From the Guidelines
The next step in managing a patient with dyssynergic defecation is biofeedback therapy, which is considered the treatment of choice for this condition. Biofeedback therapy typically involves 4-6 sessions over a 3-month period with a trained therapist who uses visual or auditory feedback to help patients identify and correct abnormal muscle contractions during defecation. Before initiating biofeedback, ensure the patient has been properly diagnosed with dyssynergic defecation through anorectal manometry, balloon expulsion testing, and/or defecography 1. While awaiting biofeedback therapy, patients should be instructed on proper toileting techniques including using a footstool to elevate the knees above the hips, leaning forward, and avoiding excessive straining. Fiber supplementation (20-30g daily) and osmotic laxatives like polyethylene glycol (17g daily) can help maintain soft stool consistency. Biofeedback is effective because it directly addresses the underlying pathophysiology of dyssynergic defecation, which involves paradoxical contraction or inadequate relaxation of the pelvic floor muscles during attempted defecation. This retraining approach has success rates of 70-80% in specialized centers and avoids the risks associated with more invasive treatments 1.
Some key points to consider when implementing biofeedback therapy include:
- Ensuring the patient has a proper diagnosis of dyssynergic defecation through anorectal manometry, balloon expulsion testing, and/or defecography
- Instructing patients on proper toileting techniques to help manage symptoms while awaiting biofeedback therapy
- Using fiber supplementation and osmotic laxatives to maintain soft stool consistency
- Considering the use of biofeedback therapy as the treatment of choice for dyssynergic defecation, as recommended by best practice advice 12 1
It's also important to note that other options, such as MR defecography, may be useful in certain situations, but biofeedback therapy is generally considered the next step in managing a patient with dyssynergic defecation 1.
From the Research
Next Steps in Management
The patient has been diagnosed with dyssynergic defecation and has undergone initial conservative measures. The next step in management would be to consider biofeedback therapy.
- Biofeedback therapy has been shown to be effective in treating dyssynergic defecation, with studies demonstrating improvement in symptoms and quality of life 2, 3, 4, 5, 6.
- The patient's mild dyssynergia and failure to respond to initial conservative measures make biofeedback therapy a suitable option.
- Biofeedback therapy can help the patient learn to relax the pelvic floor muscles and improve defecation techniques, addressing the underlying cause of the dyssynergic defecation.
Options
Considering the patient's condition and the available evidence, the options for the next step in management are:
- B) Biofeedback therapy: This is the most appropriate option, given the patient's diagnosis and the effectiveness of biofeedback therapy in treating dyssynergic defecation.
- Other options, such as MR defecography, sucralfate enemas, and topical mesalamine, may not be directly relevant to the treatment of dyssynergic defecation and are not supported by the available evidence.