Treatment of impaired defecation associated with rectocele by behavioral retraining (biofeedback)

PURPOSE: Large rectoceles have been associated with symptoms of impaired re ctal evacuation, often leading to rectocele repair. However, these symptoms , or the anatomic abnormality, may be caused, at least in part, by a primar y disturbance of rectoanal coordination. This study aimed to determine the efficacy of biofeedback therapy in such patients. METHODS: Thirty-two femal e patients (median age, 52 years) complaining of impaired rectal evacuation and with a rectocele greater than 2 cm at proctography were evaluated by s tructured questionnaire before, immediately after treatment, and at follow- up. Physiologic and proctographic findings were related to outcome. RESULTS : Immediate results were available in 32 patients and medium-term follow-up (median, 10; range, 2-30 months) in 25 patients. At follow-up 14 (56 perce nt) patients felt a little and 4 (16 percent) patients felt major improveme nt in symptoms, including 3 (12 percent) with complete symptom relief. Imme diately after biofeedback there was a modest reduction in need to strain (f rom 72 to 50 per cent), feeling of incomplete evacuation (from 78 to 59 per cent), need to assist defecation digitally (from 84 to 63 percent), and nee d to use an evacuant (from 47 to 28 percent), and this was maintained at fo llow-up. Bowel frequency was significantly normalized at follow-up (P = 0.0 2). Pretreatment presence of symptoms of digitally assisting defecation, pe lvic Boor incoordination, and proctographic rectocele size and contrast tra pping, did not predict outcome. CONCLUSIONS: Behavioral therapy, including biofeedback, leads to major symptom relief in a minority, and partial sympt om relief in a majority, of patients with a feeling of impaired defecation and the presence of a large rectocele. Residual symptoms are common. Biofee dback may be a reasonable first-line treatment for such patients.