Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 497

Pelvic floor muscle therapy, both self‐directed and with the assistance of a physiotherapist, aims to strengthen the pelvic floor muscles and therefore increase anal tone. In a typical protocol, the patient may be instructed to squeeze for 10 seconds while continuing to breathe deeply so that the abdominal wall muscles do not also contract. Ten to 20 such 10–second squeezes are separated by 20‐second periods of pelvic floor relaxation. Patients are instructed to squeeze 10–20 times in a block and to repeat this block of exercises three to five times a day, with both ‘quick’ squeezes lasting one second and ‘slow” squeezes held for up to 10 seconds. The patient may be taught how to perform this exercise using only verbal or written instructions, or the therapist may give them verbal feedback on their performance during a digital rectal examination.⁵⁷ Pelvic floor exercise has been shown to be effective for urinary incontinence in women with cognitive impairment⁵⁸ but has not been studied for faecal incontinence in this group.

Biofeedback is classically described as a learning theory with operant conditioning and was first described by Engel and colleagues in the 1970s.⁵⁹ Biofeedback is a nonsurgical, non‐invasive, relatively inexpensive outpatient method of treating faecal incontinence. During biofeedback, patients are given verbal feedback and shown a visual representation of anal canal pressure, measured with a manometer. This allows people to relearn to effectively contract the external sphincter while keeping the abdominals relaxed and to recognize the sensation of rectal distention.⁶⁰ The evidence for biofeedback is mixed, with many small studies of generally poor quality. In a 2001 review of 46 studies involving the use of biofeedback for faecal incontinence in 1364 patients (76% female), fewer than 20% of these studies included randomization, and most involved relatively small numbers of subjects. Improvement in continence occurred in at least half of the patients. No specific details regarding age‐related differences were noted.⁶¹ A randomized controlled trial (RCT) comparing ‘standard care’ – specifically, bowel habit advice, advice and instruction on pelvic floor exercises, hospital‐based computer‐assisted sphincter pressure biofeedback, and hospital‐based computer‐assisted sphincter pressure biofeedback with home biofeedback – found that conservative therapy improved continence and quality of life, with around half of participants improving, but no additional benefit from biofeedback.⁶² A Cochrane Review in 2012⁶³ concluded that

[There is] no evidence that one method of biofeedback or exercises gives any benefit over any other method, but biofeedback or electrical stimulation may offer an advantage over exercises alone if patients have previously failed to respond to other conservative managements. Addition of biofeedback to surgical sphincter repair does not appear to improve the outcome … there is not enough evidence on which to select patients suitable for anal sphincter exercises or biofeedback, or both; nor to know which modality of biofeedback or exercises is optimal … Based on the available evidence these conclusions can only be tentative. No study reported any adverse events or deterioration in symptoms, and it seems unlikely that these treatments may cause any harm.

Given that pelvic floor muscle exercises, physiotherapy, and biofeedback are non‐invasive and safe, they are worthy of attempting in those with reduced anal tone or passive leakage, especially if other conservative measures have failed and in those unfit for surgical intervention.