The aim of this case report is to describe the use of behavioral therapy-focused physiotherapy in the management of dyssynergia defecation.
The patient was a 72-year-old male who was referred to physiotherapy with complaints of being laxative dependent, two bowel movements weekly, excessive straining, incomplete faecal evacuation, sensing a blockage when attempt to defecate and resorting to digital rectal evacuation. Lately ended up in the emergency department with severe abdominal cramp/discomfort and underwent manual disimpaction procedure twice within a month. Anal manometry test confirmed of defecation dyssynergia with hyposensitive. The hospital authorities granted authorization to perform a study and Written informed consent was obtained from the patient for publication of this report.
Treatment goals were formulated together with the patient, to prevent future stool impaction, improve pelvic floor muscle function in defecation and to achieve ≥3 complete spontaneous bowel movements per week without excessive straining and restore defecation without laxative.
The patient received 45 minutes of physiotherapy treatment every week for 15 consecutive weeks for the period of 3 months. The intervention consisted of three components that focused on behavioral therapy including Education and Lifestyle modification, Active Therapy (using biofeedback, electrical stimulation, pelvic floor muscle and core muscle training) and Reinforcement.
The primary outcome measures were the EMG (μV) measurement using an intra-anal probe (MAPLe) (Voorham-van der Zalm et al., 2013) and the strength of the pelvic floor muscles based on the blink score using digital palpation of the anal (Hundley et al., 2005).Secondary outcomes include defecation pattern using Bowel Diary: frequency, straining level, digital assistance, stool consistency (Bristol Stool Scale) laxative usage and fluid intake (Sadeghi et al, 2023) and self-report of improvement based on bothersomeness related to quality of life and Patients’ Global Impression of Change (PGIC) Scale (Williams 2021; Hurst & Bolton, 2004). All outcomes were measured at baseline and after 15 sessions, and additionally at the 1-year telephone follow-up for the secondary outcome.
Upon re-examination, the patient reported that he no longer required laxatives, had 4-5 bowel movements weekly without straining, and had stool types 3–4 (Table 2). EMG measurement revealed a positive change of PFM activities and coordination (Figure1 and 2). One year follow-up showed that the symptoms did not occur and quality of life improved.
This study showed the effectiveness of a physiotherapy intervention focusing behavioral therapy in reducing the symptoms of defecation dysfunction in patients with dyssynergia defecation, however randomized studies are required to clarify the issue.
This case study suggests that behaviorally focused physiotherapy interventions can provide valuable insights on clinical strategies for the management of dyssynergia defecation.
Behavioral Therapy
Physiotherapy
