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439 Results of Behavioral Treatment (Biofeedback) for Solitary Rectal Ulcer Syndrome [2001년 1월 DCR] 2011-11-12 1638
 
Results of Behavioral Treatment (Biofeedback) for Solitary Rectal Ulcer Syndrome
Andrew J. Malouf, F.R.A.C.S., Carolynne J. Vaizey, M.D., F.R.C.S.(Gen), F.C.S.(SA),
Michael A. Kamm, M.D., F.R.C.P., F.R.A.C.P.
From St. Mark's Hospital, :namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />London, United Kingdom:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
BACKGROUND: Treatment of solitary rectal ulcer syndrome with behavioral techniques (biofeedback) has been shown to be successful in a majority of patients in the short
term. We aimed to determine the longer-term outcome of patients treated with this therapy.
PATIENTS AND METHODS: Thirteen consecutive patients (3 male; median age, 34
years) with solitary rectal ulcer who had been treated by biofeedback and assessed a median of nine months after treatment were reassessed by questionnaire. Three patients were also examined using rigid sigmoidoscopy.
RESULTS: Median follow up was 36 (range, 32-59) months after initial biofeedback treatment. One patient (previously reported as failing biofeedback therapy) was lost to follow-up. Of the four patients previously reported as asymptomatic, one remained
asymptomatic, one maintained marked improvement, and another slight improvement; one had reverted to pretreatment status. Of the three patients previously reported as having marked improvement, one maintained moderate improvement, and two had reverted to pretreatment status. The patient previously reporting slight improvement
had reverted to pretreatment status. Of the five previously reported failures, two patients experienced no improvement after further courses of biofeedback. At the three different times of review (pretreatment vs. 9 months vs. 36 months after biofeedback), reported bowel function was as follows: the need to strain (12 vs. 5 vs. 9 patients), anal digitation (10 vs. 3 vs. 8 patients), laxative use (9 vs. 4 vs. 4 patients), median time spent in the toilet per attempt at defecation (30 vs. 10 vs. 25 minutes), median visits to the toilet (5.5 vs. 2 vs. 4 per day), and ability to maintain employment (3 vs. 7 vs. 6 patients).
CONCLUSION: Improvement in symptoms of solitary rectal ulcer syndrome after biofeedback retraining deteriorates in some patients with time. Half the patients with an early clinical response to retraining, however, can be expected to have ongoing clinical benefit at a median of three years.
DISCUSSION
Initial reports using behavioral modification with biofeedback for SRUS showed promising short-term results, with high rates of symptom, alleviation without the risk of morbidity. This longitudinal study, however, has shown that the initial functional and symptomatic improvement observed with short-term follow-up is not always maintained long term. Only one-half of patients reporting symptom improvement on short-term follow-up had longer-term benefit, and three of these four patients felt that the magnitude of clinical response had diminished with time. Overall, only one-third of patients treated with biofeedback reported ongoing benefit at longer-term follow-up.
Explanations of this deterioration can only be speculative. Behavioral techniques rely on the patient's ongoing application of taught procedures and involve a high degree of long-term patient commitment. Psychologica] factors, which may be a factor in this group of patients, v may influence this commitment. Longerterm failure may also relate to the absence of regular therapist input and encouragement, and regular "refresher" sessions of treatment to maintain best practice techniques may be helpful to prevent relapse. Two patients with initial lack of response to treatment in this study had undergone a further course of biofeedback treatment in the interval between the two reviews, but neither had clinical benefit from these. A further patient had also undergone more than one failed course of biofeedback at the time of the earlier review at a median of nine months after treatment. Repeat courses of biofeedback after initial failure of treatment seems unlikely to be beneficial. Biofeedback treatment does not just focus on correcting paradoxical puborectalis contraction. Probably of greater importance is teaching patients to restrict the number of visits to the toilet, the duration of these visits, and straining on the toilet. Although not universally effective in the longer term, biofeedback therapy is noninvasive, free of side effects, and gives ongoing benefit in one-third of patients treated for symptoms of SRUS. Surgical treatment has its own associated morbidity, in particular constipation after rectopexy. 8 Short-term relief of symptoms has been reported in up to 80 percent of patients, 9 but long-term results show as few as 52 percent of patients not having a stoma are improved by surgery. 1° We would therefore continue to recommend biofeedback as a first-line therapy for this condition. In those who do come to surgery it may be useful in decreasing postoperative recurrence. In summary, behavioral treatment (biofeedback) is effective in some patients long term, including patients who have failed other treatments such as surgery. In some patients intermittent additional sessions may be needed to maintain benefit.