What's in a Name? Putting Patients First

On the basis of pathophysiology and symptom patterns, constipated patients are usually categorized into those with constipation-predominant irritable bowel syndrome, slow transit constipation (STC), and dyssynergic defecation,1 but most clinicians and researchers agree that there is a significant overlap among these subtypes. With regards to treatment, several randomized controlled trials have previously shown that biofeedback therapy is effective, both in the short and long-term management of patients with dyssynergic defecation.2–5 About two-thirds of patients with dyssynergic defecation have coexisting STC1,2; in this group, biofeedback treatment not only improves bowel symptoms and dyssynergia but also colonic transit, most likely by improving the outlet dysfunction.1–3 In contrast, patients with STC alone will not respond to biofeedback therapy.6 Now, whether dyssynergics with coexisting constipation-predominant irritable bowel syndrome respond to biofeedback therapy has not been investigated earlier, and is the topic of the study by Patcharatrakul and Gonlachanvit.7 The primary objective of their study was to determine whether the presence of IBS symptoms adversely affects the outcome of biofeedback therapy in patients with dyssynergic defecation. This is particularly important because the Rome III criteria explicitly exclude patients with IBS from consideration of a diagnosis of dyssynergic defecation. Thus, it is unclear whether patients with dyssynergic defecation and coexisting IBS symptoms should or should not be considered as appropriate candidates for treatment with biofeedback therapy. In this prospective study, consecutive subjects who fulfilled standard criteria for constipation and dyssynergic defecation,1,2 and those with or without IBS (Rome III) received 4 weekly sessions of biofeedback therapy. Both verbal and visual feedback was provided by a therapist, and with the use of a solid state pressure manometry system. The therapist was blinded to the IBS status. Standard treatment techniques were prescribed that included diaphragmatic breathing, enhancing push effort, anal relaxation, and home exercises, but rectal sensory training was not performed. A responder was defined as an individual with at least 50% improvement in constipation symptom score as assessed on a 10 cm visual analog scale, after 4 weeks of treatment. Fifty patients were enrolled of whom 29 (58%) had IBS. The 2 groups were quite comparable with regards to demographic features, constipation symptoms, as well as anorectal and colonic physiology. Thirty (60%) patients improved with biofeedback therapy. There were no differences in those who responded versus those who did not respond except that treatment failure was associated with a greater prevalence of STC and rectal hyposensitivity. Furthermore, 16 of 29 (55%) with IBS and 14 of 21 (67%) without IBS improved with regards to bowel symptoms and dyssynergia. In addition, 12 of 29 (41%) patients with IBS showed improvement of IBS symptoms, which is an important and new finding. This uncontrolled study not only confirms that biofeedback therapy is effective in the short-term management of dyssynergic defecation, but is also one of the first studies showing such a benefit in a nonwestern population. The improvement rate of 60% is lower than the approximately 75% improvement rates reported in other studies, and could be in part because of study population, learning curve with biofeedback therapy, and lack of sensory training. The most important message is that patients with symptoms of difficult defecation should be investigated for the possibility of dyssynergic defecation, and if present should be treated with biofeedback therapy, irrespective of whether they have coexisting symptoms of IBS. In addition, the corollary is true that is, in a patient with persistent IBS symptoms, the clinician should investigate the possibility of coexisting dyssynergic defecation, and if present this should be treated, as this may help to resolve the IBS symptoms. Finally, the study raises the issue that future consensus criteria should seriously consider the inclusion of pathophysiologic mechanisms in the diagnostic criteria for IBS and not merely the presence or absence of symptoms, as this may provide better and more objective guidelines for diagnosis and management.