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Abstract

We thank Drs. Van Outryve and Pelckmans for their comments on our paper1Chiarioni G. Whitehead W.E. Pezza V. Morelli A. Bassotti G. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia.Gastroenterology. 2006; 130: 657-664Abstract Full Text Full Text PDF PubMed Scopus (321) Google Scholar and we would like to respond to the interesting questions they raised below: As they pointed out, counseling sessions in the laxative group were not provided by author GC but by different physicians. We cannot exclude differences in outcome being influenced by nonspecific effects such as the physician’s enthusiasm for the treatment, but the therapists for the laxative group were similar in status (ie, they were physicians), and they indicated that they expected polyethylene glycol to be more effective than biofeedback. We therefore believe any bias from this source was minimal. Drs. Van Outryve and Pelckmans point out that the site of retained radiopaque markers may be useful for differentiating slow transit constipation from pelvic floor dyssynergia. We agree and we have shown in a previous paper2Chiarioni G. Salandini L. Whitehead W.E. Biofeedback benefits only patients with outlet dysfunction not patients with isolated slow transit constipation.Gastroenterology. 2005; 129: 86-97Abstract Full Text Full Text PDF PubMed Scopus (285) Google Scholar that some patients with delayed transit due to retention of markers in the descending colon and rectum have pelvic floor dyssynergia and may respond to biofeedback training. However, in this study we excluded all patients with delayed transit. The conclusions of this randomized controlled trial are therefore limited to patients with normal transit constipation due to pelvic floor dyssynergia. The role of rectal hyposensitivity in functional constipation with obstructed defecation is still a matter of debate. The biofeedback program we developed for pelvic floor dyssynergia does not include a specific sensory retraining component, although sensory thresholds decreased significantly in the biofeedback group. The reanalysis of our data requested by Drs. Van Outryve and Pelckmans shows no significant difference in the magnitude of threshold reduction between the 43 biofeedback responders (−29.1 mL) vs. the 11 nonresponders (−18.2 mL, t(52) = 0.894, P =.375). Thus, rectal sensation was not a predictor of response to biofeedback. This is at variance to the relevance of sensory dysfunction we previously reported in fecal incontinence.3Chiarioni G. Bassotti G. Stanganini S. Vantini I. Whitehead W.E. Sensory retraining is key to biofeedback therapy for formed stool incontinence.Am J Gastroenterol. 2002; 97: 109-117Crossref PubMed Scopus (108) Google Scholar We agree with our colleagues that dedicated Pelvic Floor Clinics may be the best options for obstructed defecation patients because many of them are disabled by multiple pelvic floor disorders. However, our data clearly show that pelvic floor dyssynergia, once identified, can be treated effectively whether or not it is accompanied by other pelvic floor disorders. We also agree that anorectal ultrasonography has some advantages compared with other diagnostic techniques because it gives both morphological and functional information of the anorectum.4Van Outryve S. Van Outryve M. De Winter B. Pelckmans P. Is anorectal endosonography valuable in dyschesia?.Gut. 2002; 5: 695-700Crossref Scopus (25) Google Scholar However, standardization of methodology is lacking. We regard anal EMG, anorectal manometry and balloon expulsion tests as the gold standards in the diagnostic work-up of obstructed defecation.5Scarlett Y.V. Anorectal manometry and biofeedback.in: Drossman D.A. Shaheen N.J. Grimm I.S. Handbook of gastroenterologic procedures. 4th ed. Lippincott Williams & Wilkins, Philadelphia, PA2005: 341-348Google Scholar Biofeedback Is Superior to Laxatives for Normal Transit Constipation Due to Pelvic Floor DyssynergiaGastroenterologyVol. 131Issue 1PreviewWe were very impressed by the positive results of biofeedback training in pelvic floor dyssynergia (PFD), in the excellent publication of Chiarioni et al.1 We do not reach a success percentage of 80% in our GI-unit, our unpublished data show a success rate of about 65% in these patients. Full-Text PDF