“Inside Out”
I want to ensure that colorectal balloon training, though sometimes hard to obtain, is the best use of time and resources for the patient and provider without causing unnecessary burden. I saw an opportunity to use the research for this blog to share an evidence-based repertoire to support the justification of colorectal balloons in clinical practice. A common complaint of rectal balloon training is the cost. For instance, a single-use colorectal balloon is $37.95, and that doesn’t include the $2.75 for the 60 ml Luer Lock syringe. These items are not listed in the medical catalog available to our military treatment facility. When I contacted GSA, I learned that adding such items to the VA catalogs can be arduous and time-consuming. The argument has been posed that you can request DME on a case-by-case basis, but firsthand experience has shown that insurance DME requests for pelvic floor interventions that the patient performs at home as part of their plan of care are even less fruitful.
The 2021 Clinical Practice Guideline (CPG) for Physical Therapy Management of Functional Constipation in Adults rates rectal balloon catheter (RBC) biofeedback training as evidence quality B and strongly recommends it. (6) This is significant considering that abdominal massage and anorectal manometry biofeedback training were rated Grade A, with a strong recommendation as well. RBC retraining received the same rating as EMG and a higher strength recommendation than direct and indirect manual therapy. That surprised me; however, I doubt anyone would be shocked to learn that electrical stimulation was rated D, weak.
Why are rectal balloons essential? Rectal balloons are a form of Biofeedback. Biofeedback is defined as “the technique of making unconscious or involuntary bodily processes perceptible to the senses... to manipulate them by conscious mental control.” In simpler terms, it’s a tool that helps patients learn proper muscle coordination required to expel stool, improve awareness of rectal fullness, or even decrease sensitivity in patients with fecal urgency. _But there are so many different forms of Biofeedback_,_ so why not use digital palpation? Proprioception?_ _Visual or verbal cues? _
A comprehensive article published in 2014 by Dr. Kelly Scott in Clinics in Colon and Rectal Surgery elaborates on the unique nature of fecal incontinence and why some patients may respond better to certain interventions (1). For example, those with outlet dysfunction or puborectalis syndrome might benefit more from biofeedback training or a combination of Biofeedback and electrical stimulation to address global overactivity of the pelvic floor muscles or dyssynergia. Dr. Scott concludes, “Pelvic rehabilitation approaches including Pelvic Floor Muscle Training, biofeedback-guided strength and endurance training, biofeedback-guided rectal sensitivity and coordination training, and electrical stimulation can be effective tools in managing Functional Incontinence. More research is needed to further define the role of rehabilitation, predictors of good outcomes, and the most efficacious treatment protocols” (1). Another study, although small, explored whether adding rectal balloon training would improve outcomes in patients with stress urinary incontinence (SUI) (2). It didn’t. But this just reinforces the idea that interventions must be tailored to the specific patient population to be effective.
An intervention ideal for one pelvic floor disorder may not be suitable for another. In 2012, a single-blind randomized controlled trial (RCT) examined whether adding Rectal Balloon Training (RBT) to PFMT was superior to PFMT alone (3). The study concluded that both were equally effective, but RBT improved urgency control, global perceived effect score, and lifestyle adaptations. The same research group, through multivariate analysis, found that a longer time since the onset of FI was associated with an unfavorable outcome to PFMT with RBT. However, the use of constipating medication, any obstetric factor, and prior experience of minor embarrassment regarding their symptoms predicted a favorable outcome overall (4).
A friend shared a snippet of a dyssynergia lecture by Dr. Susan Clinton on social media, and the “missing piece” fell into place for me. She discussed pain and perceived (and true) environmental considerations and posed a critical question: Is manual evaluation and digital palpation enough? Is it functionally relevant? She highlighted that all digital interventions, probes, etc., work from the “outside in,” but there’s nothing on the anal verge to stimulate reflexive dyssynergic action.
In strength and conditioning, we discuss the concept of specificity, and this seems to hold true for pelvic floor muscle retraining. Pelvic Health Providers need to simulate the same environment and pressure system “from the Inside Out” to identify dysfunction and work through it. Rectal balloon catheters are the most cost-effective option for this. They mimic the nature of stool within the rectum. How can we truly treat dysfunction and retrain the body if we’re not mimicking the bowel movement “inside out”?
Dr. Clinton discussed the common recreation of concordant signs—such as abdominal symptoms, distention, bolus in the throat, or heartburn—created with rectal balloons. Concordant signs are not always a given, but they increase our likelihood of a correct diagnosis and response to paired interventions. Identifying and recreating a concordant sign can also strengthen the therapeutic alliance and improve patient adherence to a plan of care, as the patient can truly connect the dots from the clinic to the commode. If you want to read more on abdominal symptoms and BFT, check out a study where researchers used the Personal Assessment of Constipation Symptom (PAC-SYM) questionnaire in 77 dyssynergic patients before and after RBC BFT (5). There’s more on PubMed, but for now—you’ll find me taking a step back and soaking this all in.
If you’re a new practitioner reading this blog, I hope you take away this key message: If you’re feeling overwhelmed & filled with questions—you’re right where you need to be and in the mindset essential for growth. Skepticism and an openness to learn are admirable clinical traits. Confidence is great, but the humility to ask questions and maintain clinical curiosity can set the stage for diligent and compassionate care. Thanks for hanging in there with me on this blog post, and I hope you, too, continue to develop your clinical reasoning, ask questions, and don’t let insurance policy dictate your clinical practice.
Citations:
1. Scott KM. Pelvic floor rehabilitation in the treatment of fecal incontinence. Clin Colon Rectal Surg. 2014 Sep;27(3):99-105. doi: 10.1055/s-0034-1384662. PMID: 25320568; PMCID: PMC4174224.
2. Roongsirisangrat S, Rangkla S, Manchana T, Tantisiriwat N. Rectal balloon training as an adjunctive method for pelvic floor muscle training in conservative management of stress urinary incontinence: a pilot study. J Med Assoc Thai. 2012 Sep;95(9):1149-55. PMID: 23140031.
3. Bols E, Berghmans B, de Bie R, Govaert B, van Wunnik B, Heymans M, Hendriks E, Baeten C. Rectal balloon training as add-on therapy to pelvic floor muscle training in adults with fecal incontinence: a randomized controlled trial. Neurourol Urodyn. 2012 Jan;31(1):132-8. doi: 10.1002/nau.21218. Epub 2011 Oct 28. PMID: 22038680.
4. Bols E, Hendriks E, de Bie R, Baeten C, Berghmans B. Predictors of a favorable outcome of physiotherapy in fecal incontinence: secondary analysis of a randomized trial. Neurourol Urodyn. 2012 Sep;31(7):1156-60. doi: 10.1002/nau.21236. Epub 2012 Apr 4. PMID: 22488751.
5. Baker J, Eswaran S, Saad R, Menees S, Shifferd J, Erickson K, Barthelemy A, Chey WD. Abdominal Symptoms Are Common and Benefit from Biofeedback Therapy in Patients with Dyssynergic Defecation. Clin Transl Gastroenterol. 2015 Jul 30;6(7):e105. doi: 10.1038/ctg.2015.30. PMID: 26225863; PMCID: PMC4816253.
6. LaCross, Jennifer A., et al. “Physical therapy management of functional constipation in adults: A 2021 evidence-based clinical practice guideline from the American Physical Therapy Association’s Academy of Pelvic Health Physical Therapy.” Journal of Women’s Health Physical Therapy, vol. 46, no. 3, 19 May 2022, <https://doi.org/10.1097/jwh.0000000000000244>.
Author: Shelby Landrum PT, DPT, Board Certified Orthopedic Clinical Specialist - CPT US Army, 2024 Early-Professional CAPP Scholarship Recipient
Author Bio: Dr. Shelby Landrum PT, DPT obtained her Doctorate of physical therapy from the Medical University of South Carolina in 2022. She then completed a post graduate residency in Orthopedics with the Department of Veteran Affairs in 2023. While completing her education, she served in the GA National Guard as a field artillery data system specialist, commissioned officer into the USAR, and gave birth to two beautiful daughters. She now serves on active duty in Fort Johnson, LA. In her free time she enjoys continuing education and is proud to have completed Pelvic Floor 1, 2A, 2B through both Herman & Wallace as well as the APTA, pregnancy and Postpartum Corrective Exercise & Pelvis Pro by Sarah Duvall, MDT A & B, and numerous pelvic sanity courses.
