1. Case History Mrs. HA, 33 year old woman with urge incontinence following traumatic delivery. Patchy scarring external sphincter in mid anal canal. Internal sphincter intact. Pelvic floor exercises helped bladder. 4 sessions biofeedback over 5 months. Discharged symptom free. No symptoms at 3 years

2. Urgency with rapid fatigue

3. Sustained squeeze with no urgency after exercises

4. Fast-twitch to speed reaction

5. Home Exercises Need to practice a lot Attempt 10 times per day Start level depends on assessment Maximal, sub-maximal and fast-twitch Aim for 5 of each Often 4-6 weeks before start to benefit Up to 4-6 months for maximal benefit

6. Urgency Toilets are not available in many places Anxiety can trigger urgency Vicious circle develops: urge  panic  urgency  more panic  incontinence  panic more next time

7. Urge resistance Need to re-learn that urge will wear off if resisted Practice “holding on” – wait once feel the urge to defaecate Behavioural retraining - start on toilet if necessary, gradually increase distance

8. Rectal balloon distension Increase sensitivity OR decrease sensitivity (one report published) progressive distension to urge volume re-learn that urge wears off if resisted

9. RCT of biofeedback for FI (Norton et al, Gastroenterology 2003) Consecutive referrals for faecal incontinence biofeedback Anorectal physiology tests and ultrasound Diary and questionnaires with appointment 1 hour assessment (Norton & Chelvanayagam, 2000) If consented, allocation to one of four groups

10. Groups Group 1: up to six one hour sessions of information and advice (teaching, diet, fluids, medication titration, urge resistance, time and attention) Group 2: as Group1, add exercises taught digitally + leaflet with home exercises Group 3: as Group 2 + computer biofeedback at each session Group 4: as Group 3 + home biofeedback machine

11. Results 171 patients, median age 56 years 82% completion, similar between groups Median 5 sessions No differences detected between the groups on ANY of the outcome measures No suggestion of a trend in the direction of hypothesis

12. Outcome for all groups 80% improved to at least some extent, whatever treatment they were given FI, anxiety, depression, quality of life and sphincter function improved in all groups 62% patients rated their change as +3 or above (-5 to +5 scale); 18% unchanged or worse. Suggests biofeedback and exercises were not the operant for change So what DID improve symptoms? (Norton et al, Gastroenterology 2003)

14. Patients’ comments on outcome of Biofeedback We asked patients which aspect of the treatment helped the most Most commented in detail –Knowing I am not the only one with FI –Experimental intervention (whatever they were asked to do) –Understanding of the problem –Practical advice –Nurse-patient relationship

15. “I felt very involved in understanding what the treatment, symptoms etc are all about. This has helped me to be aware & understand more & take note of what is going on inside me” (Patient 34, Group 2).