1. SUCCESSFUL TREATMENT OF OBSTRUCTED DEFAECATION WITH OUR HOLISTIC PROGRAM USING COMPUTER-ASSISTED VISUAL BIOFEEDBACK Kathryn Sloots BSc (Hons), RN Clinical Measurements Unit, Townsville Hospital, 100 Angus Smith Drive Townsville, 4814, Queensland, Australia Lynne Bartlett MPH School of Public Health, Tropical Medicine & Rehabilitation Science within the North Queensland Centre for Cancer Research, James Cook University, Townsville Qld 4811.

2. Obstructed Defaecation Definition Obstructed defaecation is difficulty with rectal evacuation (outlet dysfunction constipation, dyssynergic defaecation, puborectalis paradoxus) Symptoms - feeling of obstruction or blockage, may digitate to assist evacuation - straining, prolonged defaecation (>10 minutes) - incomplete evacuation, multiple attempts at evacuation

3. Obstructed Defaecation Causes - failure to appropriately relax the pelvic floor muscles (especially puborectalis) or the external anal sphincter (anismus) - weak muscles (pelvic floor or abdominal)i.e. inadequate push - inappropriate evacuation technique - altered rectal sensation Diagnosis (assessed by colorectal surgeon) - history, symptoms - anorectal manometry (sphincter pressures, RIR, rectal sensations) - transit marker studies, defaecating proctogram - exclude endocrine, metabolic, colonic disease, neurological causes

4. Aims of Treatment General Aims of treatment program: - improved rectal awareness and sensitivity - pelvic floor muscle control and relaxation - complete regular evacuation without straining Patient assessment of Aims: (first and final sessions) - questionnaire/s - personal goals - rating of bowel function

5. Education Advice Biofeedback Techniques Assessment Education & Advice: Encourages compliance with the treatment program All aspects of treatment are assessed and modified at each visit depending on the patient’s response Components of the holistic biofeedback program 1,2,4 An holistic approach

6. Computer-assisted visual and verbal biofeedback To guide relaxation and exercise techniques: - diaphragmatic breathing - muscle exercises - evacuation technique 2

7. Biofeedback: Session 1 Balloon positioned in rectal vault and inflated to volume of initial sensation to stimulate awareness and increase rectal sensitivity at each biofeedback session 2 Biofeedback exercises taught sequentially to achieve final result Diaphragmatic breathing technique 2,3 - increases parasympathetic input/activity - helps regulate bowel function (increases peristalsis, relaxes sphincters) - encourages general relaxation - helps patients focus on abdominal activity and breathing control

8. Diaphragmatic (relaxation) breathing

9. Biofeedback: Session 2 Pelvic Floor Muscle Exercises - patients may have adequate anal sphincter resting pressure and squeeze strength - recto-inhibitory reflex negative or positive - emphasis on relaxation - initial exercise regime may be rapid squeezes only until awareness and control improve and muscles relax correctly after squeezes - regime increased and adapted and endurance squeezes included as rectal sensitivity and awareness and muscle control improve 2

10. Muscle exercises Rapid anal sphincter squeezes promote -muscle awareness -muscle control -muscle relaxation -rectal awareness -rectal sensitivity 4 OD patients often comment that rapid squeezes are “harder to do” than endurance squeezes

11. Biofeedback Session 3 Defaecation Reflex - intrinsic myenteric and parasympathetic reflexes - triggers the urge to defaecate - stretch receptors (rectal sensitivity, awareness) - signal conduction (functioning nerve pathways) - muscle relaxation - involuntary (IAS) - voluntary (EAS, puborectalis) 5 Aided by - moist/soft bulky stool type - peristaltic waves - pelvic floor relaxation - correct defaecation technique - regular prompt routine

12. Relaxation of the puborectalis muscle 6

13. Evacuation technique Aim: improved rectal emptying without straining Continence Foundation of Australia recommended sitting position and evacuation technique 7 relaxation breathing alternated with evacuation technique 2 patience and consistent practice to re-educate bowel and develop new habits 2

14. Modification of treatment regime Individual symptoms or goals - unresolved urgency - faecal incontinence - rectal hyposensitivity - diet, fluids, supplements 1,2 Simulated defaecation training or recto-anal co-ordination training not required Adapt exercise regime and increase as able Further sessions if required

15. Final treatment session Assessment - anorectal manometry repeated - goals re-assessed and scored by patient - bowel function re-evaluated by patient - questionnaire repeated Exercise techniques – revised and regime increased Advice and long-term maintenance regime discussed

16. Results Data is presented as median improvement from first to final treatment sessions: Eypasch (Quality of Life) Questionnaire: Symptoms25% (P<0.001) Function13% (P<0.001) Emotion33% (P<0.001) Social 8% (P=0.003) Individual goals (patient-rated, out of 10): Complete evacuation/no straining3.0→8.5 (P=0.011) Regular bowel function/stool type1.0→8.5 (P=0.018) Others (bloating, flatulence, pain etc.) 1.5→9.0 (P=0.012) Overall bowel function score (patient-rated): 4.0→8.0 (P=0.002)

17. Patient-nominated goals, self-rated (out of ten)

18. Conclusion Multiple aspects of this holistic therapy interact to achieve outcome Treatment is tailored to patient’s individual needs and goals Visual monitoring of biofeedback techniques (muscle exercises and relaxation) improves awareness, control and confidence 4 Education and understanding, motivation and enthusiasm are vital Patients progress at individual rate as they respond to treatment 1,2

19. References and publications 1 Sloots K, Bartlett L. Practical strategies for treating postsurgical bowel dysfunction. J Wound Ostomy Continence Nurs. 2009 Sep-Oct;36(5):522-7. 2 Sloots K, Bartlett L, Ho YH. Treatment of postsurgery bowel dysfunction: biofeedback therapy. J Wound Ostomy Continence Nurs. 2009 Nov- Dec;36(6):651-8. 3 Bartlett L, Sloots K, Nowak M, Ho YH. Impact of relaxation breathing on the internal anal sphincter in patients with faecal incontinence. ANZCJ. 2012;18:38-45. 4 Bartlett L, Sloots K, Nowak M, Ho Y-H. Biofeedback for faecal incontinence: a randomized control study comparing exercise regimen. Dis Colon Rectum. 2011;54:846-856. 5 Marieb E N, Human anatomy and physiology 2 nd Ed. 2004, Benjamin/Cummings Pub. Co. Inc. 6 http://bodychange.net/2012/07/18/squatting-to-poop, accessed 11.10.2012http://bodychange.net/2012/07/18/squatting-to-poop 7 Central Coast Health, Continence Foundation of Australia in New South Wales