Biofeedback Therapy in Managing Functional Fecal Incontinence in Children: A Literature Review

Abstract

This literature review explores the role of biofeedback therapy (BFT) in managing functional fecal incontinence (FFI) in children - a common condition with a substantial impact on the quality of life. FFI diagnosis relies primarily on medical history and thorough physical examination and is categorized by the Rome IV criteria into functional constipation (FC) and functional nonretentive fecal incontinence (FNRFI). Treatment options for FFI remain limited, particularly for FNRFI. BFT employs electronic or mechanical devices, such as rectal probes or surface electrodes, to provide real-time feedback on muscle activity and rectal pressure. This feedback allows patients to better understand and control their pelvic floor muscles, improving coordination between contraction during stool retention and relaxation during defecation. It also plays a role in rectal sensory awareness, enabling patients to respond appropriately to the urge to defecate. BFT has been considered an option in refractory cases, although evidence supporting its routine use is still emerging. We conducted a comprehensive literature search focusing on studies from the past 24 years that evaluated BFT for pediatric FFI. Five relevant studies were identified and analyzed, each utilizing BFT in combination with various treatment modalities. Two studies, both randomized controlled trials (RCT) and with the largest sample, focused on the treatment of FNRFI, both concluding that BFT should be used in FNRFI refractory to conventional treatment. Another two studies, one RCT and a retrospective study, focused on patients with FC. The first did not show any additional value in the use of BFT, while the second showed positive results. Comparing both studies, they had very different methodologies and treatment plans, but besides these results, in both studies, they concluded that when selecting a treatment plan for a child with FFI, an alternative or additional treatment with BFT should be considered. Finally, the last study, a quasi-experimental study, did not differentiate between FC or FNRFI and compared the use of BFT to percutaneous tibial nerve stimulation (PTNS). Although they showed that there were slightly better results when using PTNS, they concluded that both PTNS and BFT are effective modalities in treating children with FFI in addition to conventional treatment. Overall, BFT showed positive outcomes, with no safety issues reported. BFT appears to be a useful, non-invasive option for pediatric FFI, both FC and FNRFI, especially in cases unresponsive to conventional therapies. When used in a tailored, multimodal approach, BFT holds the potential to improve continence and quality of life in children with this challenging condition, and given that 15% of children with FFI, specifically FNRFI, continue to experience symptoms into adulthood, it is crucial to consider these treatment options early to potentially reduce this rate. Besides this, more research is needed to conclude the long-term effects and to establish standardized pediatric rehabilitation protocols.