Biofeedback Is Superior to Electrogalvanic Stimulation and Massage for Treatment of Levator Ani Syndrome

Chiarioni, Giuseppe; Nardo, Adriana; Vantini, Italo; Romito, Antonella; Whitehead, William E.

doi:10.1053/j.gastro.2009.12.040

« Previous Next »Gastroenterology
Volume 138, Issue 4 , Pages 1321-1329, April 2010

Biofeedback Is Superior to Electrogalvanic Stimulation and Massage for Treatment of Levator Ani Syndrome

Giuseppe Chiarioni
- Division of Gastroenterology of the University of Verona at Verona, Italy
- Valeggio sul Mincio-Department of Biomedical and Surgical Sciences, Azienda Ospedaliera and University of Verona, Valeggio sul Mincio Hospital and Policlinico GB Rossi, Verona, Italy
- Reprint requests Address requests for reprints to: Giuseppe Chiarioni, MD, Divisione di Gastroenterologia dell'Università di Verona, Azienda Ospedaliera e Università di Verona, Centro Ospedaliero Clinicizzato, 37067 Valeggio sul Mincio (VR), Italy. fax: (39) 0457 950 188
Adriana Nardo
- Division of Surgery, Casa di Cura San Clemente Hospital, Mantova, Italy
Italo Vantini
- Division of Gastroenterology of the University of Verona at Verona, Italy
- Valeggio sul Mincio-Department of Biomedical and Surgical Sciences, Azienda Ospedaliera and University of Verona, Valeggio sul Mincio Hospital and Policlinico GB Rossi, Verona, Italy
Antonella Romito
- Valeggio sul Mincio-Department of Biomedical and Surgical Sciences, Azienda Ospedaliera and University of Verona, Valeggio sul Mincio Hospital and Policlinico GB Rossi, Verona, Italy
William E. Whitehead
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

Received 3 September 2009; accepted 9 December 2009. published online 31 December 2009.

Background & Aims

Levator ani syndrome (LAS) might be treated using biofeedback to teach pelvic floor relaxation, electrogalvanic stimulation (EGS), or massage of levator muscles. We performed a prospective, randomized controlled trial to compare the effectiveness of these techniques and assess physiologic mechanisms for treatment.

Methods

Inclusion criteria were Rome II symptoms plus weekly pain. Patients were categorized as “highly likely” to have LAS if they reported tenderness with traction on the levator muscles or as “possible” LAS if they did not. All 157 patients received 9 sessions including psychologic counseling plus biofeedback, EGS, or massage. Outcomes were reassessed at 1, 3, 6, and 12 months.

Results

Among patients with “highly likely” LAS, adequate relief was reported by 87% for biofeedback, 45% for EGS, and 22% for massage. Pain days per month decreased from 14.7 at baseline to 3.3 after biofeedback, 8.9 after EGS, and 13.3 after massage. Pain intensity decreased from 6.8 (0–10 scale) at baseline to 1.8 after biofeedback, 4.7 after EGS, and 6.0 after massage. Improvements were maintained for 12 months. Patients with only a “possible” diagnosis of LAS did not benefit from any treatment. Biofeedback and EGS improved LAS by increasing the ability to relax pelvic floor muscles and evacuate a water-filled balloon and by reducing the urge and pain thresholds.

Conclusions

Biofeedback is the most effective of these treatments, and EGS is somewhat effective. Only patients with tenderness on rectal examination benefit. The pathophysiology of LAS is similar to that of dyssynergic defecation.

Keywords: Proctalgia, Biofeedback, Electrogalvanic Stimulation, Dyssynergic Defecation

Abbreviations used in this paper: CONSORT, Consolidated Standards of Reporting Trials, EGS, electrogalvanic stimulation, LAS, levator ani syndrome, VAS, visual analog scale