From the Guidelines
For patients with dyssynergia and rectal ulcerations who have failed initial conservative measures, the next step should be biofeedback therapy combined with topical treatments for the ulcerations. This approach is supported by recent evidence from 2023, which highlights the effectiveness of biofeedback therapy in treating dyssynergic defecation, with success rates of 70% to 80% in clinical trials 1. The biofeedback therapy typically involves 4-6 sessions over 2-3 months with a trained therapist who uses visual or auditory feedback to help patients identify and correctly contract/relax their pelvic floor muscles. This addresses the underlying dyssynergic defecation by retraining proper coordination of abdominal, rectal, and anal sphincter muscles during defecation. For the rectal ulcerations, topical treatments such as sucralfate enemas (10% suspension, 10-20 mL twice daily for 4-6 weeks) or 4% lidocaine gel can provide symptomatic relief and promote healing. If ulcerations are severe, short-term use of hydrocortisone suppositories (25 mg once or twice daily for 1-2 weeks) may help reduce inflammation. Patients should continue with a high-fiber diet (25-30g daily) and adequate fluid intake during this treatment phase. This combined approach is effective because it simultaneously addresses both the mechanical dysfunction causing straining and the resultant mucosal damage, allowing the rectum to heal while correcting the underlying dyssynergic pattern, as recommended by a roundtable review and recommendations on optimizing the utility of anorectal manometry for diagnosis and therapy 1. Key considerations in the management of these patients include identifying the type of dyssynergia to personalize biofeedback maneuvers, and the potential use of rectal desensitization training or sensory adaptation training to optimize benefits from biofeedback therapy 1.
From the Research
Next Steps in Management
The patient has already undergone initial conservative measures, including minimizing time on the commode, high-fiber diet, and bulk laxatives. Given the presence of dyssynergia and rectal ulcerations, the next step in management would be to consider biofeedback therapy.
- Biofeedback therapy has been shown to be effective in improving symptoms and anorectal function in patients with dyssynergic defecation 2, 3, 4, 5, 6.
- The studies suggest that biofeedback therapy can help restore coordination of the pelvic floor, leading to improved healing of rectal ulcerations and reduction of dyssynergic defecation symptoms 2, 3.
- Biofeedback therapy has also been shown to improve abdominal symptoms, which are common in patients with dyssynergia 4.
- A systematic review and meta-analysis found that biofeedback therapy was superior to non-biofeedback therapy for clinical improvement in patients with dyssynergic defecation 6.
Recommended Course of Action
Based on the evidence, the recommended next step in the management of this patient would be to initiate biofeedback therapy. This would involve referring the patient to a qualified therapist who can provide biofeedback training to help the patient learn how to coordinate their pelvic floor muscles and improve their defecation dynamics.
- The patient should be educated on the benefits and process of biofeedback therapy, and encouraged to participate in regular sessions to achieve optimal results.
- The patient's symptoms and anorectal function should be monitored and assessed regularly to evaluate the effectiveness of biofeedback therapy and make any necessary adjustments to the treatment plan.