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Electrophysiological Basis of Fecal Incontinence and Its Implications for Treatment: Elroy Patrick Weledji; Ann Coloproctol. 2017;33(5):161-168. Published online October 31, 2017; DOI: https://doi.org/10.3393/ac.2017.33.5.161

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The majority of patients with neuropathic incontinence and other pelvic floor conditions associated with straining at stool have damage to the pudendal nerves distal to the ischial spine. Sacral nerve stimulation appears to be a promising innovation and has been widely adopted and currently considered the standard of care for adults with moderate to severe fecal incontinence and following failed sphincter repair. From a decision-to-treat perspective, the short-term efficacy is good (70%–80%), but the long-term efficacy of sacral nerve stimulation is around 50%. Newer electrophysiological tests and improved anal endosonography would more effectively guide clinical decision making.

Citations

Citations to this article as recorded by

The Japan Society of Coloproctology Practice Guidelines for Fecal Incontinence 2024 (Revised Second Edition)
Keiji Koda, Toshiki Mimura, Tetsuo Yamana, Mitsuru Ishizuka, Tomoko Takahashi, Shota Takano, Tatsuya Abe, Yuji Nishizawa, Hidetoshi Katsuno, Masami Sato, Kaoru Nishimura, Masahiro Yoshida, Kotaro Maeda
Journal of the Anus, Rectum and Colon.2026; 10(1): 64. CrossRef
Characterization of Anal Slow Waves and Ultraslow Waves in Patients With Constipation and Healthy Subjects
Lulu Zhang, Yoav Mazor, Gillian Prott, Michael Jones, Allison Malcolm
Neurogastroenterology & Motility.2025;[Epub] CrossRef
Fecal incontinence: challenges in electrodiagnosis and rehabilitation
Naglaa A. Gadallah, Abeer K. El Zohiery, Youssy S. Gergius, Shaymaa A. Moussa
Egyptian Rheumatology and Rehabilitation.2023;[Epub] CrossRef
A systematic review of translation and experimental studies on internal anal sphincter for fecal incontinence
Minsung Kim, Bo-Young Oh, Ji-Seon Lee, Dogeon Yoon, Wook Chun, Il Tae Son
Annals of Coloproctology.2022; 38(3): 183. CrossRef
Fecal Incontinence and Diarrhea During Pregnancy
Stacy B. Menees, Anthony Lembo, Aline Charabaty
American Journal of Gastroenterology.2022; 117(10S): 26. CrossRef
Analgesic effect of structured anal skin care for perianal dermatitis after low anterior resection in the rectal cancer patients: prospective, single-center, open-label, therapeutic confirmatory, randomized clinical trial
Gyung Mo Son, In Young Lee, Mi Sook Yun, Jung-Hea Youn, Hong Min An, Kyung Hee Kim, Seung Mi Yeo, Bokyung Ku, Myeong Suk Kwon, Kun Hyung Kim
Annals of Surgical Treatment and Research.2022; 103(6): 360. CrossRef
Diagnostic approach to faecal incontinence: What test and when to perform?
Wisam Sbeit, Tawfik Khoury, Amir Mari
World Journal of Gastroenterology.2021; 27(15): 1553. CrossRef
A historical perspective of sacral nerve stimulation (SNS) for bowel dysfunction
Elroy P. Weledji, Lukas Marti
IJS Short Reports.2021; 6(3): e25. CrossRef
Physiotherapy for Prevention and Treatment of Fecal Incontinence in Women—Systematic Review of Methods
Agnieszka Irena Mazur-Bialy, Daria Kołomańska-Bogucka, Marcin Opławski, Sabina Tim
Journal of Clinical Medicine.2020; 9(10): 3255. CrossRef
The anatomy of urination: What every physician should know
Elroy P. Weledji, Divine Eyongeta, Eleanor Ngounou
Clinical Anatomy.2019; 32(1): 60. CrossRef
Recent advances in managing fecal incontinence
Giovanna Da Silva, Anne Sirany
F1000Research.2019; 8: 1291. CrossRef
Recent advances in managing fecal incontinence
Giovanna Da Silva, Anne Sirany
F1000Research.2019; 8: 1291. CrossRef
Endoflip vs high‐definition manometry in the assessment of fecal incontinence: A data‐driven unsupervised comparison
Ali Zifan, Catherine Sun, Guillaume Gourcerol, Anne M. Leroi, Ravinder K. Mittal
Neurogastroenterology & Motility.2018;[Epub] CrossRef

Original Articles

Biofeedback Therapy Before Ileostomy Closure in Patients Undergoing Sphincter-Saving Surgery for Rectal Cancer: A Pilot Study: Jeong-Ki Kim, Byeong Geon Jeon, Yoon Suk Song, Mi Sun Seo, Yoon-Hye Kwon, JI Won Park, Seung-Bum Ryoo, Seung-Yong Jeong, Kyu Joo Park; Ann Coloproctol. 2015;31(4):138-143. Published online August 31, 2015; DOI: https://doi.org/10.3393/ac.2015.31.4.138

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Abstract PDF

Purpose

This study prospectively investigated the effects of biofeedback therapy on objective anorectal function and subjective bowel function in patients after sphincter-saving surgery for rectal cancer.

Methods

Sixteen patients who underwent an ileostomy were randomized into two groups, one receiving conservative management with the Kegel maneuver and the other receiving active biofeedback before ileostomy closure. Among them, 12 patients (mean age, 57.5 years; range, 38 to 69 years; 6 patients in each group) completed the study. Conservative management included lifestyle modifications, Kegel exercises, and medication. Patients were evaluated at baseline and at 1, 3, 6, and 12 months after ileostomy closure by using anal manometry, modified Wexner Incontinence Scores (WISs), and fecal incontinence quality of life (FI-QoL) scores.

Results

Before the ileostomy closure, the groups did not differ in baseline clinical characteristics or resting manometric parameters. After 12 months of follow-up, the biofeedback group demonstrated a statistically significant improvement in the mean maximum squeezing pressure (from 146.3 to 178.9, P = 0.002). However, no beneficial effect on the WIS was noted for biofeedback compared to conservative management alone. Overall, the FI-QoL scores were increased significantly in both groups after ileostomy closure (P = 0.006), but did not differ significantly between the two groups.

Conclusion

Although the biofeedback therapy group demonstrated a statistically significant improvement in the maximum squeezing pressure, significant improvements in the WISs and the FI-QoL scores over time were noted in both groups. The study was terminated early because no therapeutic benefit of biofeedback had been demonstrated.

Citations

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Effectiveness of pelvic floor muscle training in the recovery of patients after low anterior resection: A systematic review and meta-analysis
Min Jeong Kim, Seonmi Yeom, Young Man Kim
European Journal of Oncology Nursing.2025; 77: 102918. CrossRef
BENEFÍCIOS DA FISIOTERAPIA EM PACIENTES COLOSTOMIZADOS E ILEOSTOMIZADOS: UMA REVISÃO NARRATIVA
Ana Carolina Aboukalam da Cruz, Anderson Viana Pantoja, Leonardo Gomes de Souza, Maicon Maximiliano de Almeida, Marcus Vinicius Henriques Brito, George Alberto da Silva Dias
REVISTA FOCO.2025; 18(7): e9137. CrossRef
The effectiveness of physiotherapy interventions on fecal incontinence and quality of life following colorectal surgery: a systematic review and meta-analysis of randomized controlled trials
Ming Yan Pun, Pak Ho Leung, Tsz Ching Chan, Chunn Pang, Kin Hei Chan, Priya Kannan
Supportive Care in Cancer.2024;[Epub] CrossRef
Application of pelvic floor rehabilitation in patients with colorectal cancer: a scoping review
Lu Zhou, Changkun Zhong, Yuanyuan Su, Zhengyang Zhang, Ling Wang
Techniques in Coloproctology.2024;[Epub] CrossRef
Effectiveness of Pelvic Floor Muscle Training for Patients Following Low Anterior Resection
Young Man Kim, Eui Geum Oh
Journal of Wound, Ostomy & Continence Nursing.2023; 50(2): 142. CrossRef
ILEOSTIM trial: a study protocol to evaluate the effectiveness of efferent loop stimulation before ileostomy reversal
N. Blanco, I. Oliva, P. Tejedor, E. Pastor, A. Alvarellos, C. Pastor, J. Baixauli, J. Arredondo
Techniques in Coloproctology.2023; 27(12): 1251. CrossRef
Low anterior resection syndrome
Seung‐Bum Ryoo
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Efficacy of Pelvic Floor Muscle Training for Postoperative Patients With Rectal Cancer: A Systematic Review and Meta-Analysis
Yuki Nakashima, Kenichi Fudeyasu, Yuki Kataoka, Shunsuke Taito, Takashi Ariie, Yukio Mikami
Cureus.2023;[Epub] CrossRef
„Low anterior resection syndrome“ – Ursachen und therapeutische Ansätze
Sigmar Stelzner, Juliane Kupsch, Sören Torge Mees
Der Chirurg.2021; 92(7): 612. CrossRef
Anterior resection syndrome: a randomized clinical trial of a 5-HT3 receptor antagonist (ramosetron) in male patients with rectal cancer
S -B Ryoo, J W Park, D W Lee, M A Lee, Y -H Kwon, M J Kim, S H Moon, S -Y Jeong, K J Park
British Journal of Surgery.2021; 108(6): 644. CrossRef
Investigating Risk Factors for Complications after Ileostomy Reversal in Low Anterior Rectal Resection Patients: An Observational Study
Mateusz Rubinkiewicz, Jan Witowski, Michał Wysocki, Magdalena Pisarska, Stanisław Kłęk, Andrzej Budzyński, Michał Pędziwiatr
Journal of Clinical Medicine.2019; 8(10): 1567. CrossRef
Mind–Body Interventions for Irritable Bowel Syndrome Patients in the Chinese Population: a Systematic Review and Meta-Analysis
Weidong Wang, Fang Wang, Feng Fan, Ana Cristina Sedas, Jian Wang
International Journal of Behavioral Medicine.2017; 24(2): 191. CrossRef
Lentivirus‐mediated shRNA interference of ghrelin receptor blocks proliferation in the colorectal cancer cells
An Liu, Chenggang Huang, Jia Xu, Xuehong Cai
Cancer Medicine.2016; 5(9): 2417. CrossRef
Biofeedback Therapy After Sphincter-Preservation Surgery for the Treatment of Rectal Cancer
Ik Yong Kim
Annals of Coloproctology.2015; 31(4): 119. CrossRef

Clinical Significance of Perineal Descent in Pelvic Outlet Obstruction Diagnosed by using Defecography: Hyun Nam Baek, Yong Hee Hwang, Yong Hwan Jung; J Korean Soc Coloproctol. 2010;26(6):395-401. Published online December 31, 2010; DOI: https://doi.org/10.3393/jksc.2010.26.6.395

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Abstract PDF

Purpose

The aim of this study was to evaluate the clinical significance of perineal descent (PD) in pelvic outlet obstruction patients diagnosed by using defecography.

Methods

One hundred thirty-six patients with pelvic outlet obstruction (POO; median age 49 years) had more than one biofeedback session after defecography. Demographic finding, clinical bowel symptoms and anorectal physiological studies were compared for PD at rest and PD with dynamic changes.

Results

Age (r = 0.33; P < 0.001), rectocele diameter (r = 0.31; P < 0.01), symptoms of incontinence (P < 0.05) and number of vaginal deliveries (r = 0.46; P < 0.001) were correlated with increased fixed PD. However, the female gender (P < 0.005), rectal intussusceptions (P < 0.05), negative non-relaxing puborectalis syndrome (P < 0.00005) and rectocele (P < 0.0005) were correlated with increased dynamic PD. Duration of symptoms, number of bowel movements, history of pelvic surgery and difficult defecation were not related with PD. There was no significant correlation between fixed and dynamic PD and success of biofeedback therapy.

Conclusion

Age, vaginal delivery and diameter of the rectocele are associated with increased fixed PD. Female gender, rectal intussusceptions and a rectocele are correlated with increased dynamic PD. Biofeedback is an effective option for POO regardless of severity of PD.

Citations

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Evaluation of Perineal Descent Measurements on Pelvic Floor Imaging
Isabelle M. A. van Gruting, Kirsten Kluivers, Aleksandra Stankiewicz, Joanna IntHout, Kim W. M. van Delft, Ranee Thakar, Abdul H. Sultan
Journal of Clinical Medicine.2025; 14(2): 548. CrossRef
Association of body composition with the symptoms of pelvic floor disorders in middle-aged women: a longitudinal study
Mari A. Kuutti, Enni-Maria Hietavala, Hanna-Kaarina Juppi, Sarianna Sipilä, Pauliina Aukee, Eija K. Laakkonen
Menopause.2025; 32(9): 810. CrossRef
Enhancing clinical practice: The role of digital rectal examination in diagnosing functional defecation disorders
Lian-Jun Zhu, Xing-Lin Zeng, Xiang-Dong Yang
World Journal of Gastrointestinal Surgery.2025;[Epub] CrossRef
Transverse perineal support improves long-term outcomes in patients undergoing stapled transanal rectal resection for obstructed defecation syndrome: a multicenter observational case-control study
Adolfo Renzi, Luigi Marano, Pasquale Talento, Luigi Brusciano, Angela Pezzolla, Domenico Izzo, Carmine Antropoli, Francesco D’Aniello, Giandomenico Di Sarno, Gianluca Minieri, Grazia Cantore, Gianmattia Terracciano, Domenico Barbato, Ludovico Docimo, Mass
Annals of Coloproctology.2025; 41(4): 330. CrossRef
Influence of Pubovisceral Avulsion on Perineal Body Descent and Prolapse Development
Durwash Badr, Liam C. Martin, Henry Chill, Alireza Hadizadeh, Ghazaleh Rostaminia, Steven D. Abramowitch
International Urogynecology Journal.2025;[Epub] CrossRef
Rectal prolapse (62.2, 62.3), adults
Yu. A. Shelygin, S. I. Achkasov, D. V. Alyoshin, O. M. Biryukov, V. S. Groshilin, V. N. Kashnikov, I. V. Kostarev, N. V. Kostenko, A. I. Moskalev, A. A. Mudrov, A. V. Muravyov, N. V. Oleinik, V. V. Polovinkin, V. M. Тimerbulatov, A. Yu. Titov, O. Yu. Fome
Koloproktologia.2024; 23(3): 10. CrossRef
Rectal prolapse (62.2, 62.3), adults
Yu. A. Shelygin, S. I. Achkasov, D. V. Alyoshin, O. M. Biryukov, V. S. Groshilin, V. N. Kashnikov, I. V. Kostarev, N. V. Kostenko, A. I. Moskalev, A. A. Mudrov, A. V. Muravyov, N. V. Oleinik, V. V. Polovinkin, V. M. Тimerbulatov, A. Yu. Titov, O. Yu. Fome
Koloproktologia.2024; 23(3): 10. CrossRef
The role of obesity on urinary incontinence and anal incontinence in women: a review
SK Doumouchtsis, J Loganathan, V Pergialiotis
BJOG: An International Journal of Obstetrics & Gynaecology.2022; 129(1): 162. CrossRef
The Digital Rectal Examination
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Gastroenterology Clinics of North America.2022; 51(1): 25. CrossRef
Consensus Definitions and Interpretation Templates for Fluoroscopic Imaging of Defecatory Pelvic Floor Disorders
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Consensus Definitions and Interpretation Templates for Fluoroscopic Imaging of Defecatory Pelvic Floor Disorders Proceedings of the Consensus Meeting of the Pelvic Floor Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdom
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Ugo Grossi, Gian Luca Di Tanna, Henriette Heinrich, Stuart A. Taylor, Charles H. Knowles, S. Mark Scott
Alimentary Pharmacology & Therapeutics.2018; 48(11-12): 1186. CrossRef
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Current Obstetrics and Gynecology Reports.2017; 6(3): 237. CrossRef
Defecographic Findings in Patients with Severe Idiopathic Chronic Constipation
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The Korean Journal of Gastroenterology.2017; 70(1): 39. CrossRef
Descending perineum syndrome: a review of the presentation, diagnosis, and management
Zaid Chaudhry, Christopher Tarnay
International Urogynecology Journal.2016; 27(8): 1149. CrossRef

Review

Anorectal Physiology: Test and Clinical Application: Hyeon-Min Cho; J Korean Soc Coloproctol. 2010;26(5):311-315. Published online October 31, 2010; DOI: https://doi.org/10.3393/jksc.2010.26.5.311

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Abstract PDF

The physiology of the anorectal region is very complex, and it is only recently that detailed investigations have given us a better understanding of its function. The methods that are used for the evaluation of anorectal physiology include anorectal manometry, defecography, continence tests, electromyography of the anal sphincter and the pelvic floor, and nerve stimulation tests. These techniques furnish a clearer picture of the mechanisms of anorectal disease and demonstrate pathophysiologic abnormalities in patients with disorders of the anorectal region. Therefore, therapeutic recommendations for anorectal disease can be made best when the anatomy and the physiology of the anorectal region are understood.

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How Can We Treat If We Do Not Measure: A Systematic Review of Neurogenic Bowel Objective Measures
Argy Stampas, Amisha Patel, Komal Luthra, Madeline Dicks, Radha Korupolu, Leila Neshatian, George Triadafilopoulos
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Anal endosonographic assessment of the accuracy of clinical diagnosis of obstetric anal sphincter injury
Angharad Jones, Linda Ferrari, Paula Igualada Martinez, Eugene Oteng-Ntim, Alison Hainsworth, Alexis Schizas
International Urogynecology Journal.2022; 33(11): 2977. CrossRef
Anatomy, physiology, and updates on the clinical management of constipation
Graham Dupont, Lauren Wahl, Tamara Alcala Dominguez, TL Wong, Robert Haładaj, Grzegorz Wysiadecki, Joe Iwanaga, R. Shane Tubbs
Clinical Anatomy.2020; 33(8): 1181. CrossRef
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Marika Britton, Sushil Maslekar, Fiona Marsh
The Obstetrician & Gynaecologist.2020; 22(4): 275. CrossRef
Pelvic floor investigations for bowel dysfunction (part 2): anorectal physiology (manometry)
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Transanal irrigation for bowel dysfunction: the role of the nurse
Lindsey Shaw
British Journal of Nursing.2018; 27(21): 1226. CrossRef
Anal sphincter dysfunction in multiple sclerosis: an observation manometric study
Silvia Marola, Alessia Ferrarese, Enrico Gibin, Marco Capobianco, Antonio Bertolotto, Stefano Enrico, Mario Solej, Valter Martino, Ines Destefano, Mario Nano
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Original Article

Prognostic Factors Associated with Poor Outcome of Biofeedback Therapy for Constipated Patients with Pelvic Outlet Obstruction.: Kim, Sung Jin , Hwang, Yong Hee , Jung, Yong Hwan; J Korean Soc Coloproctol. 2008;24(5):313-321.; DOI: https://doi.org/10.3393/jksc.2008.24.5.313

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Abstract PDF: PURPOSE
The aim of this study was to identify the prognostic factors associated with poor outcome of biofeedback therapy.
METHODS
One hundred thirty-seven (137) constipated patients with pelvic outlet obstruction (median age 49 years) had more than one biofeedback session after defecography. Follow-up data (mean follow-up: 14 months; range: 2~37 months) were obtained in 114 patients. Any differences in demographics, clinical symptoms, and parameters of an anorectal physiological study were evaluated between the success group and the failure group.
RESULTS
At follow-up, 80 (70 percent) patients felt improvement in symptoms, but 34 (30 percent) patients did not. Pre-biofeedback presence of symptoms of difficult defecation predict poor outcome (88 vs. 69 percent for failure vs. success, P<0.05). The positive and the negative predictive values of difficult defecation for poor outcome were 35 percent and 86 percent, respectively. A negative mean pressure change on pre-biofeedback anal manometry was related to a poor outcome (65 vs. 26 percent for failure vs. success, P<0.001). The positive and the negative predictive values of negative mean pressure change for poor outcome were 51 percent and 83 percent, respectively. A negative electrical current change on pre-biofeedback anal electromyography was related to a poor outcome (23 vs. 9 percent for failure vs. success, P<0.05). The positive and the negative predictive values of negative electrical-current change for poor outcome were 53 percent and 74 percent, respectively.
CONCLUSIONS
Difficult defecation, negative mean pressure change in pre-biofeedback anal manometry, and negative electrical current change in pre-biofeedback anal electromyography were predictors associated with poor outcome of biofeedback therapy for constipated patients with pelvic outlet obstruction.

Review

The Roles of Anorectal Physiologic Tests and Treatment of Chronic Constipation.: Hwang, Yong Hee; J Korean Soc Coloproctol. 2008;24(2):148-159.; DOI: https://doi.org/10.3393/jksc.2008.24.2.148

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Abstract PDF: Patients with chronic constipation should be evaluated with physiological tests (defecography and cinedefecography, anal manometry, anal electromyography, and colon transit time) after structural disorders and extracolonic causes have been excluded. In the case of colonic inertia, at first, conservative treatment is necessary. If surgery is indicated, a subtotal colectomy with ileorectal anastomosis is the treatment of choice. Biofeedback is the best option for animus. For patients failing biofeedback, botulinum toxin injection of the puborectalis or sacral nerve stimulation may be indicated. Biofeedback treatment is also considered to be an option for moderate-degree rectoceles, rectal intussusception, and perineal descending syndrome. For the treatment of a severe rectocele, a surgical approach, including transrectal, transvaginal, and transperineal repair or stapled transanal rectal resection (STARR) should be considered. However, the long-term effects of a new technique including botulinum toxin injection, sacral nerve stimulation, and STARR remain to be established.

Original Articles

Effect of Electrical Stimulation and Biofeedback Therapy for Constipated Patients with Impaired Rectal Sensation.: Kim, Young Kyu , Hwang, Yong Hee , Jung, Yong Hwan; J Korean Soc Coloproctol. 2007;23(4):232-236.; DOI: https://doi.org/10.3393/jksc.2007.23.4.232

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Abstract PDF: PURPOSE
Biofeedback therapy is widely used for the management of constipation associated with pelvic outlet obstruction. Some patients have shown poor outcome after biofeedback alone. A subgroup of patients complains of absence of desire to defecate. The main pathophysiology of constipation may be impaired rectal sensation or compliance. This study evaluated the effect of electrical stimulation and biofeedback therapy (EST-BF) for this subgroup of constipated patients with impaired rectal sensation.
METHODS
Of the 37 patients diagnosed with pelvic outlet obstruction by using cinedefecography, 9 patients (M:F=2:7, age=22~77 years, median=57 years) who had impaired rectal sensation (rectal desire threshold > or =100 ml) on anorectal manometry were selected. These patients were treated with EST-BF therapy 2~6 (median: 5) sessions, Kontinece, Multichannel system, HMT, Inc, Seoul, Korea). Treatment consisted of 20 minutes of variant-mode electrical stimulation and 20 minutes of EMG biofeedback therapy per week administered by a specialized colorectal surgeon. All patients were evaluated by using a standardized questionnaire and a threshold for rectal sensation based on balloon distention before and after treatment.
RESULTS
At post EST-BF, six (67%) patients had experienced an improvement in symptoms, including five (56%) patients with complete symptom relief. Significant improvement in rectal sensation, especially the rectal defecation desire threshold (pre-EST-BF vs. post- EST-BF: 181.0+/-38.7 vs. 88.3+/-29.1) was achieved.
CONCLUSIONS
EST- BF may be an effective option for use in the treatment of functional constipation with impaired rectal sensation.

Outcome and Predictors of Success of Biofeedback for Descending Perineum Syndrome.: Hur, Le Na , Hwang, Yong Hee , Jung, Yong Hwan; J Korean Soc Coloproctol. 2007;23(3):145-151.; DOI: https://doi.org/10.3393/jksc.2007.23.3.145

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Abstract PDF

Purpose
To determine the outcome and identify predictors of success of biofeedback for descending perineum syndrome (DPS). Methods: 103 patients diagnosed with DPS by defecography were evaluated by standardized questionnaire, before, immediately after treatment, and at follow-up. Clinical bowel symptoms and anorectal physiological studies were also analyzed. Results: At post- biofeedback, 81 patients felt improvement in symptoms, including 29 with complete symptom relief. At follow-up (median: 13 months, n=82), 58 patients felt improvement in symptoms, including 12 with complete symptom relief. There was a significant reduction in difficult defecation (from 78 to 34, 37%, from pre-biofeedback to post-biofeedback, and at follow-up respectively; P<0.001), incomplete defecation (from 88 to 44, 41%; P<0.001), hard stool (from 63 to 25, 0%; P<0.01), small caliber stool (from 63 to 0,0%; P<0.001, P<0.005), fecal incontinence (from 10 to 1,1%; P<0,01), anal pain (from 21 to 2, 6%; P<0.001, P<0.05), laxative use (from 30 to 11, 6%; P<0.001), enema use (from 16 to 0, 1%; P<0.001) and digitation (from 11 to 1%, from pre-biofeedback to at follow-up; P<0.05). Normal spontaneous bowel movement was increased from 47% pre-biofeedback to 79% post-biofeedback (P<0.001), 86% at follow-up (P<0.001). Difficult defecation predict poor outcome (96 vs. 66%; failure vs. success, P<0.01). Positive mean pressure change predict good outcome (69 vs. 35%; success vs. failure, P<0.05). Conclusions: Biofeedback is an effective option for DPS.

Citations

Citations to this article as recorded by

An Analysis of Factors Associated with Increased Perineal Descent in Women
Jina Chang, Soon Sup Chung
Journal of the Korean Society of Coloproctology.2012; 28(4): 195. CrossRef
The Roles of Anorectal Physiologic Tests and Treatment of Chronic Constipation
Yong Hee Hwang
Journal of the Korean Society of Coloproctology.2008; 24(2): 148. CrossRef

Outcome and Predictors of Biofeedback Therapy for Patients with Internal Rectal Intussusception.: Kwon, Soon Ho , Hwang, Yong Hee , Choi, Kun Pil; J Korean Soc Coloproctol. 2002;18(6):379-385.

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Abstract PDF: PURPOSE
The aim of this study was to determine the outcome and identify predictors of success of biofeedback therapy for patients with internal rectal intussusception.
METHODS
Twenty-one patients (median age. 54 years, 15 female, 6 male) diagnosed with internal rectal intussusception by using cinedefecography were evaluated by standardized questionnaire, before, immediately after treatment, and at follow-up. Clinical bowel symptoms and anorectal physiological studies were also analyzed.
RESULTS
Follow up (median: 15, range 2~24 months) results were evaluated by an independent observer in 20 patients. At post-biofeedback, 20 (95%) patients felt improvement in symptoms, including 7 (33%) with complete symptom relief. At follow-up, 17 (85%) patients felt improvement in symptoms, including 7 (35%) with complete symptom relief. There was a significant reduction in difficult defecation (from 90 to 29, 10 percent, from pre-biofeedback to post-biofeedback, and at follow up respectively; P<0.001), sensation of incomplete defecation (from 90 to 24, 35 percent; P<0.001), enema use (from 29 to 0, 0 percent; P<0.01), and anal pain (from 19 to 0, 0 percent; P<0.05). Digitation (from 19 to 0 percent, from pre- biofeedback to at follow up; P<0.05) and laxative use (from 29 to 5 percent; P<0.05) were also decreased. Normal spontaneous bowel movement was increased from 52 percent, at pre-biofeedback to 86 percent, at post- biofeedback (P<0.05), 95 percent at follow up (P<0.005). Low bowel frequency, at pre-biofeedback (P<0.01), and hard stool (P<0.05) predicted poor outcome. Long puborectalis length during push (P<0.05) and dynamic descent (P<0.05) on defecography also predicted poor outcome. Low electrical activities of puborectalis and anal sphincter muscle during rest (P<0.001), squeeze (P<0.01) and push (P<0.005) on pre-biofeedback electromyography were related to poor outcome. No patient developed full rectal prolapse during follow up.
CONCLUSIONS
Biofeedback is an effective option and should be considered as the first line therapy especially for patients that don't have low bowel frequency, long puborectalis during push, and dynamic descent before treatment.

The Clinical Characteristics and Outcomes of Biofeedback Treatment for Patients with Nonrelaxing Puborectalis Syndrome.: Ahn, Eun Jung , Jeong, Gyu Young , Cheon, Seung Hui , Lee, Eun Joung , Oh, Soo Youn , Chung, Soon Sup , Lee, Ryung Ah , Kim, Kwang Ho , Park, Eung Bum; J Korean Soc Coloproctol. 2006;22(3):169-176.

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Abstract PDF: PURPOSE
Biofeedback treatment is thought to be appropriate for patients with nonrelaxing puborectalis syndrome (NRPR). The aim of this study is to analyze the physiologic characteristics and to assess the outcomes of biofeedback treatment for patients with NRPR.
METHODS
Forty-six (46) patients with NRPR were evaluated with anorectal physiologic studies, including colonic transit time (n=26), anorectal manometry (n=41), defecography (n=46), anal sphincter EMG (n=28), and colonoscopy or barium enema (n=33). The treatment consisted of a training program with EMG-based biofeedback for 30 minutes once a week and routine supportive care, including Kegel practice.
RESULTS
The mean age was 52.8 years, and the sex ratio was 1 male to 0.6 female. A delayed colonic transit time was noted in 5 patients (19.26%). In the NRPR group, the maximal voluntary contraction and the mean squeezing pressure were higher than they were for other patients with pelvic outlet obstructive disease. Also, the perineal descents and the dynamic change of anorectal angle were shorter. Polyps were observed in 6 patients (18.2%), melanosis coli in 4 patients (12.1%), and diverticula in 3 patients (9.1%). The rectoanal inhibitory reflex (RAIR) was negative in 3 patients (7.3%). The patients underwent a mean of 4.0 sessions, and the mean follow-up was 7.4 months. Twenty-three (23) patients (82.1%) experienced improved of symptoms or EMG findings. The patients (17.9%) who did not improve had several abnormal findings: neuro-psychologic disease with delayed colonic transit time in 2 cases, negative RAIR in 2 cases, and melanosis coli in one case.
CONCLUSIONS
We think that biofeedback training is an effective treatment for patients with NRPR. In addition, several factors, such as neuro-psychologic diseases, delayed colonic transit time, negative RAIR, or melanosis coli may influence the prognosis for biofeedback treatment, so further large-scaled studies will be needed to confirm these findings.

Are There Anorectal Physiologic Factors Prior to Biofeedback Treatment for Constipation that Affect Compliance Rate?.: Shin, Dong Ho , Kim, Seung Cheol , Kim, In Kyoung , Hong, Hyun Ki , Joo, Jae Sik; J Korean Soc Coloproctol. 2006;22(3):162-168.

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Abstract PDF: PURPOSE
The most important factor for the success of biofeedback treatment of constipation is patients' enthusiastic participation and willingness to comply with the treatment protocol. The purpose of this study was to analyze differences among groups of patients classified according to the number of biofeedback sessions and to identify any anorectal physiological and clinical factors related with better compliance with biofeedback treatment.
METHODS
From Aug. 2001 to July 2003, 80 patients who had undergone biofeedback treatment for constipation by a single therapist were classified into three groups according to the number of sessions: only one session (Group I, n=26), two or three sessions (Group II, n=27), and more than four sessions (Group III, n=27). We reviewed the clinical and the anorectal physiological characteristics retrospectively.
RESULTS
The mean age was 39.1 (range, 8~77) years, and the mean duration of constipation was 7.7 (range, 0.5~30) years and mean frequency of defecation was 2.2 times/week. Patients' pretreatment use of laxatives was significantly lower in Group I (38.5 percent) than in Group II (70.4 percent) or Group III (51.9 percent) (P<0.05). There were no significant differences in anal manometric parameters (mean and maximal resting pressure, maximal squeezing pressure, sensitivity, and rectal capacity). In the cinedefecographic findings, the megarectum was significantly higher in Group III (58.3 percent) than in Group I (38.9 percent) or Group II (27.8 percent) (P=0.02), but other findings of anismus, rectocele, intussusception, and delayed emptying showed no significant differences. The cinedefecographic parameters (anorectal angle, perineal descent, anal canal length, and puborectalis length), were not significantiy different among the groups.
CONCLUSIONS
We strongly recommend biofeedback treatment for constipation patients who abuse laxatives and/or for whom cinedefecography reveals megarectum.

Fecal Soiling Manometric findings and treatment.: Lee, Kwang Real , Whang, Do Yun , Kim, Kun Wook , Park, Weon Kap , Yoo, Jung Jun , Lim, Seok Won , Kim, Hyun Shig , Lee, Jong Kyun; J Korean Soc Coloproctol. 1998;14(3):477-482.

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Abstract PDF: BACKGROUND
Fecal continence is maintained by complex coordination of the sphincter mechanism and the anorectal sensation. Although most patients with fecal incontinence have a dysfunction of anal sphincter, fecal soiling seems to be related with a change in the anorectal sensation. PURPOSE: This study was done to evaluate the manometric findings and the methods of treatment for patients with fecal soiling.
METHODS
The manometric findings from 25 patients with fecal soiling were compared with those from 22 normal controls. The patients were treated with biofeedback and with bulking agent.
RESULTS
All the patients affected by fecal soiling were male except for one. There were no differences in the mean maximal resting pressure (MRP), and the mean maximal squeezing pressure (MSP) between the patients and the controls. The mean sphincter length and the mean length of the high pressure zone (HPZ) of the patients were significantly longer (50.5 vs. 55.6 mm and 28.2 vs. 31.3 mm, respectively; p<0.05 student t-test) than those of the controls. The minimal sensory volume (MSV) was significantly larger in the patient group, with a mean of 24.2 ml vs. 17.8 ml, than in the control group (p<0.05). The mean volume necessary to induce the recto-anal inhibitory reflex (RR) was 47.1 ml for the control group and 32.6 ml for the patient group (p<0.05). In the longitudinal profile of the anal sphincter, the HPZ was shifted proximally and the pressure peak was broader in the fecal soiling group. Of the 14 patients treated with biofeedback, 11 responded well.
CONCLUSION
Almost all of the patients affected by fecal soiling were men. The MRP and the MSP of the patients with fecal soiling were not lower than those of the normal controls. The sphincter length was longer in the patients with soiling than in the controls(p<0.05). However, for the fecal soiling group the distribution of the pressure along the anal canal was different in the sense that the HPZ was shifted proximally and the pressure peak was broader. The changes in the MSV and the RR suggest that there may be a defect in the anorectal sensation. The patients responded well to the combined use of biofeedback and a bulking agent.

Development and Clinical Application of the Biofeedback Anal Sphincter Control System for the Treatment of Patients with Functional Defecation Disorders Author Ung-Chae.: Park, Ung Chae , Kim, Jong Joo , Lee, Jong Kuk , Woo, Eung Je , Park, Seung Hun; J Korean Soc Coloproctol. 1998;14(3):459-466.

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Abstract PDF: Biofeedback is the treatment of choice for functional defecation disorders such as idiopathic chronic constipation and neurogenic fecal incontinence. The pre-existing biofeedback systems have many disadvantages. The aims of current project are, first, to develop the biofeedback system into the application software in the Windows environment, and, second, to assess the possibility of clinical usage for patients with functional defecation disorders. The hardware and software of the BASCO (Biofeedback Anal Sphincter Control) system were based on the signal measurement and signal processing of anal sphincter EMG (Electromyography). BASCO system was applied to 5 normal healthy controls and 20 patients with functional defecation disorders. Patients group was categorized as constipation group (N1=15) and incontinence group (N2=5). With use of current system, EMG-based biofeedback therapy was performed, and the outcome was analysed. Anal EMG signal data was processed by the software, and displayed in the monitor of personal computer. The software of EMG-display and database management were adequately operated. In N1 group, a paradoxical elevation or equalized activity of anal EMG pattern was shown in the simulated defecation. In N2 group, low electrical activity was shown. These findings were used for the EMG-based biofeedback therapy as a pilot study. The clinical symptoms were improved in 12 of N1 group and 3 of N2 group in the period of 3.7 (range, 1~12) months follow-up. In Conclusion, newly-developed BASCO system was adequately operated in the volunteer and patients groups. The multi-tasking and multi-processing functions were adequately shown in the real time. Current results could be used for clinical appraisal. Specifically, this system could be used for the practical application of biofeedback therapy in the patients with chronic constipation or fecal incontinence.

Effect of Biofeedback Treatment in Patients with Fecal Incontinence.: Park, In Ja , Yu, Chang Sik , Kim, Hee Cheol , Jung, Young Hak , Han, Kyong Rok , Park, Sang Kyu , Kim, Jung Rang , Song, Jin Sook , Lee, Hyang Ran , Kim, Jin Cheon; J Korean Soc Coloproctol. 2005;21(3):138-144.

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Abstract PDF: PURPOSE
We aimed to assess the efficacy of biofeedback therapy for patients with fecal incontinence (FI) according to the etiology.
METHODS
Twenty-nine patients with fecal incontinence were treated with biofeedback therapy using a EMG-based system. The efficacy was assessed by using changes in the FI score (Cleveland Clinic, Florida: 0~20) and satisfaction based on a subjective evaluation score from 0 to 100. The median follow up duration was 12 (3~25) months.
RESULTS
Ten patients had idiopathic fecal incontinence. Fourteen patients had fecal incontinence due to a sphincter saving operation for rectal cancer. Four cases had spinal cord injury and one patient had a major external sphincter tearing due to trauma. The mean age was 52 (16~78) years. The median number of biofeedback sessions was 10 (3~15) overall. The mean efficacy was 42.8%, and the mean satisfaction score was 56.6. Improvements in the FI score and in the patients' satisfaction varied according to the etiology, 69.5% and 71.5 in the idiopathic group, 28.5% and 49.3 in the postoperative group, and 35% and 24 in the spinal cord injury group. In the idiopathic group, 50% of the patients showed an improvement in the FI score of more than 75%, and 90% of the patients showed an improvement of more than 50%. The number of liquid incontinence episodes was improved 78.3% later in the biofeedback group, and this result was much better than in the postoperative incontinence group (31.8%, p=0.03).
CONCLUSIONS
The success rate of the biofeedback therapy for fecal incontinence is acceptable. Subjective satisfaction is relatively higher than the improvement in the ecal incontinence score. Idiopathic fecal incontinence may be the best indication for biofeedback therapy.

Treatment of Abnormal Rectal Sensation in Cerebrospinal Disease with.: Nah, Yong Ho; J Korean Soc Coloproctol. 1997;13(4):597-602.

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Abstract PDF: Cerebrospinal disease or injuries frequently result in defecatory difficulty. Management of these patients requires an understanding of the alterations in the mechanisms regulating colorectal function in the cerebrospinal disease. Rectal sensation is usually impaired in cerebrospinal disease and this is one of the pathogenic mechanisms of defecatory difficulty Aim : This study was carried out to evaluate a biofeedback treatment in the patients with impaired rectal sensation after cerebrospinal disease. Subjects : Thirteen patients (5F, 8M, mean age 36 years, range 14~56) with impaired rectal sensation and constipation over 6 months duration developed after brain or spine operation were studied. These included 7 traumatic head injury (5: temporoparietal epidural hematoma, 2: frontal lobe epidural hematoma) and 6 HNP (3: L4~5, 3: L5 ~S1) operation. METHODS: These patients were evaluated by questionnaire, office examination, colon transit studied, anorectal manometry including rectal sensation, balloon expulsion studies, and defecography. All patients underwent biofeedback treatment twice a week for 2 or 3 months.
Results
: Six brain hematoma and two HNP patients had impaired rectal sensation with anismus and the remaining 5 had only impaired rectal sensation. One brain hematoma (temporoparietal) had anosmia. All patients had normal anal basal pressure, squeeze pressure, rectal compliance, and intact rectoanal inhibitory reflex. Colonic transit time was delayed, but the delay was accounted for by prolonged rectal transit time. The mean volume at which anal relaxation first occurred were 12 ml (range 5~15 ml). The mean threshold volume at which these patients experienced rectal sensation were 90 ml (range 60~130 ml). Biofeedback conditioning in these 13 patients led to normal sensory threshold (mean 20m1, range 10~30 ml) in all patients. Biofeedback also provided spontaneous good passage of stool. Conclusion : Biofeedback treatment appears to be effective in impaired rectal sensation after cerebrospinal operation. Also central neural mechanism may be involved in the pathogenesis of anismus.

Biofeedback Therapy for Patients with Rectocele.: Kim, Bong Soo , Hwang, Yong Hee , Choi, Kun Pil; J Korean Soc Coloproctol. 2001;17(2):69-75.

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Abstract PDF: PURPOSE
The aim of this study was to determine the outcome and identify predictors of success of biofeedback therapy for rectocele.
METHODS
Twenty four female patients (mean age 43.8 years) with rectal emptying difficulties and a rectocele greater than 2 cm at defecography were evaluated before hand with a standardized questionnaires, immediately after biofeedback therapy, and at follow up. Defecography, manometry, colon transit studies and electrophysiology were also analyzed.
RESULTS
Follow up (mean 7.2; range 2~17 months) results were evaluated by an independent observer in 20 patients. At the end of biofeedback, 22 (92 percent) patients felt improvement in symptoms, including 13 (54 percent) with symptomatic relief. At follow-up, 14 (70 percent) patients felt improvement in symptoms, including 3 (15 percent) with complete relief of symptoms. There was a significant reduction in difficult defecation (from 79 to 29, 40 percent, from pre-biofeedback to post-biofeedback, at follow-up respectively; P<0.001, P<0.05), sensation of incomplete defecation (from 96 to 46, 60 percent; P<0.001, P<0.005), laxative use (from 54 to 25, 30 percent; P<0.05), enema use (from 21 to 0,0 percent; P<0.05), anal pain (from 21 to 0, 5 percent; P<0.05) and digitation (from 21 to 4, 5 percent). Normal spontaneous bowel movement was significantly increased from 50 percent pre-biofeedback to 83 post-biofeedback (P<0.05), 65 percent at follow-up. Abdominal pain (P<0.05) and digitation (P<0.05) related to poor results. High mean squeeze pressure (P<0.001) and high maximum squeeze pressure (P<0.05) on pre-biofeedback manometry were also related to a poor outcome. Age, duration of symptoms, parity, number of sessions of biofeedback, gynecologic surgery history, and rectocele size at defecography had no prognostic value. Anismus and colonic inertia did not influence the outcome of biofeedback.
CONCLUSIONS
Biofeedback is an effective treatment option for patients with obstructed defecation due to rectocele.

Biofeedback Therapy in Patients with Nonrelaxing Puborectalis Syndrome: Are there differences of therapeutic effect according to methods of diagnosis?.: Jeong, Jae Heon , Choi, Jeong Seok , Seo, Yong Jun , Kim, Jun Hyun; J Korean Soc Coloproctol. 2001;17(1):26-32.

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Abstract PDF: PURPOSE
To evaluate therapeutic effect of biofeedback therapy according to methods of diagnosis in patients with norelaxing puborectalis syndrome.
METHODS
From September, 1, 1998 to February, 30, 1999, the patients who were diagnosed with norelaxing puborectalis syndrome on anal electromyography (EMG) and/or cinedefecography (CD) underwent biofeedback therapy. The patients were divided into 3 groups according to the diagnostic method; CD group - only diagnosed on cinedefecography, EMG group - only diagnosed on anal electromyography, CD EMG group - diagnosed on both tests.
RESULTS
Nineteen patients were diagnosed nonrelaxing puborectalis syndrome on CD and/or EMG. There were 14 females and 5 males with a mean age of 40.8+/-18.4 years. The patients were classified into CD group; five patients (26.3%); EMG group, eight patients (42.1%); CD EMG group, six patients (31.6%). The patients had 5.4 3.7 sessions of outpatient EMG-based biofeedback sessions. Subjective symptoms after biofeedback therapy improved in 4 (80.0%), 6 (75%), 5 (83%) patients in CD, EMG, CD EMG groups, respectively. There was a statistically significant increase in spontaneous bowel movements, and a reduction in assisted bowel movements after biofeedback therapy in patients in all three groups (p<0.05). However, no significant difference was found among the three groups.
CONCLUSION
This study demonstrated that biofeedback therapy had a high therapeutic effect regardless to the diagnostic method. Therefore, biofeedbck therapy can be performed if one test results in the diagnosis of norelaxing puborectalis syndrome in patients with constipation.

Clinical and Physiologic Study of Encopresis.: Chung, Soon Sup , Kwon, Jae Bong; J Korean Soc Coloproctol. 2000;16(3):171-176.

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Abstract PDF: The pathophysiology of pediatric encopresis has been incomprehensible. The current study was designed to assess its clinical and physiologic findings. Moreover, outcome of treatment was evaluated.
METHODS
The clinical and functional findings of 18 patients (13 boys, 5 girls) were analyzed, retrospectively. Physiologic studies for cooperative child included anal manometry (n=12), cinedefecography (n=3), and PNTML (pudendal nerve terminal motor latency, n=1). For exclusion of the organic cause, barium contrast study was carried out in all case. Patients were categorized by leading symptom as constipation or incontinence. Physiologic findings and outcome of treatment were analyzed based on the categorized groups. Biofeedback therapy by using newly-developed anal sphincter control system (KONTINENCE CLINICAL(TM)) in my institute, was underwent a mean 4.1 (range, 2~12) sessions. The outcome was analyzed in the period of 5.4 (range, 1~33) months follow-up.
RESULTS
Patients were categorized as having constipation (group I, n=12) or incontinence (group II, n=6) group. In the manometric parameters, there were no statistical differences between the values of the mean resting pressure (RP), the maximum RP, and the maximum voluntary contraction between group I and II. In the cinedefecography, 3 of group I patients revealed as having the pelvic floor dyssynergia. The findings of PNTML were not specific in group II (n=1). Regarding to the therapeutic outcome, 8 of 10 patients were cured or improved.
CONCLUSIONS
There were no differences in the resting and squeeze profiles of manometric parameters between two groups. However, pelvic floor dyssynergia was identified in the cinedefecography of constipated group. Conventional and biofeedback treatment for encopretic children provides acceptable outcome.

Review

Biofeedback Therapy in Patients with Functional Evacuation Disorders.: Park, Ung Chae; J Korean Soc Coloproctol. 2003;19(4):260-269.

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Abstract PDF: Biofeedback therapy has emerged as a useful adjunct for patients with functional evacuation disorders over the past decade. The goals of biofeedback retraining may vary and could depend on the underlying dysfunction. In patients with obstructive defecation, the goals are to relax the anal sphincter, improve rectoanal coordination, and improve sensory perception. Methods of biofeedback therapy varied widely between centers. However, no difference was described when EMG-based biofeedback was compared to manometry-based biofeedback, or when visual or auditory feedback was given. In regards to biofeedback adjuncts, including sensory retraining with either an intrarectal balloon, a portable home-training unit or both can be practicable. There are inconsistencies in the literature regarding the patient selection criteria for biofeedback treatment. The patient group is not homogeneous. Different case selection, different regimens and different methods of biofeedback may explain the variability in success rate. Quality research that would assist in predicting outcome is still lacking. Although no specific denominator could possibly be assigned to correctly predict the overall outcome of therapy, biofeedback is not successful in all patients with outlet obstructed constipation. Results with success rates is ranging from 8.3 percent to 100 percent. The treatment of constipation by biofeedback has been viewed with some skepticism as the low success rate may simply be a placebo effect. The majority of scepticism to therapeutic outcome are derived from entry criteria for treatment. Lower success rates have been described when entry criteria were broadened. Prebiofeedback clinical findings which are presupposed to prognostic relevance are age, gender, duration of symptoms and presence of rectal pain, lower motor neuron disease, and psychiatric problems. I feel strongly that informations about the predictive factors are vital to all physicians either performing or recommending biofeedback to their patients. If biofeedback could be undertaken according to specific criteria, we, colorectal surgeon will save a fruitless endeavour, one would expect more improvements in more patients. Additional well-designed controlled trials are needed to establish the clinical and physiologic factors.

Original Articles

Development of Second Stage Software in the Anal Sphincter Control System Based on the Anal Electromyography, and Investigation of Therapeutic Outcome of the Patients withChronic.: Park, Ing Chae , Seong, Moo Kyung , Chung, Soon Sup , Kim, Jong Jun , Park, Seung Hun; J Korean Soc Coloproctol. 1999;15(4):281-290.

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Abstract PDF: To eliminate the inconvenient shortcomings of our formerly designed system for the biofeedback treatment, the development of second stage software was indispensable. PURPOSE: The aims of current study were to supplement the prototype software, and to improve the application software for the database management system. Moreover, we assessed the practical value and outcome of biofeedback therapy for the patients with functional evacuation disorders by using the upgraded system.
METHODS
A new system was worked out a design to be composed of Windows based GUI (graphical user interface), DB (database) management software, and networking system. Main software performs a signal processing and a protocol making mode to train pelvic sphincter. DB program administers patient profiles and the recorded signal data. Networking system was designed to execute RS-232C serial communication of signal data with use of fast ethernet LAN networking. To affirm the reproducibility of signal display for the clinical practice, system was applied to 5 healthy volunteers. To evaluate the practical appraisal, system was applied to 27 patients with functional evacuation disorders who were undertaken anorectal physiologic tests. Patient groups were categorized as nonrelaxing puborectalis group (group I, n=17), incontinencegroup (group II, n=10). Overall patients were underwent a mean 3.7 (range, 2~10) sessions of biofeedback treatment, and the outcome was analysed in the period of 5.8 (range, 3~12) months follow-up.
RESULTS
Signal data not having drift or noise were adequately processed and displayed in a real time. Specifically, data upload with use of multi-processing overay display function was appropriately embodied. Overall data and profiles of patients groups were safely saved, sorted, and reproduced by using the upgrading database management software. Regarding to the therapeutic outcomes, 63 percent of 27 overall patients (12 of 17 patients in group I, 5 of 10 patients in group II) were improved. The subjective symptoms of 2 patients in group I were recurred in a period of 3 months follow-up.
CONCLUSIONS
Hardware and software functions of upgraded system were applicable to the Windows environment of personal computer. A developed system with second stage software made it possible to perform biofeedback treatment. Specifically, current results could be useful for the improvement of the motivation and patient's willingness in the self-learning process of biofeedback treatment.

Role of Anorectal Physiologic Studies for the Diagnosis and Treatment of Non- relaxing Puborectalis Syndrome.: Kim, Nam Hyuk , Hwang, Yong Hee , Choi, Kun Phil; J Korean Soc Coloproctol. 2003;19(4):221-228.

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Abstract PDF: PURPOSE
To assess the effectiveness of cinedefecography (CD), anal electromyography (EMG), and anal manometry (ARM) for the diagnosis of non-relaxing puborectalis syndrome (NRPR) and to compare the outcomes for patients after biofeedback therapy (BF).
METHODS
The clinical criteria used in this study for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. Patients who satisfied the clinical criteria were evaluated by use of anorectal physiology tests: CD, EMG, and ARM. The EMG criteria included failure to achieve a significant decrease in the electrical activity of the puborectalis (PR) during attempted evacuation. The ARM criteria included failure to achieve a significant decrease in intra-anal pressure during attempted evacuation. The CD criteria included either paradoxical contraction or failure of the PR to relax together with incomplete evacuation. Other possible etiologies for incomplete evacuation, such as rectal intussusception or rectocele, were excluded in all cases. Fifty-eight constipated patients diagnosed as having NRPR by at least one of anorectal physiolosic tests had more than one BF session. The outcomes for fifty-one patients (mean age, 44.8 years; male-to-female ratio, 22:29) were reported as either improved or unimproved at a mean follow-up of 12.7 (range, 2~30) months. The sensitivities, the specificities, and the positive and negative predictive values for the CD, EMG, and ARM diagnoses of NRPR were calculated to assess the diagnostic accuracy of each test and to identify predictors associated with the outcome of BF.
RESULTS
The sensitivities of EMG, CD, and ARM were 96%, 89%, and 85%, respectively (P>0.05). The positive predictive values of the three tests were 63% for EMG, 52% for ARM, and 51% for CD (P>0.05). The negative predictive values of the three tests were 90% for EMG, 43% for ARM, and 25% for CD (P<0.05). The specificities of the three tests were 38% for EMG, 13% for ARM, and 2% for CD (P<0.05). The positive predictive values the two-study-positive groups and the three-study-positive group were 63% for the EMG- and ARM-positive group, 61% for the CD- and EMG-positive group, 51% for the CD- and ARM-positive group, and 61% for the three-study- positive group (P>0.05).
CONCLUSIONS
A combination of the CD and the EMG tests is suggested for the diagnosis of NRPR.

The Effectiveness of Biofeedback Therapy for Children Patients with Chronic Constipation.: Jung, Sang Ho , Kim, Jong Tae , Cho, Hyun Un , Go, Hong Jun , Jung, Gwang Gun , Park, Soon Tae , Ha, Woo Song , Hong, Soon Chan , Lee, Young Joon , Lee, Byung Ju , Choi, Sang Kyung; J Korean Soc Coloproctol. 2003;19(3):137-143.

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Abstract PDF: PURPOSE
Chronic constipation is not uncommon even in children. Recently biofeedback treatment (BT) is considered as a useful modality in the treatment of various types of constipation. The aim of this study was to evaulate the effectiveness of BT in children with chronic constipation.
METHODS
We reviewed 24 cases of childhood constipation (17 boys, 7 girls) who visited the Jinju Hakmoon colorectal surgery clinic and GNUH1 between April, 2001 and September, 2002. Balloon-mediated anorectal manometry system was used for BT. The effects of therapy was assessed by bowel movement, defecation time, fecal soiling and balloon evacuation test in the early course of therapy. The long term follow up survey was done by telephone interview at January 2003 and the effects of therapy was assessed by bowel movement, defecation time, fecal soiling and parents' satisfaction.
RESULTS
Patients received the BT for the three times on average, and as the result of the therapy, 20 patients experienced disappearance of symptoms (87%) or at least improvement of symptoms. In terms of manometric values, the mean resting pressure was 113.4 mmHg before the BT, but decreased to 86.3 mmHg after the BT (P=0.0012). Mean pushing pressure dropped to 85.98 mmHg from 130.45 mmHg (P=<0.0001). Mean sensitivity decreased from 55 ml to 35 ml (P=0.0053). Mean compliance decreased from 20.28 H2O/cm to 4.21 H2O/cm (P=0.0015). 13 patients (76%) showed disappearance or improvement of symptoms in the long term follow up.
CONCLUSIONS
The Balloon mediated biofeedback therapy is effective in children with chronic constipation. It is safe, easy to administer and also improve symptoms and objective parameters of anorectal function. Balloon mediated biofeedback therapy could be the first-line therapy in child patient with chronic constipation who failed conservative management.

Outcome and Prognostic Factors Associated with Poor Outcome of Biofeedback Therapy for Constipated Patients with Non- relaxing Puborectalis Syndrome.: Baek, Soon Mann , Kim, Nam Hyuk , Hwang, Yong Hee , Kim, Kyong Rae , Choi, Kun Pil; J Korean Soc Coloproctol. 2003;19(2):74-81.

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Abstract PDF: PURPOSE
Biofeedback is a major treatment method for constipated patients with non-relaxing puborectalis syndrome. However a significant percent of patients still showed poor outcome, and little has been known about the predictors associated with outcome of biofeedback. The aim of this study was to determine the outcome and identify predictors associated with poor outcome of biofeedback therapy for constipated patients with non- relaxing puborectalis syndrome.
METHODS
Fifty-two constipated patients with non-relaxing puborectalis syndrome (median age, 47 years) who had more than one biofeedback session after defecography were evaluated by standardized questionnaire, before, immediately after treatment, and at follow-up. Clinical bowel symptoms and anorectal physiological studies were analyzed. Any differences in demographics, clinical symptoms, and parameters of anorectal physiological study were evaluated between success group (patients felt improvement in symptoms at follow-up) and failure group (patients felt no improvement).
RESULTS
Follow up (mean follow-up; 17 months) results were evaluated by an independent observer in 45 patients. At post-biofeedback, 42 (81 percents) patients felt improvement in symptoms, including 7 (13 percents) with complete symptom relief. At follow-up, 25 (56 percents) patients felt improvement in symptoms, including 1 (2 percents) with complete symptom relief. There was a significant reduction in difficult defecation (from 81 to 44, 53 percent, from pre-biofeedback to post-biofeedback, and at follow up respectively; P<0.005, P<0.01), sensation of incomplete defecation (from 90 to 50, 40 percent; P< 0.00001, P<0.000005), laxative use (from 25 to 10, 11 percent; P<0.05), and enema use (from 13 to 0, 2 percent; P<0.01, P<0.05). Normal spontaneous bowel movement was increased from 42 percent pre-biofeedback to 81 percent post-biofeedback (P<0.0001), 80 percent at follow up (P<0.0005). Pre-biofeedback presence of symptoms of bowel habit change predict poor outcome (15 vs. 0 percent; failure vs. success, P<0.05). High pressure zone in prebiofeedback manometry was longer in failure group than in success group (2.80 vs 2.01 cm, P<0.05). In the success group, 11 (44 percent) had a rectocele, 1 (4 percent) had a rectal intussussception, 18 (72 percent) had a descending perineal syndrome, and 3 (12 percent) had a sigmoidocele. In the failure group, 4 (20 percent) had a rectocele, and 1 (5 percent) had a rectal intussusception, 14 (70 percent) had a descending perineal syndrome, and a sigmoidocele was not accompanied (P<0.05). Accompanied rectocele, rectal intussusception, descending perineal syndrome, and sigmoidocele did not influence outcome.
CONCLUSIONS
Biofeedback is an effective option and should be considered as the first line therapy. Bowel habit change and long high pressure zone in pre-biofeedback manometry were predictors associated with poor outcome of biofeedback therapy for constipated patients with non-relaxing puborectalis syndrome.

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