Practical aspects of biofeedback therapy for PFM dysfunction to treat symptoms of urinary incontinence, voiding dysfunction, constipation, and fecal incontinence include the technical, therapeutic, behavioral, and pelvic muscle rehabilitation (PMR) components. The technical component involves the instrumentation used to provide meaningful information or feedback to the user. Devices include surface electromyography (sEMG), water-perfused manometry systems, and the solid-state manometry systems with a latex balloon. Although each system has inherent advantages and disadvantages, most systems provide reproducible and useful measurements. A solidstate system is preferable to a water-perfused system because there is no distraction or embarrassment from leakage of fluid and the patient can be moved to a sitting position without adversely affecting calibration. Surface electromyography instrumentation is widely used and proven effective for biofeedback training. Although not suitable for either coordination training or sensory conditioning for fecal incontinence, sEMG, used at Cleveland Clinic Florida for the routine care of patients with pelvic floor dysfunction, is more cost effective and suitable for office use.3 Patients are able to remain fully clothed during the session and position changes are easily accomplished to assist with functional maneuvers. The therapeutic component involves the clinician taking an active role by establishing a rapport with the patient, reviewing bowel and bladder habits, educating the patient, and interpreting data. Clinicians must have a complete understanding of bowel and bladder functioning, considering the coexistence of multifactorial concomitant PFM dysfunction. For example, increased PFM sEMG activity during voiding is indicative of functional outlet obstruction, which may inhibit a detrusor contraction, thus requiring excessive straining by increasing intraabdominal pressure to empty the bladder. This also consequently produces a dysfunctional defecation pattern and contributes to symptoms of constipation. Chronic straining at stool is another source of PFM denervation that contributes to PFM weakness and incontinence. Patients with fecal incontinence may complain of multiple daily bowel movements and a feeling of incomplete evacuation resulting in postdefecation seepage along with concomitant symptoms of urinary incontinence. For these reasons, it is difficult to offer a specific standard biofeedback therapy protocol that is beneficial for all patients. Therefore, the clinician must address all bowel and bladder symptoms and develop an individualized program for each patient with progressive realistic goals. The behavioral component is aimed toward systematic changes in the patient's behavior to influence bowel and bladder function. The PMR component involves designing an exercise program suitable for each patient to achieve the ultimate goal of efficient PFM function.
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