99

Pelvic Floor Rehabilitation in the Treatment of

Fecal Incontinence
Kelly M. Scott, MD1

1 Department of Physical Medicine and Rehabilitation, University of Address for correspondence Kelly M. Scott, MD, Department of
Texas Southwestern Medical Center, Dallas, Texas Physical Medicine and Rehabilitation, University of Texas
Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX
Clin Colon Rectal Surg 2014;27:99–105. 75390-9055 (e-mail: [email protected]).

Abstract Fecal incontinence (FI) is a prevalent problem that can drastically affect quality of life.

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Pelvic floor rehabilitation is an important first-line treatment for patients with FI, and
many published case reports and a small number of randomized controlled trials (RCTs)
provide limited evidence for its efficacy. Pelvic floor rehabilitation approaches to the
treatment of FI include pelvic floor muscle training, biofeedback, and volumetric
training with rectal balloon catheters. Various forms of external electrical stimulation
Keywords have also been described and may be of added benefit. Behavioral bowel retraining is an
► fecal incontinence important part of a good rehabilitative approach as well. Pelvic floor rehabilitation
► pelvic floor muscle treatment for FI is thought to be effective and safe, with reported success rates in a
training majority of studies at 50 to 80%. Many more high-quality RCTs are needed to define
► biofeedback optimal treatment protocols.

CME Objectives: On completion of this article, the reader significant benefit to the use of a rehabilitative approach—the
should be familiar with pelvic floor rehabilitation for fecal majority reports a response range of 50 to 80%.5 There has
incontinence. only been one published nonrandomized study which re-
ported no benefit to treatment.6 The patients in that study
Fecal incontinence (FI) is defined as the involuntary loss uniformly had FI due to a neurogenic etiology, which might
of liquid or solid stool that is a social or hygienic problem.1 contribute to the lack of demonstrated benefit from pelvic
Prevalence has been reported at 2 to 24% of the adult rehabilitation.
population,1 with 1 to 2% experiencing significant impact Understandably, there can be a publication bias toward
on daily activities.2 Treatments include conservative meas- studies with positive results when no randomization has
ures such as dietary modifications, medications, and pelvic occurred, and it is important to therefore expand research
floor rehabilitation, as well as more invasive approaches into the area of randomized controlled trials (RCTs) to dem-
such as the use of perianal injectable bulking agents, sacral onstrate true efficacy. There have been a small number of
nerve stimulation, or surgery.3 Many patients prefer to RCTs on pelvic floor rehabilitation for FI, less than 30 in total of
avoid the risk of interventions, and a stepwise approach high quality, according to two recently published Cochrane
to treatment has been advocated to minimize injury to reviews on the topic.7,8 These RCTs vary widely in terms of
patients.4 treatment protocols and typically had small sample sizes, but
Pelvic floor rehabilitation has been used successfully in the for the most part also showed clear benefit for rehabilitative
treatment of FI, and can produce significant functional and treatments.9 There have been no significant risks reported to
quality of life benefits for patients.6 Most of the reported the patient beyond that of time investiture and financial
literature in this area have been in the form of case reports expense. The goal of this review is to summarize the current
and nonrandomized prospective trials. In fact, more than 70 research and describe the different options available for
such uncontrolled studies have been published, with a great rehabilitative treatment of the pelvic floor in the manage-
range of treatment protocols. Almost all these studies show a ment of FI.

Issue Theme Fecal Incontinence; Copyright © 2014 by Thieme Medical DOI http://dx.doi.org/
Guest Editor, J. Marcus Downs, MD Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0034-1384662.
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Tel: +1(212) 584-4662.
100 Pelvic Floor Rehabilitation in the Treatment of FI Scott

Pelvic Floor Rehabilitation Pelvic Floor Muscle Training

Pelvic floor rehabilitation is a term which comprises many PFMT describes any number of different approaches for
different therapeutic approaches, including but not limited to increasing strength, endurance, and coordination of the
electromyographic (EMG) biofeedback-guided pelvic floor pelvic floor and anal sphincters. Thoracoabdominopelvic
muscle training (PFMT), which is currently the most widely muscle training has also been advocated, as it has been
used rehabilitative treatment modality. Pelvic floor rehabili- theorized that training all core muscles to work in tandem
tation is typically performed under the guidance of a pelvic would be more effective than a narrow focus on the pelvic
floor physical therapist, although nurses, physicians, and floor muscles alone.15 Particular attention is often paid to the
other staff can receive training to perform many of these transversus abdominus in such expanded approaches. PFMT
interventions. The different rehabilitative techniques can be typically consists of verbally guided instruction in pelvic floor
used independently, but more frequently are used in con- and sphincter contractions (Kegel contractions).16 Patients
junction with one another in a multimodal approach to can be taught to contract in a variety of ways—some examples
produce the maximum benefit for the patient.9 The primary include maximal voluntary sustained sphincter contractions,

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goal of all forms of pelvic floor rehabilitation is to improve submaximal sustained contractions, and fast-twitch or
pelvic floor and anal sphincter muscle strength, tone, endur- “quick-flick” contractions.15,17 A commonly reported PFMT
ance, and coordination to effect a positive change in function technique is to compare the pelvic floor to an elevator, able to
with a decrease in symptoms. Additional goals include in- stop at different floors as it ascends and descends.16 Other
creasing the patient’s awareness of their own muscles, im- reported methods include working on coordination of anal
proving rectal sensitivity, and reducing scar burden to allow sphincter activity and working to isolate a contraction of the
for improved muscle function. anal sphincter.17 Some practitioners use their hand placed
Pelvic floor rehabilitation techniques include bowel man- externally, or a digit placed vaginally or rectally to help
agement education and retraining, PFMT, biofeedback thera- instruct the patient in the correct exercise techniques, but
py (BFT), the use of electrical stimulation, and manual most would argue that this constitutes a form of low-tech
myofascial release and connective tissue mobilization biofeedback training.
techniques. Only one clinical trial, by Norton et al in 2003, compared
pelvic rehabilitation to a bowel education and retraining
program.17 This study demonstrated comparable benefit in
Bowel Management Education and
all treatment groups, and the authors concluded that no
Retraining
added benefit was seen with pelvic rehabilitation compared
The incorporation of lifestyle education into the therapeutic with education alone. However, the education treatment
treatment program is of vital importance for patients with FI. group received instruction in a “bowel urge resistance pro-
Such training can certainly be done apart from or instead of gram” which included training to hold stool in the rectal vault
the other pelvic floor rehabilitation approaches described while sitting on the toilet for increasing amounts of time. It is
below, but it is thought that the best results occur when both not clear whether such urge suppression techniques are
are undertaken simultaneously. The patients in many of the substantially different from pelvic floor muscle strength
published studies on FI and rehabilitation are typically, training with sustained submaximal contractions, and there-
therefore, instructed in basic behavioral and bowel retraining fore this study’s reported conclusions of no benefit from PFMT
principles alongside undergoing pelvic rehabilitation apart from educational instruction may not be valid.
methods.7 PFMT without the concurrent use of biofeedback has been
Bowel education and retraining can include many different well established for use in patients with urinary inconti-
aspects. A focus on lifestyle modifications including instruc- nence.16 However, there have not been many trials that have
tion as to optimal fluid intake and dietary adjustments can be looked at PFMT apart from biofeedback training in the
important in certain patient populations.10 Patients with treatment of FI. Three studies have shown digitally taught
irritable bowel syndrome and FI, for example, often find PFMT to be equivalent to PMFT combined with
that regulating dairy, gluten, and fiber can be an important biofeedback.17–19
component of controlling their stool leakage.11 It is generally Only one RCT has been done to evaluate the difference
recommended that all patients with FI increase their fiber between varied types of pelvic floor exercises.19 Bartlett et al
intake, as Bliss et al were able to demonstrate that fiber in 201115 found no difference in outcomes between two
supplementation significantly reduced the rate of FI.12 Be- separate PFMT techniques, both trained with biofeedback
havior modification can also be explored with patients, guidance (sustained submaximal anal and pelvic floor exer-
including training on the establishment of a predictable cises vs. rapid squeeze plus sustained submaximal exercises).
pattern of bowel evacuation, timing of defecation relative to Both groups had significant improvement in FI.
activities to limit incontinent episodes, techniques to reduce
straining, proper defecation posture when sitting on the
Biofeedback Therapy
toilet, and fecal urge suppression techniques.6,10,13 Weight
reduction is typically encouraged, as obesity is a well-docu- BFT is a term that can be used to describe many different types
mented risk factor for the development of FI.14 of training regimens for the pelvic floor. Biofeedback is

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 Pelvic Floor Rehabilitation in the Treatment of FI Scott 101

defined as the process of gaining greater awareness of many as commonly studied in recent decades as it was in the past.
physiological functions, primarily using instruments that More recent studies have referred to “coordination training”
provide information on the activity of those same systems, instead as a combination between motor skills training and
with a goal of being able to manipulate them at will.20 BFT has sensory discrimination training.24,26
been used in medicine for more than 30 years and has been
used for the treatment of FI since as early as 1974.21 For pelvic
Summary of Selected Biofeedback Trials
floor rehabilitation purposes, the most common type of
biofeedback is EMG BFT, which was first introduced in Ilnyckyj et al in 2005 looked at anal sphincter exercises plus
1979.22 Data are recorded either through surface electrodes biofeedback plus education versus exercises and education
or via the use of intravaginal or intrarectal sensors. Other alone in a group of 18 women.18 Exercises were taught with
forms of pelvic floor BFT include the use of ultrasound (either verbal and written instructions in the education group. The
intrarectal, intravaginal, or perineal); rectal balloons; digital biofeedback group was instructed in how to do the exercises
guidance (the use of an intrarectal/intravaginal finger or hand with visual manometric, physical (hand), and verbal cueing.
placed on the perineum); and anorectal manometry.7,23 No differences were found between the groups, and overall

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There are three main approaches in how biofeedback is 61% of participants demonstrated a complete response.
used as a part of pelvic floor rehabilitation for FI.7 The most Norton et al in 2003 demonstrated no difference between
common type is for strength and endurance training for the three groups who were all taught the same pelvic floor
pelvic floor and/or anal sphincter. The biofeedback apparatus exercises.17 One group was taught exercises only, one group
gives information about how strongly the muscles are being was taught exercises with the use of a hospital-based, com-
contracted, and the patient can use that information to learn puter-assisted sphincter pressure biofeedback device, and
how to do the pelvic floor exercises more effectively. It is also one group was instructed in hospital biofeedback-guided
thought that biofeedback motivates the patient to improve by exercises along with the use of a home EMG biofeedback
giving information on performance and progress. The theory device. All groups demonstrated improvement in around 50%
behind strength and endurance training is that if the sphinc- of participants.
ter muscles are stronger, the patient will be able to hold in the Solomon et al in 2003 randomized 120 patients to one of
stool for a longer period of time and enable them to make it to three groups—manometric biofeedback, ultrasound-guided
the restroom with less accident. biofeedback, or pelvic floor exercises taught via digital exam-
The second treatment modality is to use BFT to improve ination with verbal guidance alone.19 They also did not find a
rectal sensitivity or compliance. This type of treatment has statistically significant difference between their groups, and
also been termed volumetric rehabilitation or discrimination approximately two-thirds of patients in all groups had a
training and is typically done with rectal balloons.24 The clinical benefit.
balloon is inflated with air or water to determine the first Heymen et al in 2009 looked at whether the addition of
sensation of rectal filling. It is then gradually inflated with manometric biofeedback-guided rectal balloon sensitivity,
decreasing amounts of air or water to teach the patient to strength, and coordination training to a standard PFMT
appreciate stool in the rectal vault at progressively lower program would improve continence.26 Biofeedback training
volumes. The rationale behind sensory retraining is to allow resulted in greater reduction in FI severity and days with FI. At
the patient to detect smaller volumes of stool at an earlier the 3-month follow-up, 76% of patients treated with BFT
time, again making it possible for them to reach the restroom versus 41% of patients treated with pelvic floor exercises
before an accident occurs. It also allows for the patient to have reported adequate relief. Benefit to the biofeedback group
more time to perform a voluntary anal sphincter contraction carried over into the 12-month follow-up as well.
before the volume of stool in the rectal vault overwhelms the Miner et al in 1990 conducted a study of 25 patients in
patient’s ability to hold it inside. Rectal balloons can also be which they compared rectal balloon training with sensory
used on patients with fecal urgency and rectal hypersensitiv- biofeedback to a “sham retraining” group which performed
ity—the balloons are in those cases simply inflated to pro- the same balloon maneuvers without any feedback or in-
gressively larger volumes, which the patient is then coached struction from the therapist.27 They found that the biofeed-
in how to tolerate without feeling the need to expel the rectal back group had reduced frequency of incontinence compared
contents.7 with the sham group, as well as reduced sensory thresholds
The third BFT approach deals with coordination training compared with the sham group (although both groups had
for the anal sphincter. Multiple balloons are again inserted—a improved thresholds). Miner et al subjected both groups to
large one in the rectum itself and one or two smaller ones in subsequent strength and coordination training, and they did
the anal canals. These are typically connected to a manomet- not find that this extra training significantly improved conti-
ric pressure-recording device. When the larger balloon is nence. At the end of their study, 50% of patients had no
inflated, the rectal–anal inhibitory reflex is triggered, and incontinence episodes at all and 76% of patients had reduced
the patient is taught to appreciate the momentary internal the frequency of incontinence episodes by more than 75%.
anal sphincter relaxation that results. The patient can then be They showed that the improvements seen were associated
taught to do a voluntary external sphincter contraction to with the improvements in rectal sensation in both groups,
counteract the involuntary relaxation of the internal sphinc- and were not associated with any change in sphincter pres-
ter.7,25 This type of coordination training does not seem to be sures or in the continence to rectally infused saline. They

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102 Pelvic Floor Rehabilitation in the Treatment of FI Scott

were able to demonstrate sustained improvement over Summary of Selected Trials Involving Both
2 years in 16 of the 22 patients who presented for follow-up. Biofeedback and Concurrent Electrical
A study by Bols et al conducted in 2011 looked at rectal Stimulation
balloon sensitivity training in addition to PFMT versus PFMT
alone.28 They randomized 80 patients. The PFMT in this study Fynes et al in 1999 studied 40 women with FI after obstetric
did not have any EMG biofeedback guidance and consisted of injury.34 Patients were randomized to two groups with quite
voluntary contractions and relaxations of the pelvic floor and different treatment protocols. One group received vaginal
anal sphincter in different starting positions. The PFMT was pelvic floor manometric pressure biofeedback and home
meant to improve strength, duration, timing, and coordina- exercises taught by a nurse. The other group received anal
tion of contractions. Both groups showed equal improvement EMG biofeedback and home exercises in combination with
in continence, and approximately 50% of all patients had anal electrical stimulation by a physical therapist. The group
clinically important change in their Vaizey continence score. receiving anal EMG biofeedback and electrical stimulation
They found that there was no benefit to adding the rectal showed improved incontinence and improved proportion of
balloon sensitivity training in terms of modifying the conti- patients who became asymptomatic compared with the other

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nence score; however, adding sensory retraining did lead to group. It is hard to determine what effect, if any, the actual
improvements in quality of life, external anal sphincter electrical stimulation had in this case, as the two groups had
fatigue, and maximal tolerable rectal volume. such different treatment protocols.
A systematic review of 46 previously published nonran- Mahony et al in 2004 compared intra-anal EMG biofeed-
domized trials on BFT and PFMT was conducted by Norton back alone versus intra-anal biofeedback that was augmented
and Kamm in 2001.29 A total of 1,364 patients were included with electrical stimulation of the anal sphincter in postpar-
in the review. A total of 49% were said to be cured of tum women with FI.35 Sixty women were randomized, and of
symptoms of FI following BFT and 72% were reported to be those, 52 had external anal sphincter defects. Both groups
cured or improved. However, only 8 out of the 46 studies demonstrated significant improvements in continence
employed a control group. A large retrospective review of 513 scores, anal squeeze pressures, and quality of life, and there
consecutive patients treated with biofeedback for FI was was no statistically significant difference between the groups.
published by Byrne et al in 2007.30 They demonstrated A couple of studies by Schwandner et al have looked at a
more than 70% of patients with improved short-term out- new type of combination treatment they termed triple target
comes, including decrease in incontinence scores by 32% and treatment or 3T. 3T consists of AM-MF stimulation, EMG-
quality of life improved by 89%. triggered AM-MF stimulation, and EMG biofeedback training.
The group has published a RCT comparing 3T to standard EMG
biofeedback in 2010 and another in 2011 comparing 3T to the
Electrical Stimulation
more standardly used LFS.33,36 The 2010 study was signifi-
Electrical stimulation is another modality that has been pro- cantly underpowered because less than 40% of their subjects
posed for the rehabilitative treatment of FI. The goal of electrical completed the 9-month treatment protocol, but the intention
stimulation is to enhance the strength and/or endurance of to treat analysis demonstrated improved continence in the 3T
striated muscle contraction—the target is typically the external group. The 2011 study showed statistically significant im-
anal sphincter in the case of patients with FI. Another goal can be provements in continence in the 3T group compared with
to allow patients with decreased kinesthetic awareness to standard LFS; however, the LFS group did not have EMG
become more cognizant of where their pelvic floor muscles biofeedback and the 3T group did. This 2011 study had more
are in space and what it feels like when the muscles and acceptable drop-out rates than the 2010 study, and was
sphincter are contracting. Electrical stimulation has been shown conducted for only 6 months instead of 9 months. The
to transform fast-twitch muscle fibers to slow-twitch muscle Schwandner group has also published further subgroup
fibers, which is thought to help with improving endurance.31 It analysis based on their 2010 study.37 They reported that
also increases capillary density, allowing more blood flow to the patients with sphincter damage and neuropathic anal incon-
oxidative slow-twitch fibers.32 Electrical stimulation can be tinence responded better to 3T than to EMG biofeedback
delivered to the pelvic floor and anal sphincter in many different alone. This is potentially significant because these patient
forms, including via surface electrodes or intrarectal probes and subgroups have traditionally not fared well in pelvic floor
with many different stimulation parameters and treatment rehabilitation studies, but more research is needed as to the
protocols. Low-frequency stimulation (LFS) has typically been effectiveness of 3T training, the optimal length of treatment
the norm, although a new form of amplitude-modulated medi- needed, and whether patients have the ability to be compliant
um-frequency (AM-MF) stimulation has recently been pro- with treatment over long time periods.
posed.33 All forms of electrical stimulation are often used in
conjunction with PFMT or biofeedback training, although stim-
Summary of Selected Trials Involving
ulation can be used without any other concurrent rehabilitative
Electrical Stimulation without Concurrent
treatment. Electrical stimulation can also be used to augment a
Biofeedback Training
volitional contraction once the contraction threshold reaches
a predefined level, and such a strategy has also been employed Osterberg et al in 2004 compared electrical stimulation to
in trials. levatorplasty and found that surgery afforded improved

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 Pelvic Floor Rehabilitation in the Treatment of FI Scott 103

incontinence at 3 months, but not at 12 or 24 months.38 There and fiber, and pelvic floor rehabilitation (pelvic floor exer-
was no difference in fecal urgency or use of pads between the cises with biofeedback provided by digital guidance only).
groups. Quality of life was greater in the surgical group at all Tjandra et al48 in 2008 found that sacral nerve stimulation
time points. significantly improved the number of incontinent episodes
Naimy et al in 2007 studied 40 women with FI after third- per week and incontinent days per week by the 12-month
or fourth-degree obstetric tears.39 The women were random- follow-up. Quality of life also improved significantly. This
ized to receive either EMG-guided biofeedback muscle train- study did not demonstrate any improvement in incontinence
ing or electrical stimulation delivered via anal probe. Each or quality of life in the group randomized to optimal medical
patient in either group had two sessions of instruction with a management, which does not match with the majority of
physical therapist, but then were left to complete the bio- reported RCTs showing a clear benefit for the medical man-
feedback or electrical stimulation for 20 to 30 minutes twice agement and rehabilitative approach. Again, more research in
daily on their own at home for 8 weeks. Neither group this area is needed.
improved in terms of Wexner incontinence scores nor in
terms of FI quality of life scores, and there was no statistical
Predictors of Success with Pelvic Floor

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significance between groups. Both treatments resulted in
Rehabilitation
improvement in patients’ subjective perception of inconti-
nence control. There have only been a few studies which have looked at
Norton et al in 2006 compared daily anal electrical stimu- which types of patients will most likely benefit from a
lation of two different frequencies—35 versus 1 Hz (which rehabilitative approach to treatment for FI. Good sphincter
they considered to be a “sham” treatment).40 Treatments function and mild to moderate symptomatology are consid-
were conducted daily for 8 weeks, and while 90 patients ered as more favorable prognostic factors.49 Disruption of the
participated in the study, only 70 completed it. On intention anal sphincter, spinal cord transection or other neurogenic
to treat analysis, there were no differences between the disorders, severe impairment of rectal sensory function,
groups in terms of any outcome measures, and 63% of patients cognitive impairments, severe depression or other mental
who completed treatment felt that it had improved their illness, and age younger than 6 years are all thought to be
symptoms at least somewhat. They speculated that improve- predictors of poor response to biofeedback and other reha-
ments in both groups were possibly related to improved bilitative treatments.24
rectal sensation rather than direct muscle strengthening, or
alternatively a placebo effect.
Discussion
A study by Healy et al in 2006 randomized 48 patients to
endoanal electrical stimulation with a home unit versus It is evident that more RCTs need to be conducted, but these
endoanal electrical stimulation plus augmented biofeedback early preliminary results seem to suggest that there is a
under supervision of a physical therapist.41 Both groups definite role for pelvic floor rehabilitation in the treatment
improved in terms of continence scores, manometric pressure of FI. Biofeedback pelvic floor training seems to be effective in
readings posttreatment, and quality of life. a majority of patients in most studies, although there is some
question as to whether the results are due to improved
strength and endurance of the anal sphincter and pelvic floor
Pelvic Floor Rehabilitation following
muscles, or whether the improvement can be attributed to
Surgery
improved rectal sensitivity. Electrical stimulation is also an
Only one randomized trial has been conducted on the use of area where more research is needed; however, there is a
pelvic floor rehabilitation following surgery for sphincter possibility that it can produce an added benefit when added
repair. Davis et al in 2004 compared anal sphincter repair to biofeedback training alone. Trials conducted to date have
with or without subsequent biofeedback training which was used widely divergent treatment protocols and therefore we
started 3 months postoperatively.42 There were 38 total do not have good evidence to suggest one type of rehabilita-
patients randomized in this small study. No difference was tive technique or training regimen as being superior at this
found between the groups regarding continence score at time.
9 months, patient satisfaction, or quality of life measures. It is important, as well, to consider the patient as an
In contrast, there have been many nonrandomized trials and individual and to understand that the causes of FI are varied,
retrospective reviews which have reported significant benefit even within the umbrella of pelvic floor dysfunction itself.
to BFT and pelvic floor rehabilitation after surgery.43–47 More Whitehead et al in 1985 demonstrated that 5 out of 18 of their
RCTs in this area are obviously needed. patients with FI had resolution of symptoms once their
underlying constipation was improved, and therefore it is
important to rule out and treat constipation in any patient
Pelvic Floor Rehabilitation versus Sacral
with FI.50 There is good empiric evidence that BFT and other
Nerve Stimulation
rehabilitative treatments can be very effective for constipa-
There has been one randomized trial comparing sacral nerve tion caused by outlet dysfunction, such as in those patients
stimulation to an “optimal medical management” program with nonrelaxing puborectalis syndrome.23,24 Such rehabili-
that included bulking agents, dietary management of fluid tative approaches to constipation and overactive pelvic floor

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104 Pelvic Floor Rehabilitation in the Treatment of FI Scott

muscles might include rectal balloon training for dyssynergia 13 Stokes G. Psychological approaches to bowel care in older people
or EMG biofeedback-guided relaxation training of overactive with dementia. In: Potter J, Norton C, Cottenden A, eds. Bowel Care
pelvic floor muscles.7,24 Terra et al in 2008 demonstrated that in Older People. London: Royal College of Physicians; 2002:97–109
14 Townsend MK, Matthews CA, Whitehead WE, Grodstein F. Risk
one positive predictor of successful outcomes with pelvic
factors for fecal incontinence in older women. Am J Gastroenterol
floor rehabilitation for the treatment of FI is the presence of 2013;108(1):113–119
perineal and/or perianal scar tissue on physical examina- 15 Bartlett L, Sloots K, Nowak M, Ho YH. Biofeedback for fecal
tion.51 Many pelvic floor therapists are skilled at manual incontinence: a randomized study comparing exercise regimens.
techniques for myofascial release and connective tissue mo- Dis Colon Rectum 2011;54(7):846–856
16 Bo K, Berghmans B, Morkved S, van Kampen M, eds. Evidence-
bilization. Moreover, the addition of these techniques to the
Based Physical Therapy for the Pelvic Floor: Bridging Science and
standard treatments described earlier could provide even
Clinical Practice. Edinburgh: Elsevier Ltd; 2007:171–178
more benefit for select patients who suffer from FI and 17 Norton C, Chelvanayagam S, Wilson-Barnett J, Redfern S, Kamm
have significant scarring of their pelvic floor muscles or MA. Randomized controlled trial of biofeedback for fecal inconti-
sphincters. More research into these areas is also needed. nence. Gastroenterology 2003;125(5):1320–1329
18 Ilnyckyj A, Fachnie E, Tougas G. A randomized-controlled trial

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
comparing an educational intervention alone vs education and
Conclusion biofeedback in the management of faecal incontinence in women.
Neurogastroenterol Motil 2005;17(1):58–63
Pelvic rehabilitation approaches including PFMT, biofeed- 19 Solomon MJ, Pager CK, Rex J, Roberts R, Manning J. Randomized,
back-guided strength and endurance training, biofeedback- controlled trial of biofeedback with anal manometry, transanal
guided rectal sensitivity and coordination training, and elec- ultrasound, or pelvic floor retraining with digital guidance alone in
trical stimulation can be effective tools in the management of the treatment of mild to moderate fecal incontinence. Dis Colon
Rectum 2003;46(6):703–710
FI. More research is needed to further define the role of
20 Durand VM, Barlow D. Abnormal Psychology: An Integrative
rehabilitation, predictors of good outcomes, and the most Approach. Belmont, CA: Wadsworth Cengage Learning; 2009:331
efficacious treatment protocols. 21 Engel BT, Nikoomanesh P, Schuster MM. Operant conditioning of
rectosphincteric responses in the treatment of fecal incontinence.
N Engl J Med 1974;290(12):646–649
22 MacLeod JH. Biofeedback in the management of partial anal
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