of sEMG muscle activity, should be monitored simultaneously during the sEMG evaluation and the sEMG biofeedback-assisted pelvic muscle exercise training. Interpretative problems arise when monitoring only pelvic floor muscles without controlling changes in the intraabdominal pressure. The transmission of abdominal artifact to perennial measurements invalidates changes in the pelvic floor muscle measurements and can inadvertently reinforce maladaptive abdominal contractions.9 The recommended surface electrode placement for monitoring abdominal muscle activity is along the long axis on the lower right quadrant of the abdominal oblique muscles. Perianal placement of surface electrodes may be used to monitor the pelvic floor muscles when internal sensors are inappropriate as in young pediatric patients. Figure 13.6. Surface perianal placement (From Vickers D, Davila GW. Kegels and biofeedback. In Davila GW, Ghoniem, GM,Wexner SD, eds. Pelvic...

Indications and Patient Evaluation

It is a shared belief that the indication for neuromodulation is severe constipation not amenable to standard drugs or biofeedback therapy or a failed conventional surgical management. The integrity of the nervous supply must be considered. Patients with complete spinal cord lesion or peripheral nervous lesions such as spina bifida or iatrogenic nerve lesion are not candidates for sacral neuromodulation.6,7 The initial assessment includes a complete clinical history and physical examination. Before applying the stimulator, patients undergo a radiopaque marker transit study and anorectal physiologic evaluation. This evaluation includes defecography and rectoanal manovolumetry.6 Rectoanal manovolumetric evaluation includes the sphincter parameters of maximum resting pressure and maximum squeeze pressure, rectoanal inhibitory reflex threshold, urge to defecate expressed as volume and distention pressure, maximum rectal volume at 1 minute of distention with 40 cm of H2O, the contraction...

Differentiation Between Paradoxical Puborectalis Contraction and Puborectalis Hypertrophy

Paradoxical puborectalis contraction is a very common disorder and is thought to be the sole cause of puborectalis syndrome, especially since biofeedback is successful in some patients with PPC.17 Few series include patients with PH, and many surgeons believe that division of the pub- orectalis should be abandoned due to the potential for incontinence. However, in these authors' experience, PH is also a very important cause of puborectalis syndrome. Ger et al14 studied 116 patients with chronic constipation and found that the evacuation pressure by anorectal manometry (ARM) was divided into a normal relaxed pattern, an equivocal or nonrelaxed pattern, and a paradoxical contracted pattern. Some patients with the equivocal or nonrelaxing pattern may have had PH. If PPC is the only cause of puborectalis syndrome, then theoretically biofeedback should cure all patients. However, at most only 70 of patients with PPC respond to biofeedback. In fact, more recent data suggest success rates of...

Dyskinetic Puborectalis

Puborectalis muscle, lack of perineal descent, a lack of straightening of the rectoanal angle, and poor opening of the anal canal.37 Definition of specific measurement criteria (anorectal angle change, perineal descent) would be misleading due to the wide range of normal results.38 During the exam, the patient may strain numerous times and evacuate only a small amount of contrast with each attempt or fail to empty any contrast at all. Straining against the pelvic floor or a non-opening anal canal can accentuate the anterior bowing of a rectocele or cause posterior rectal bowing. Once diagnosed, dyskinetic puborectalis is usually treated with biofeedback and bowel management. Patients who fail conservative treatment have been offered botulinum toxin injections into the puborectalis muscle with limited success.39 Several studies have shown that neither electromyography nor cinedefecography is ideal relative to either specificity or sensitivity in the diagnosis of paradoxical...

Dental History

Should normally be treated and resolved before fixed prosthodontic treatment begins. A screening questionnaire will efficiently identify these problems. The patient should be questioned regarding any previous treatment for joint dysfunction (e.g., occlusal devices, medications, biofeedback, or physical therapy exercises).

Treatment Method

In biofeedback, monitoring equipment is used to translate the activity of specific bodily functions into images or sounds. The images may be seen on a computer screen or the sounds may be heard. The monitoring methods that are used depend on which physiologic activity is of interest electromyography (EMG) biofeedback is used to monitor muscle tension thermal biofeedback to monitor skin temperature electrodermal response to monitor perspiration respiration biofeedback to monitor the rate, rhythm, and volume of breathing finger pulse biofeedback to monitor pulse rate and brainwave biofeedback to monitor brain electrical activity. During a biofeedback session, a biofeedback therapist assists an individual in altering the activity of a particular body process through mental or physical exercises. The individual learns methods to produce the desired change through feedback from the monitor, input from the therapist, and experimentation. These methods eventually can be used without the use...


Controversial aspects the nonrelaxation of the puborectalis during straining can be observed in normal or asymptomatic patients.37 However, the characteristic history of prolonged periods of straining, necessitating the use of suppositories or enemas, and tenesmus in females, is an indication of such functional outlet obstruction. Together with a clinical history, electromyogra-phy, and cinedefecography, anorectal manome-try can aid in the selection of patients for more specific evaluations and biofeedback treatment.38 In addition, patients in whom a nonrelaxation of the striated muscles can be easily demonstrated during anal manometry, biofeedback therapy can be utilized. In a long-term study on the effects of visual biofeedback and muscle retraining as a therapeutic modality in anismus, Battaglia el al39 demonstrated in 24 patients the likelihood of continued benefit from biofeedback retraining during the time course.

Signal Detection

SEMG instrumentation Signal detection Signal processing Data acquisition and display sEMG evaluation Abdominal muscles Pelvic floor muscles Pelvic muscle exercise principles Overload Specificity Maintenance Reversibility Biofeedback treatment goals Short-term Long-term Behavioral strategies Patient education Dietary modification Habit training for difficult, infrequent, or incomplete evacuation Urge suppression for urinary and fecal incontinence Biofeedback-assisted pelvic muscle exercises Figure 13.2. Disposable surface electromyograph (EMG) electrodes. (From Vickers D, Davila GW. Kegels and biofeedback. In Davila GW, Ghoniem GM, Wexner SD, eds. Pelvic Floor Dysfunction A Multidisciplinary Approach. London Springer-Verlag, 2006 303-310.)

Signal Processing

The Orion platinum multimodality biofeedback system shows a typical display during a pelvic floor muscle (PFM) contraction. (Courtesy of SRS Medical, Redmond, WA.) Figure 13.3. The Orion platinum multimodality biofeedback system shows a typical display during a pelvic floor muscle (PFM) contraction. (Courtesy of SRS Medical, Redmond, WA.) Figure 13.5. The multiple electrode probe (MEP) internal sensor. (Courtesy of SRS Medical, Redmond, WA. From Vickers D, Davila GW. Kegels and biofeedback. In Davila GW, Ghoniem, GM, Wexner SD, eds. Pelvic Floor Dysfunction A Multidisciplinary Approach. London Springer-Verlag, 2006 303-310.) Figure 13.5. The multiple electrode probe (MEP) internal sensor. (Courtesy of SRS Medical, Redmond, WA. From Vickers D, Davila GW. Kegels and biofeedback. In Davila GW, Ghoniem, GM, Wexner SD, eds. Pelvic Floor Dysfunction A Multidisciplinary Approach. London Springer-Verlag, 2006 303-310.)


editation is a type of mind-body therapy, a class of therapies that also includes biofeedback, hypnosis, and guided imagery. For thousands of years, meditation has been practiced in some form, especially in the context of religious practice. Also, meditation is one of several components of some complementary and alternative medicine (CAM) therapies, including Ayurveda (which uses transcendental meditation or TM) and traditional Chinese medicine.


Primary nonretentive encopresis, and stool toileting refusal. Encopresis affects 1 to 3 of children, with higher rate in boys than in girls. It is characterized by the passage of large feces at intervals of less than twice per week and deferring bowel movements by contracting the pelvic floor muscles. The history usually varies from other types of constipation in children, such as aganglionosis, and no additional diagnostic testing is necessary. However, further diagnostic investigation using anal manometry is reserved for use in children who fail conservative therapy or whose history and physical examination suggest an organic etiology. In addition, manometry can detect disturbances, chiefly in the activity of the external anal sphincter, and can be a useful indicator for biofeedback therapy in these patients.33'34


Well as decreased mood disturbance and anxious mood (Cruess et al., 2000a) in HIV-positive patients. A similar study demonstrated that behavioral stress management techniques such as self-induced relaxation using progressive muscle relaxation, electromyographic (EMG) biofeedback, self-hypnosis, and meditation resulted in improvement in anxiety, mood, and self-esteem (Taylor, 1995). Lutgendorf and colleagues (1998) also observed improvement in cognitive coping strategies, namely positive reframing and acceptance in addition to improvements in social supports.

Patient Selection

The management of constipation is often complex, and antegrade enemas are indicated particularly for patients with structural (such as rectal agenesis)53 and neuropathic abnormalities of the hindgut, and idiopathic constipation (particularly those individuals with obstructed defecation).54 However, in common with other surgical procedures, the continent colonic conduit has its own inherent risks and complications. Therefore, it should be reserved for patients with intractable symptoms with severely impaired quality of life who have failed maximum medical and behavioral (bowel retraining biofeedback) therapy, and who are desperate to avoid a permanent stoma. The modern management of patients with constipation in a specialist surgical unit involves a mul-tidisciplinary team of professionals, reflecting the multifaceted approach to the different aspects of patient assessment, education, support, and treatment.

Physical Examination

Two Finger Cul Sac

Due to nonrelaxing puborectalis syndrome.43 This type of rectocele usually represents a compensatory mechanism due to the functional closure of the anal canal during attempted defecation and consequent high intrarectal pressure. This finding is of primary importance because, under these circumstances, surgical treatment of a rectocele will fail instead, biofeedback should be indicated.

Multiple Sclerosis

Among patients with multiple sclerosis, 50 to 70 report constipation or fecal incontinence and many complain of both.51 Symptom overlap can make treatment particularly difficult. We start with rectal disimpaction and a whole-bowel cathartic, such as polyethylene glycol, followed by a bowel regimen of high-fiber diet, laxatives, and enemas. If the constipation proves intractable, defecography may reveal outlet obstruction due to a lack of pelvic floor relaxation.52 Such patients may respond to biofeedback, especially those with limited disability and nonprogressive disease.53