A Cochrane review of biofeedback and exercises for treatment of fecal incontinence found only five randomized or quasi-randomized control trials that qualified for inclusion (100). The authors concluded that there is insufficient evidence to evaluate the efficacy of exercises and biofeedback for treatment of fecal incontinence. Specifically, they were not able to determine which patients were suitable for treatment nor which method of treatment was optimal. A meta-analysis of biofeedback techniques included a review of 13 studies using strength training alone, 4 studies with sensory training alone, and 18 with coordinated sensory and strength training (99). The authors found no advantages between coordinated training (67% improved) and strength training (70% improved). However, strength training using EMG appeared to be better than strength training with anal canal pressure biofeedback (74% vs. 64% improved, respectively, P < .04). The limitations of this study and the literature were acknowledged.
A large randomized control trial of biofeedback for fecal incontinence in 171 patients, divided into four treatment groups, showed no significant benefit when comparing standard care to similar care with the addition of biofeedback (54% vs. 53% improvement, respectively) (101). In all groups, there was a high median rating of change of symptoms and median satisfaction with benefits relatively maintained at 1-year follow-up. All groups displayed improvement in the validated symptom surveys and quality-of-life measures as well as in anal sphincter function. The authors concluded that interactions with the therapist, patient education, and development of better coping strategies seem to be the most important factors for improvement rather than pelvic muscle exercises or biofeedback. Additional benefit may be derived with augmented biofeedback using electrical stimulation (102).
There are no clear indicators to predict which patients will benefit from biofeedback. Potential factors include age, duration and severity of incontinence, prior treatments or surgery, and severity of neurologic or physical damage. Controversy exists as to whether response to biofeedback is dependent on the presence of a structurally intact anal sphincter or normal pudendal nerve function (103–106). Similarly, there is insufficient evidence that electrical stimulation improves fecal incontinence (107). There is an obvious need for well-designed control trials using validated symptom surveys and quality-of-life instruments. More objective measures are desirable, and studies should carefully document duration of treatment and length of follow-up.
The goal of bowel regimens is to achieve predictable elimination of feces. This can be accomplished by using the gastrocolic reﬂex as well as by dietary and pharmacologic means. Defecation immediately following meals involves the physiologic response of the gastrocolic reﬂex to facilitate predictable emptying. The strength of the gastrocolic reﬂex varies among individuals and may be hypoactive or hyperactive with certain systemic disorders, such as diabetes and multiple sclerosis. This technique can be especially useful in the morning to give the individual freedom from fecal incontinence throughout the day. The use of suppositories or enemas in the morning or at night in conjunction with the gastrocolic reﬂex may provide further relief of daytime symptoms. The goal is to leave the rectum empty between evacuations. Enema use, typically once or twice daily, should be titrated to the patient’s baseline colonic activity. Regular toileting in elderly patients in nursing homes can improve fecal incontinence caused by overﬂow incontinence from fecal impaction. The use of cone-tip colostomy-irrigation catheters is reserved for patients in whom other therapeutic modalities have failed. These catheters avoid the risk of rectal perforation and provide a dam to prevent efﬂux of the irrigating solutions (108).
Surgical Treatment In general, surgical treatment should be employed after conservative measures have failed. Although there may be exceptions to this principle, most surgeons follow this recommendation because of the poor long-term outcomes and high complication rates with surgery for fecal incontinence.