What is the recommended treatment for dyssynergic defecation, specifically the role of biofeedback therapy?

Biofeedback Therapy for Dyssynergic Defecation

Biofeedback therapy is the first-line treatment for dyssynergic defecation and should be offered to all patients diagnosed with this condition, as it improves symptoms in more than 70% of patients and provides sustained long-term benefits. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

1. Identify patients with chronic constipation unresponsive to laxatives
2. Perform anorectal testing to confirm dyssynergic defecation:
   • Anorectal manometry to identify dyssynergic pattern
   • Rectal balloon expulsion test
   • If results are discordant, consider additional testing (fluoroscopic or MR defecography) 1

Treatment Algorithm

First-Line Treatment

• Biofeedback therapy should be initiated as the primary treatment for confirmed dyssynergic defecation 1
• Consists of:
  • Visual feedback techniques
  • Postural training
  • Diaphragmatic breathing exercises
  • Pelvic floor muscle coordination training
  • Simulated defecation training 2

Second-Line Options (for biofeedback non-responders)

If biofeedback therapy fails, consider:

1. Ongoing medical management with emphasis on suppositories and enemas
2. Evaluation for pelvic floor structural abnormalities
3. Management of colonic motor dysfunction with prokinetic agents
4. Consider surgical interventions or devices in refractory cases 1

Efficacy of Biofeedback Therapy

Biofeedback therapy demonstrates superior outcomes compared to other treatments:

• Corrects dyssynergic pattern in 78% of patients 3
• Improves bowel satisfaction in 64% of patients 3
• Increases complete spontaneous bowel movements 2
• Normalizes colonic transit time 4
• Provides sustained improvement at 1-year follow-up 4

A randomized controlled trial demonstrated that biofeedback therapy was superior to both sham feedback and standard therapy (diet, exercise, laxatives) in treating dyssynergic defecation 2. Another study showed continued efficacy at 1-year follow-up, while standard therapy was largely ineffective 4.

Predictors of Response to Biofeedback

Certain factors may predict better response to biofeedback therapy:

• Lower baseline bowel satisfaction scores 3
• Use of digital maneuvers for evacuation 3
• Lower or more normal baseline thresholds for first rectal sensation and urge 1

Notably, baseline demographic features, constipation symptoms, manometric parameters, and colonic transit results do not significantly impact treatment success 3.

Implementation Considerations

• Typically consists of 6 biweekly sessions, each lasting about 1 hour 3
• Can be performed by trained pelvic floor physical therapists, advanced practice registered nurses, or registered nurse therapists 1
• Cost is relatively modest compared to other interventions ($796 for a 3-month trial) 1

Common Pitfalls to Avoid

1. Delayed diagnosis: Patients with chronic constipation unresponsive to laxatives should undergo anorectal testing to identify dyssynergic defecation 1
2. Inadequate therapy: Ensure biofeedback is performed by properly trained therapists with appropriate equipment 1
3. Premature escalation to invasive treatments: Biofeedback should be tried before considering surgical interventions 1
4. Overlooking comorbid conditions: Depression may predict poor response to biofeedback therapy 1
5. Limited availability: Despite its effectiveness, biofeedback therapy is not widely available, which may limit access for some patients 1

Biofeedback therapy represents a non-invasive, effective approach for dyssynergic defecation with sustained benefits and should be considered the treatment of choice for this condition, regardless of baseline symptoms or anorectal physiology findings 3, 2.