Intended for healthcare professionals

Clinical Review

Biofeedback for pelvic floor dysfunction in constipation

BMJ 2004; 328 doi: (Published 12 February 2004) Cite this as: BMJ 2004;328:393
  1. G Bassotti, deputy chief (,
  2. F Chistolini, gastroenterology fellow1,
  3. F Sietchiping-Nzepa, gastroenterology fellow1,
  4. G de Roberto, gastroenterology fellow1,
  5. A Morelli, professor of gastroenterology and chief1,
  6. G Chiarioni, deputy chief2
  1. Gastroenterology and Hepatology Section, Department of Clinical and Experimental Medicine, University of Perugia, Via Enrico Dal Pozzo, 06100 Perugia, Italy,
  2. Gastrointestinal Rehabilitation Division, Valeggio sul Mincio Hospital, Azienda Ospedaliera and University of Verona, Valeggio sul Mincio (VR), Italy
  1. Correspondence to: G Bassotti, Strada del Cimitero, 2/a, 06131 San Marco

    Pelvic floor dyssynergia is one of the commonest subtypes of constipation, and the conventional treatment (dietary fibre and laxatives) is often unsatisfactory. Recently biofeedback training has been introduced as an alternative treatment. The authors review the evidence for this approach and conclude that, although controlled studies are few and open to criticism, about two thirds of patients with pelvic floor dyssynergia should benefit from biofeedback training


    Chronic constipation is a common self reported gastrointestinal problem that affects between 2% and 34% of adults in various populations studied. Among the subtypes of constipation, obstructed defecation seems particularly common, occurring in about 7% of the adult population.1 In most people with this conditionan inappropriate (paradoxical) contraction or a failed relaxation of the puborectal muscle and of the external anal sphincter often occurs during attempts to defecate (fig 1). This paradoxical contraction of the pelvic floor muscles during straining at defecation is considered a form of maladaptive learning and is generally defined (without specifying the underlying pathophysiological mechanism) as outlet dysfunction constipation or, more precisely, pelvic floor dyssynergia.2

    Fig 1

    Anorectal manometric tracings of a normal subject (upper tracing) and a patient with pelvic floor dyssynergia (lower tracing) during straining at defecation (arrows). Note that the normal subject relaxes the anal sphincter, whereas the patient displays a paradoxical contraction of the sphincter

    Cardinal symptoms of pelvic floor dyssynergia are straining at stools and feelings of incomplete evacuation, and the diagnostic criteria, recently updated in the Rome II report, include those for functional constipation (see box)3 plus at least two out of three investigations (radiology, manometry, and electromyography) showing inappropriate contraction or failure to relax the pelvic floor muscles during attempts to defecate.2

    Summary points

    Obstructed defecation is a common subtype of constipation that may not be responsive to treatment with laxatives and dietary …

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