Biofeedback Therapy Improves Continence in Quiescent Inflammatory Bowel Disease Patients with Ano-Rectal Dysfunction

Abstract

Introduction : Despite optimal disease control and absence of objective markers of mucosal inflammation, fecal incontinence (FI) secondary to anorectal dysfunction is common, difficult to treat and significantly reduces quality of life (QoL) in quiescent Inflammatory Bowel Disease (IBD). Whilst biofeedback therapy (BFT) is an established treatment for FI, its role in IBD patients with anorectal dysfunction has not been explored. Methods: Retrospectively we reviewed all IBD cases referred for ano-rectal manometry (ARM) and BFT at our institution between 2009-2014. For each patient, data confirming IBD quiescence (endoscopic, histology, radiography and biochemistry), IBD phenotypes, medication, surgical and obstetric histories, baseline FI frequency, QoL scores (rated 0-10) and results of anorectal investigations were recorded. Patients were classified as responders or non-responders to BFT based on symptoms at follow-up. Results: Nine quiescent IBD patients (6/9 crohn's and 3/9 ulcerative colitis, median age 53, 7/9 females), with baseline median FI frequency 11.5/week and QoL score 6, had BFT following ARM. Manometrically, all had external anal sphincter weakness, 6/9 internal anal sphincter weakness, 2/9 with co-existing dyssynergic defecation and 8/9 had rectal hypersensitivity. Following a median 2 BFT sessions; 8/9 (89%) patients improved with reduced FI frequency (U=0.5, P=0.003) and 5/9 (56%) became fully continent. Conclusions: BFT appears to be just as effective for FI in IBD patients as it is in non-IBD populations and may have a role in restoring continence and QoL. This data highlights the importance of anorectal physiology studies in symptomatic patients once active inflammation is excluded. and significantly impair quality of life (QoL) (2-3). Despite this, there is recognized unmet clinical need for continence care in IBD (2) and failure to recognize anorectal dysfunction leads to underutilization of pelvic floor therapeutic services (4) and may lead to potentially premature treatment 'escalation' and prolonged, futile exposure to corticosteroid therapy (5). Potential mechanisms for anorectal dysfunction in the absence of active inflammation in IBD include; alterations in rectal wall compliance and calibre, widening of the pre-sacral space, altered rectal sensitivity and muscle tone and neuroplastic changes resulting in aberrant dysmotility, sensation, and secretion associated with gastrointestinal inflammation (both during and after) (5-6). Indeed, such alterations in anorectal function, have been demonstrated in physiological studies in both quiescent crohn's disease (CD) (7-8) and in ulcerative colitis (UC) (9). Moreover, manometric parameters have been shown to be associated with severity of symptoms(10). Whilst the role of BFT in FI is well established, its efficacy for FI in an IBD specific population has not previously been reported to our knowledge. Therefore, the aim of this retrospective study was to evaluate outcomes of BFT in quiescent IBD patients with FI at our institution. Methods IBD patients We retrospectively reviewed the clinical data of all consecutive IBD patients referred with FI to the Gastro-intestinal Physiology unit between 2009-14 at the Pennine Acute Hospitals NHS Trust, Greater Manchester, United Kingdom. Data were collected from patient health records. Protocols Baseline visit and anorectal manometry: A detailed medical, surgical, dietary, gynae-obstetric history including the parity and medication history was obtained at the baseline visit and entered into a dedicated proforma with recorded details including the baseline FI frequency (number of episodes per week). Data on IBD activity (endoscopy, histology, radiography