Better Bowels With Rectal Balloon Biofeedback

Key Messages

  • Biofeedback with rectal balloon therapy is a useful treatment technique for many benign anorectal disorders
  • The ACG recommend biofeedback with rectal balloon therapy as first line treatment for defecatory disorders and chronic proctalgia, and second line treatment for faecal incontinence
  • Biofeedback with rectal balloon therapy can be used for defecation training, sensory training, and faecal incontinence coordination or urge resistance training

Rectal balloon therapy is emerging as an exciting biofeedback tool to effectively treat a variety of benign anorectal disorders. Wald and co-authors recently published the American College of Gastroenterology Clinical Guideline: Management of Benign Anorectal Disorders1, and strongly recommended the use of biofeedback with rectal balloon therapy for treatment of defecatory disorders, chronic proctalgia, and faecal incontinence.

What Is Rectal Balloon Therapy?

Rectal balloon therapy (RBT) involves inserting a lubricated balloon-tipped catheter into the rectum, and filling the balloon with water or air.  It can be used for diagnostic purposes, for example the Balloon Expulsion Test used to diagnose defecation disorders, or can be used therapeutically as a form of biofeedback.

Indications for therapeutic RBT:

  • Defecation training: correct dyssynergia of the abdominal, puborectalis and anal sphincter muscles to achieve complete bowel emptying
  • Faecal incontinence coordination training: improve recto-anal coordination to preserve continence
  • Faecal incontinence urge resistance training: improve pelvic floor and anal sphincter function
  • Sensory training: enhance rectal sensory perception in patients with impaired sensation

Fig 1: Rectal Balloon Therapy set-up

The recently published ACG Clinical Guideline: Management of Benign Anorectal Disorders2 strongly recommended the use of biofeedback with RBT for treatment of defecatory disorders, chronic proctalgia, and faecal incontinence.

Defecatory Disorders

A defecatory disorder (DD) refers to a patient having difficulty emptying stool from the rectum, with a history of chronic or recurrent constipation.  DD’s are caused by varying structural or functional anorectal disorders.  Functional disorders include dyssynergia, which is the contraction or failure of the pelvic floor muscles to relax during defecation, and/or inadequate defecatory propulsion.

There is a growing body of evidence3-5 showing that biofeedback with RBT leads to significant improvement in a patient’s ability to empty their rectum.  Biofeedback has been found to be more effective than:

  • Laxatives3
  • Diazepam or placebo tablets5
  • Sham biofeedback or medical management4
  • Patient education7
  • Dietary advice from a nutritionist and laxatives8
  • Isolated balloon defecation9

ACG Recommendation:

Biofeedback is the preferred treatment for defecatory disorders in adults
Level of Recommendation: Strong
Quality of evidence: Moderate

RBT Biofeedback Protocol

The RBT biofeedback protocol used in most randomised controlled trials consists of the following steps (adapted from Chaironi & Whitehead6):

  1. Patient education: explaining dyssynergia and how this contributes to the defecatory disorder
  2. Simulated defecation training: using biofeedback from a rectal balloon, teaching a patient to tighten their abdominal wall muscles and use their diaphragm to generate intra-abdominal pressure
  3. Pelvic floor muscle relaxation with defecation training: using feedback from intra-anal EMG, teaching a patient to relax the pelvic floor muscles with simulated defecation
  4. Practicing simulated defecation: the patient practices expelling a lubricated, inflated rectal balloon, with some gentle assistance by the therapist pulling lightly on the catheter

Chronic Proctalgia

Chronic proctalgia is defined as recurrent episodes of rectal pain, with episodes lasting more than 20 minutes.  It is thought to be caused by spasm of the striated muscles of the pelvic floor.  Whilst research in this area is limited, commonly advocated treatments for chronic proctalgia include: Biofeedback to teach relaxation of the pelvic floor muscles, electrical stimulation to the pelvic floor muscles, levator ani massage, sitz baths and Botox injections.

ACG Recommendation:

Biofeedback to teach relaxation of pelvic floor muscles during
simulated defecation is the preferred treatment.
Level of Recommendation: Strong
Quality of evidence: Moderate

This recommendation is predominately based on a randomized controlled trial by Chiarioni et al10, who compared pelvic floor biofeedback, electrical stimulation and massage. They reported 87% of patients gained relief of pain following biofeedback, compared with 45% for electrical stimulation and 22% for digital massage, with results maintained at 12 months.  Their biofeedback treatment protocol included teaching pelvic floor muscle relaxation with intra-anal EMG biofeedback, and defecatory retraining using rectal balloon therapy.

Faecal Incontinence

Faecal incontinence is defined as the involuntary loss of solid or liquid feaces.  It can be caused by a variety of factors, including anal sphincter weakness, neuropathy, pelvic floor disturbance, inflammatory conditions, central nervous system disorders, or diarrhea1.  Conservative treatment includes:

  1. Education
  2. Dietary modifications
  3. Skin care
  4. Pharmacologic agents to modify stool delivery and liquidity
  5. Antidiarrheal agents in patients with diarrhea1.

ACG Recommendation:

Pelvic floor rehabilitative techniques are effective and superior to pelvic floor exercises alone in patients with faecal incontinence who do not respond to conservative measures.
Level of Recommendation: Strong
Quality of evidence: Moderate

Pelvic floor rehabilitative techniques use RBT to retrain the coordination needed to maintain faecal continence. The patient is instructed to contract the external anal sphincter and pelvic floor muscles when they feel balloon distension, and this is repeated with progressively smaller volumes.

Sensory training with RBT can also be effective for treating bowel urgency due to a hypersensitive rectum. Repeated inflations and deflations are performed with feedback to train the patient to recognize the sensation within normal ranges.

Rectal Balloon Therapy @ WMHP

Our physiotherapists have been using RBT over the past few years and are finding it a very effective treatment, especially for patients with defecatory disorders. Although patients are a little hesitant initially, once they start to see their symptoms improve they are very thankful we encouraged them to try it as part of their treatment plan.


1 Wald, A., Bharucha, A., Cosman, B., Whitehead, W. (2014). ACG Clinical Guideline: Management of Benign Anorectal Disorders. Am J Gastroenterol, 109, 1141–1157.
2 Chiarioni, G., Kim, S., Vantini, I et al (2014). Validation of the balloon evacuation test: reproducibility and agreement with findings from anorectal manometry and electromyography. Clin Gastroenterol Hepatol, (e-pub ahead of print).
3 Chiarioni G, Whitehead WE, Pezza V et al. (2006). Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology, 130, 657–64.
4 Rao, S., Seaton, K., Miller, M. et al. (2007). Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol, 5, 331–8.
5 Heymen S, Scarlett Y, Jones K et al. (2007). Randomized, controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergia-type constipation. Dis Colon Rectum, 50, 428–41.
6 Chiarioni G, Whitehead WE. Biofeedback therapy for constipation. In: Parkman HP, McCallum RW, Rao SSC (eds). GI Motility Testing: A Laboratory and Office Handbook. 2011, pp. 179–87.
7 Simon, M. & Bueno, A. Behavioural treatment of the dyssynergic defecation in chronically constipated elderly patients: a randomized controlled trial. Appl Psychophysiol Biofeedback, 34, 273–7.
8 Rao, S., Valestin, J., Brown, C. et al.(2010). Long-term efficacy of biofeedback therapy for dyssynergic defecation: randomized controlled trial. Am J Gastroenterol, 105, 890–6.
9 Pourmomeny, A., Emami, M., Amooshahi, M et al. (2011). Comparing the efficacy of biofeedback and balloon-assisted training in the treatment of dyssynergic defecation. Can J Gastroenterol, 25, 89–92.
10 Chiarioni, G., Nardo, A., Vantini, I et al (2010). Biofeedback is superior to electro-galvanic stimulation and massage for treatment of levator ani syndrome. Gastroenterology, 138, 1321–9.

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