Kathryn Sloots is a Registered Nurse with a science degree and PhD who has worked for 18 years in the areas of bowel and bladder continence (including anorectal biofeedback, urodynamics, research and education). She has published several papers on bowel continence and presented at continence conferences. Kathryn is passionate about promoting bowel and bladder continence, increasing awareness and information for health professionals and the public, and improving access to continence care. Here she discusses the holistic biofeedback program and its effectiveness as a treatment for a range of bowel conditions.

Dr Kathryn Sloots

Can you explain what a holistic biofeedback program involves?

People who are having trouble coping with bowel symptoms that have not responded to conservative measures may be referred for treatment with anorectal biofeedback. A holistic biofeedback program addresses their specific combination of symptoms, including their physical symptoms and the mental, emotional and social impacts on their quality of life. Because bowel problems can be embarrassing and difficult to talk about, the mental and emotional aspects of treatment are just as important as the physical. Treatment sessions need to be offered in a setting which gives privacy, adequate time to discuss in their own words what the issues are, and what they would like to achieve from the treatment program.

The biofeedback program combines behavioural strategies and biofeedback training. The behavioural section involves education about the bowel and normal function, discussion about the causes of the symptoms the person is experiencing and support and coping strategies to help them achieve their treatment goals. To guide the advice on support and coping strategies I like to use questionnaires to determine their most troubling symptoms and the impact on their lifestyle. For example, they may give their symptoms a score of 9/10 for intensity and impact on their ability to cope with daily life or it may be a score of 2/10 which indicates their symptoms are easier to manage. Coping measures will include advice on lifestyle adjustment and daily routines, diet modification, fluid intake, medications, suitable continence products and tips for coping when socialising, and setting specific treatment goals to keep both the patient and therapist on track.

Biofeedback training techniques include breathing exercises for whole body relaxation, exercising pelvic floor muscles and the anal sphincter for strengthening and relaxing these muscles, modification of rectal sensitivity and improving anorectal coordination to help achieve easy and effective defaecation.

The aim of the treatment program is for the person to achieve their personal goals for satisfactory bowel control and the confidence to manage their bowel function so they can enjoy their lifestyle.

How would you explain anorectal biofeedback in simple terms?

Biofeedback is a training technique that increases awareness of body processes that are not usually consciously controlled. The feedback helps people to locate and move their pelvic floor muscles and anal sphincter to learn exercises which improve the strength and control of these muscles and their ability to relax them.

If a person cannot feel sensations in their rectum, they do not receive the usual signals that tell them when they need to defaecate, even if it is urgent. Conversely, some people have excessive rectal sensitivity and are not able to discriminate between a normal level of sensation and the urgent messages they feel. Biofeedback gives information which is used during treatment sessions that can help to retrain the bowel and the responses to bowel signals.

How it works:

Information regarding the person’s bowel signals or sensations and their body’s responses is given as visual and verbal feedback. Visual feedback is produced by muscle pressures which are shown on a screen different colours or as a pressure wave. The feedback helps with muscle training because the visual image shows increasing pressure as the muscle is squeezed and decreasing pressure when relaxing. This helps people to effectively exercise and strengthen muscles and alco coordinate muscle activity and relaxation for bowel evacuation. Being able to measure pressure is also very useful for people who cannot feel their muscles moving.  Even a small pressure rise on the screen can show them when they are moving the muscles correctly which is reassuring and motivates them to continue regular exercising.

Rectal sensitivity training with a small balloon is used to modify rectal sensations and the person’s response to those sensations.  Training for low or hyposensitivity improves awareness of body signals so the person learns when they are squeezing and relaxing their muscles appropriately or need to evacuate their rectum. Training for hypersensitivity reduces the excessive response to rectal stimulation, and combined with breathing relaxation, helps to dampen down the urgency messages and increase control and confidence.

One of my patients who lived in a caravan park had terrible urgency and faecal incontinence and the only toilet block was quite a distance away. At her final biofeedback treatment session, she told me she had been putting up some new curtains with her husband when she needed to go to the toilet. When she told him he quickly cleared a path through the van for her to get out, but she decided she wanted to finish putting up the curtains before she went to the toilet, and so she did, without having any bowel leakage. This is a great example of the improvement in control and confidence that can be achieved with biofeedback treatment.

Who would most benefit from this type of program?

Biofeedback can be used to treat bowel problems such as incontinence and constipation. Bowel incontinence is the leakage of solid or liquid faeces or gas, and all these distressing symptoms can be treated with biofeedback.  There are many causes of incontinence including reduced anal sphincter tone and muscle damage, loose stool consistency causing urgency and frequency, or constipation with overflow leakage. It can also be related to bowel disease or occur after some types of colorectal surgery.

Biofeedback is also used to treat people with constipation using pelvic floor muscle strengthening and/or relaxation, correction of evacuation technique, dietary modification and establishing a regular routine to assist defaecation. Difficulty evacuating and incomplete evacuation may be linked to pelvic floor muscle weakness, not being able to relax the muscles correctly or altered physiology such as a prolapse.

Biofeedback can also be useful before and after some forms of bowel surgery. Biofeedback before surgery addresses problems with bowel function and improves pelvic floor muscle tone and the ability to relax these muscles to increase the chances of successful surgical outcome. Faecal leakage, incomplete evacuation and difficulty getting the bowel into a good routine can be troublesome after colectomy for constipation or surgery for cancer in the colon or the rectum.  We usually recommend a person waits until six months after surgery to allow the bowel to heal and adjust which it may do quite well on its own.  If symptoms persist, biofeedback can be very successful in restoring the person’s bowel routine, control and confidence.

How long does a biofeedback program run for?

Treatment time varies depending on the diagnosis and severity of symptoms. We allow people to work through their program at a comfortable rate, while encouraging them to remain engaged and motivated for steady progress. For some people six weeks may be sufficient time to see good progress and feel confident to continue using the exercises and techniques at home.  Others may take a lot longer, and may need additional support, especially psychological support if they are not coping with their symptoms and struggling to manage their lifestyle demands.

What are the options when conservative therapies don’t work or are unsuitable?

If treatments such as dietary modification, medication and biofeedback do not result in satisfactory improvement in symptoms, other possible treatment options include trans-anal irrigation or sacral neuromodulation. These can be very effective for managing faecal incontinence or constipation and can greatly improve quality of life. Some people may require corrective surgery and in severe cases a stoma may be the best option to manage bowel function. Whatever the situation, it is essential to have a consultation with a colorectal specialist to discuss all the options and make an informed decision about what to do next.

After 20 years as a specialist in this area what are some of the changes you have seen?

Biofeedback is now recognised as an effective conservative therapy, along with the benefits of using other conservative measures and support in a holistic program. There is much greater collaboration between health professionals, so dietitians, physiotherapists, psychologists, and biofeedback therapists work as a team to provide holistic treatment. Biofeedback can also help to avoid unnecessary surgery, or a combination of surgery and biofeedback can be very effective in improving quality of life.  

I’m happy to say that more people these days have better knowledge of the physiology of their bodies which, for example, helps them understand how to exercise their muscles or why dietary modification can improve their symptoms. People experiencing problems with bowel function are usually keen to help themselves and cooperate with the treatment advice which makes treating them satisfying and very rewarding.

What have been some of the challenges?

Faecal incontinence is often still a ‘taboo’ subject and people can feel embarrassed and reluctant to seek help. A member of the holistic team may be the first person they have been able to talk to openly about the impact of their symptoms on their quality of life. That’s why it is so important to take the time to let people tell their story.

Sometimes people offered biofeedback treatment can’t or won’t make the effort to follow the advice they are given. They hope for a quick fix or a magic wand, but it takes effort and perseverance to get results. Encouragement to change old habits and regularly practice the exercises and techniques they are shown can be crucial for long term success.

Searching online to self-diagnose has become popular and can be dangerous, and online misinformation is also a concern. It is essential for people with altered bowel habits or distressing symptoms to get an accurate diagnosis and advice about the range of suitable treatment options from a colorectal specialist.

As you mentioned earlier, faecal incontinence is still heavily stigmatised in our society. How do you think that could change?

There has been a lot more discussion and education around urinary incontinence, and continence products are now freely advertised, but people are not comfortable talking about bowel incontinence. Bladder and bowel health are fundamental aspects of our general health. Many health practitioners are not aware just how widespread incontinence is and the impact it can have on peoples’ lives. I would like to see more emphasis on bowel health and available treatments in medical education courses.

Discussing faecal incontinence more openly and recognising it as a health issue that is more common than most people realise will enable people to seek the advice and treatment they need. In some tribal cultures, enquiring about a person’s bowel function is part of the friendly greeting when meeting them. They say, “Good morning and how are your bowels today?” They understand the importance of healthy bowel function. We need to encourage people from early childhood to feel comfortable discussing concerns about their bowel function.