Is Pelvic Floor Dysfunction (PFD) dyssynergia type II indicated for physiotherapy?

Physiotherapy for Pelvic Floor Dysfunction Dyssynergia Type II

Physiotherapy is strongly recommended as a first-line treatment for pelvic floor dysfunction dyssynergia type II, with biofeedback therapy showing 70-80% effectiveness in treating dyssynergic defecation. 1

Rationale for Physiotherapy in PFD Type II

Pelvic floor dysfunction (PFD) dyssynergia type II is characterized by paradoxical contraction or failure to relax pelvic floor muscles during defecation attempts. The evidence strongly supports physiotherapy interventions:

• The American Gastroenterological Association provides a strong recommendation with high-quality evidence that pelvic floor retraining through biofeedback therapy should be used rather than laxatives for defecatory disorders 1
• Understanding the specific dyssynergia type (such as type II) helps clinicians personalize and tailor biofeedback maneuvers to optimally benefit patients 1
• Clinical trials demonstrate that biofeedback therapy effectively treats 70-80% of patients with dyssynergic defecation 1

Recommended Physiotherapy Approach

1. Initial Assessment

• Anorectal manometry to confirm dyssynergic defecation pattern
• Balloon expulsion test to assess evacuation ability
• Assessment of rectal sensation thresholds

2. Physiotherapy Components

• Biofeedback Training:

  • Visual feedback (computer monitor) or audible/verbal feedback
  • Training to relax pelvic floor muscles during straining
  • Correlation of relaxation and pushing to achieve defecation 1
  • Rectoanal coordination training during defecation

• Correct Toilet Posture Training:

  • Buttock support
  • Foot support
  • Comfortable hip abduction to prevent activation of abdominal muscles 1

• Muscle Re-education:

  • Teaching abdominal/pelvic floor muscle interaction
  • Developing coordinated patterns necessary for relaxed voiding 1
  • Pelvic floor awareness and control enhancement

3. Biofeedback Methods

Two primary approaches are used:

1. Programs that improve flow rate by having patients view voiding curves during active voiding
2. Programs that teach muscle isolation using perineal EMG surface electrode feedback 1

Treatment Protocol

• Session Frequency: Once or twice weekly sessions 2
• Duration: Typically 8-10 weeks of therapy 3, 2
• Components per Session:
  • Pelvic floor muscle relaxation training
  • Simulated defecation training
  • Transanal electrostimulation may be added for enhanced results 4

Evidence of Effectiveness

Research demonstrates significant improvements with physiotherapy for PFD:

• Combined biofeedback plus transanal electrostimulation significantly decreased Wexner scores for defecation from 16.7 to 10.0 and obstructed defecation scores from 18.3 to 5.7 4
• Quality of life scores improved significantly from 61 to 23 with EMG biofeedback therapy 4
• Bimodal rehabilitation combining pelviperineal kinesitherapy and biofeedback showed significant improvement in stool frequency and reduced laxative dependency 5
• Pelvic floor physical therapy with myofascial release techniques improved urinary symptoms in 62.5% of patients reporting they were "much better" or "very much better" 2

Predictors of Treatment Success

Patients more likely to respond to biofeedback therapy include those with:

• Lower or more normal baseline thresholds for first rectal sensation and urge
• Lower baseline constipation scores
• Shorter colonic transit times
• Lower intolerable urgency thresholds 1

Negative predictors include:

• Depression
• Elevated first rectal sensory threshold volume 1
• Increased frequency of abdominal pain 1

Potential Challenges

• High dropout rates (36.8% in one study) suggest motivation or logistical factors may affect treatment success 2
• Institutional requirements and billing constraints may limit access to biofeedback therapy 1
• Confusion over reimbursement changes may deter providers from offering biofeedback therapy 1

Conclusion

Physiotherapy with biofeedback is clearly indicated for pelvic floor dysfunction dyssynergia type II, with strong evidence supporting its effectiveness as a first-line treatment. The approach should include biofeedback training, correct posture education, and muscle re-education, with treatment typically lasting 8-10 weeks.