Bowel management – how to help: Biofeedback may be helpful if first line measures have not worked
There are two broad categories of bowel symptoms, once red flags have been excluded; not going (constipation or obstructive defaecation) and not being able to stop going (faecal incontinence).
First line conservative care can be offered by any health care professional (HCP), from primary care practice nurse, GP, or pharmacist, to specialist teams comprising colorectal surgeons, gastroenterologists, bowel nurses and pelvic floor physiotherapists.
Essential first responses often include possible medication or diet causes, contributing mobility or pre-existing bowel habits, previous surgery or life changes.
We have noted that 60 to 70% of symptoms will improve when simple measures such as diet, fluids, and technique and position for evacuation are addressed.
This is often the stage at which proper laxative use can be guided, or loperamide use (to slow down rather than stop) can be outlined depending on whether constipation or incontinence is an issue.
These first line measures are very cost effective when delivered by the first clinician the patient sought help from.
“We have noted that 60 to 70% of symptoms will improve when simple measures are addressed”
Once onward referral is indicated and the patient attends for specialist care – for example with a specialist physiotherapist or nurse – management may include:
• Use of a bowel diary
• Assessment of obstetric trauma
• Pelvic floor power and strengthening exercises
• Splinting options for a rectocele
• Handheld rectal irrigation
• Consideration of possible internal rectal prolapse and concurrent bladder symptoms addressed.
For a small group of patients, bio-feedback may be offered as a specialist management.
The phrase bio-feedback is used very broadly – a careful rectal examination that encourages correct functional use of the muscles both for contracting and relaxing during strain is actually a form of bio-feedback. The patient will be actively engaged and through language, verbal feedback, repetition and communication this can re-train and re-educate. The shared goal would be for the patient to put into practice what they have learned and begin to see symptom improvement.
Sometimes the muscles that need retraining are inherently over active and it is a harder challenge to teach the process of ‘letting go’. Specialist therapists and nurses may offer a handheld device to indicate the muscle activity visually and facilitate the process of learning to let go. This may be through an electromyography unit or pressure sensitive manometry.
Other techniques may include training awareness of the whole zone around the pelvis and practising letting go via diaphragm, deep core muscles and pelvic floor. This harnesses the patient’s own awareness and does not require an external machine to illustrate the result.
There may be a need to reduce the sensitivity within the rectum and allow it to fill without great urgency. This usually requires use of the pelvic floor muscles to trigger a delay, or a holding on sensation. This technique can be adopted by the patient during real bowel urgency at home and sometimes it is practised in the form of rectal balloon catheters with or without visual feedback.
There are some centres that offer a series of repeated sessions using balloon catheters to help to re-educate release work of the muscles during expulsion and hold ability during filling.
Generally, any management option should be patient-centred and the effect reviewed regularly. Clinical experience shows us that for some patients, improvement is rapid, patient goals are met quickly and self-management achieved early. For others, repetition is needed and if progress is not achieved a review of the approach or escalation into a multidisciplinary team case review is indicated.
Sally Sheppard is Team Lead Women’s and Men’s Health Physiotherapy Service, Poole Hospital NHS Foundation Trust.
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