Balloon-assisted Training in Dyssynergic Defecation

Dyssynergic defecation occurs when the pelvic floor muscles (PFM) are not coordinating in a manner that supports healthy bowel movements. Ideally, emptying of the bowels is accompanied by a lengthening, or bearing down of the PFM, and with dyssynergia, the muscles instead shorten. Because a portion of the levator ani muscles slings directly around the anorectal junction (where the rectum meets the anal canal when the muscles are tight, the "tube" where the fecal material has to pass through narrows, making it difficult to pass stool. If emptying the bowels is difficult, patients will often strain for prolonged periods of time, an unhealthy pattern for the abdominopelvic area, and constipation may occur due to the stool remaining in the colon for prolonged periods of time, where the water is reabsorbed from the stool, becoming harder and more difficult to pass.

Can patients with this condition be helped by pelvic rehabilitation providers? Absolutely, with correction of muscle use patterns, bowel re-training education, food and fluid recommendations, and pelvic muscle rehabilitation addressed at optimizing the muscle health. Much of the time, patients with this dysfunctional muscle use pattern present with tension and shortening in the pelvic floor muscles, although they may also present with muscle lengthening and weakness. Surface electromyography (sEMG a form of biofeedback, has also been utilized and the literature supports sEMG for bowel dysfunctions including dyssnergia.

Another technique used by pelvic rehabilitation providers for re-training dyssynergia (also known as non-relaxing puborectalis, or paroxysmal puborectalis, naming the muscle fibers that sling around the rectum) is the use of balloon-assisted training. In this technique, a small, soft balloon is inserted into the rectum and is attached to a large syringe that will inject either water or air into the balloon, causing the balloon to enlarge within the rectum. This training technique allows the patient to provide feedback about sensation of rectal filling including when the patient perceives urges to defecate. The patient can practice expelling the balloon, and in the event of a dyssynergic pattern of pelvic floor muscles, the balloon would not be expelled due to increased muscle tension and shortening of the anorectal area. In this manner, the patient is trained to bring awareness to the anorectal area, and to respond with healthy patterns of defecation.

One study that compared biofeedback training to balloon-assisted training found that biofeedback was more effective in training patients for reduction of constipation. 65 patients, 49 women and 16 men, were included and were diagnosed with constipation and dyssynergia. In the balloon training (n = 31 patients were trained to expel the balloon with increased abdominal pressure and relaxed PFM, whereas in the biofeedback group (n = 34 the patients were trained to relax the pelvic floor muscles while increasing abdominal pressure. The good news is that while the biofeedback group reported higher levels of success in emptying, both groups reported positive effects of their training, with improved amount of stool passed, decreased maneuvers required to empty the bowels, and decreased time needed to defecate.

If you would like to learnabout sEMG for bowel dysfunction, sign up for the Pelvic Floor series 2A continuing education course. We are sold out for the rest of the year for PF2A, and the next opportunity to take the course will be next March in Madison, Wisconsin, or May of 2015 in Seattle. If you want to learn how to use balloon-assisted re-training techniques, you still have an opportunity this year to get into a course. Faculty member Lila Abatte has developed the Bowel Pathology, Function, Dysfunction, the Pelvic Floor course that still has seats left for the November, Torrance, California course.