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SAN ANTONIO -- Biofeedback training resulted in significant improvement in dyssynergic defecation associated with constipation in older patients, a small retrospective analysis showed.

The mean score on a global scale of bowel movement satisfaction almost doubled, and the feeling of incomplete evacuation after a bowel movement decreased by 95%. Assessment by high-resolution anal manometry showed resolution of dyssynergic defecation in 79% of the patients.

The results suggested that the efficacy of biofeedback for dyssynergic defecation observed in younger patients applies to their elders as well, Samantha Spilman, MD, of the University of California San Diego, reported here at the (ACG) meeting.

"Biofeedback for dyssynergic defecation led to meaningful improvement in both patient-reported outcomes and objective manometric parameters in older adults," said Spilman. "Patients with type 2 [inadequate propulsive force] dyssynergic defecation showed the most gains in defecation index."

"Biofeedback improved dyssynergic defecation in older adults as defined by ACG criteria, as well as the narrower Rome IV definition," she added. "Given the profound burden of constipation with dyssynergic defecation in older adults, we propose biofeedback therapy to continue to be given strong consideration as first-line therapy for this population."

Dyssynergic defecation, a manifestation of , occurs in as with chronic constipation. Biofeedback therapy has proven to be highly effective in correcting dyssynergic dysfunction, said Spilman. However, few studies evaluated use of biofeedback for older patients with chronic constipation associated with dyssynergic defecation. The therapy is covered by Medicare.

Spilman and colleagues retrospectively reviewed records of patients 65 or older who enrolled for biofeedback therapy for dyssynergic defecation during 2015 to 2018 and identified those who attended at least two therapy sessions. At each session, patient-reported outcomes (PROs) were assessed, and anorectal manometry was performed.

The combined patient education and physical therapy to help patients retrain pelvic floor muscles and improve the strength and coordination of anorectal musculature. Training sessions included activities such as breathing exercises and instruction in postural techniques.

Investigators identified 58 patients who met the inclusion criteria. They had attended a median of three biofeedback sessions. The patients had a median age of 74, body mass index of 28.5, and constipation duration of 9.5 years. A third of the patient had a history of childhood constipation, and 22% had a diagnosis of irritable bowel syndrome. The cohort had an even distribution of men and women.

PRO data showed significant improvement in Global Stool Satisfaction from an average of 2.8 (on a scale of 1-10) to 5.0 (P<0.0001). Number of stooling medications, stool frequency, and Bristol Stool Score did not change significantly. Prior to biofeedback therapy, 95% of the patients reported a feeling of incomplete evacuation at the end of a bowel movement; afterward, the proportion reporting that feeling decreased to 24% (P=0.026). The proportion of patients who used manual maneuvers to remove stool decreased from 31% to 19% (P=0.31).

Manometry data showed that patients benefited from biofeedback therapy regardless of whether the dyssynergia primarily involved defects in propulsion or paradoxical contraction of sphincter muscles during defecation (P=0.0006), Spilman reported. Patients with both defects (type 2) derived the most benefit versus other subtypes of dyssynergic defecation. The mean defecation index (intrarectal pressure divided by residual intra-anal pressure during simulated defecation) also improved significantly with biofeedback therapy.

Overall, 81% of the patients no longer had dyssynergia after biofeedback therapy.

Spilman acknowledged several limitations of the study: small sample size, no baseline assessment of cognitive function (which could affect learning capacity), and no balloon expulsion testing at the end of biofeedback therapy.

"The major point of this study is that older adults have a large burden of dyssynergia, and we're trying to decrease medication use," she said. "Here we present a therapy approach that is nonpharmacologic and can help patients resolve their constipation and dyssynergia."

In response to a question, Spilman acknowledged that one-fourth of patients discontinued biofeedback before completing the recommended three to four sessions. Investigators had no information about the reasons for discontinuation.

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