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Review

Home Biofeedback Training for Pelvic Floor Disorders: Is There Hope for Hopeless Patients?

by
Marek Vojtko
,
Peter Banovcin
,
Martin Duricek
,
Jakub Hoferica
and
Peter Liptak
*
Clinic of Internal Medicine-Gastroenterology, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University, 03601 Martin, Slovakia
*
Author to whom correspondence should be addressed.
Gastrointest. Disord. 2025, 7(2), 35; https://doi.org/10.3390/gidisord7020035
Submission received: 8 April 2025 / Revised: 8 May 2025 / Accepted: 16 May 2025 / Published: 19 May 2025
(This article belongs to the Topic Advances in Gastrointestinal and Liver Disease: From Physiological Mechanisms to Clinical Practice)
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Abstract

:
The most common anorectal disorders are fecal incontinence, functional anorectal pain, and functional defecation disorders. They are often presented by overlapping symptoms with various degrees of severity. Therefore, a personalized approach to the patient is crucial for diagnosing and determining the prognosis of the disease. Biofeedback training is appropriate to consider when the motoric function disorder is known, the patient could learn voluntary control of response, and this could further lead to an improvement in the condition. Biofeedback is recommended for short-term and long-term treatment of constipation in adults and fecal incontinence in adults. It could also be considered for treatment of specific cases of anorectal pain. As office biofeedback is often time-consuming and comes with a substantially high cost, there is an emerging trend of home biofeedback administration. However, only a few significant studies have been published on this new approach. Although comprehensive data are needed to evaluate the proper strategy and development of various treatment protocols for different types of defecation disorders, home biofeedback therapy offers a potentially effective tool in the personalized treatment of defecation disorders.

1. Introduction

Anorectal disorders often present with overlapping symptoms with various degrees of severity. Therefore, a personalized approach to the patient is crucial for diagnosing, treating, and determining the disease prognosis [1].
The most common anorectal disorders on which this review focused are fecal incontinence, functional anorectal pain, and functional defecation disorders [2].
Fecal incontinence (FI) is the recurrent uncontrolled passage of fecal material for at least three months [2]. Its prevalence is higher in women [3] than in men, and although there are no sufficient data, based on large community studies, FI is relatively common, with a prevalence of up to 7% in the population worldwide [4]. Therapy for fecal incontinence should be specifically tailored to each individual patient’s symptom presentation [5].
Functional defecation disorders are best described by the paradoxical movement of pelvic floor muscles, hence the term pelvic floor dyssynergia. Clinical manifestation includes constipation, often with straining and a feeling of incomplete evacuation. The criterion for diagnosis is the presence of at least two abnormal results from three of the following: an anorectal manometry, a balloon expulsion test, and imaging methods [2]. Constipation in general is present in approximately 14% of patients worldwide, with a higher prevalence in women and the elderly [6,7]. Tanner and colleagues published a study in which 22% of patients with chronic constipation presented with pelvic floor dyssynergia [8].
Functional anorectal pain consists of three possibly overlapping disorders, namely, proctalgia fugax, levator ani syndrome, and unspecified anorectal pain. Distinguishing markers are the duration of pain and the presence of anorectal tenderness [2]. The prevalence of functional anorectal pain in the population is approximately 6–7% [9], although, as in other pelvic floor disorders, it is possible to conclude that the prevalence could be higher due to underreporting by patients.
It is possible to conclude that pelvic floor disorders in general are highly prevalent, especially in primary care settings and in obese and older women [10]. It has been reported that approximately one quarter of women in the United States of America have at least one disorder from the spectrum of pelvic floor disorders [11].
Biofeedback training is considered when the motoric function disorder is known, and voluntary control of response could be learned by the patient, which could further improve the condition. Biofeedback training consists of learning and enhancing motoric skills with augmented feedback on a physiological response, exposing the patient to a graded physiological sensation to improve their perception of the response, or a combination of the two [12].
The position paper of the American Neurogastroenterology and Motility Society (ANMS) and the European Society of Neurogastroenterology and Motility (ESNM) recommends biofeedback for short-term and long-term treatment of constipation in adults and fecal incontinence in adults [13]. It is also possible that short-term biofeedback could be helpful in the treatment of levator ani syndrome with dyssynergic defecation and solitary rectal ulcer syndrome with dyssynergic defecation; however, the evidence for such an approach is low. The ANMS and the ESNM do not support using biofeedback in children with constipation or fecal incontinence [13].
Structural abnormalities have to be ruled out when indicating biofeedback for pelvic floor dyssynergia; on the other hand, this is not a contraindication in cases of fecal incontinence [14]. As was shown by results of a study performed in Turkey, both patients with and without sphincter abnormalities could benefit from biofeedback treatment for fecal incontinence [15].
There are several types of biofeedback devices, from simple visual feedback (e.g., gradually lighting diodes) [16,17] to devices with voice command [18] and different types of stimulation [19] (Figure 1).
The majority of biofeedback training is performed in ambulatory settings in specialized centers, so its availability is not universal.
As ambulatory biofeedback is often time consuming and comes with a substantially higher cost of medical care, there is an emerging trend of home biofeedback implantation, even using unusual and highly personalized approaches such as an Internet of Medical Things [20]. However, few relevant studies considering this new approach have been published so far [18,21,22,23] (Table 1).
In general, defecation disorders resulting from abnormal functions of pelvic floor structures could be suitable for personalized biofeedback therapy [26]. Every patient for whom biofeedback is considered should be evaluated appropriately, including methods such as three-dimensional (3D) anorectal manometry or magnetic resonance (MR) defecography when possible; otherwise, simpler methods, such as a balloon expulsion test or X-ray defecography, should be utilized [27].
The important factor to consider when suggesting a patient for biofeedback therapy is the inconsistent variability between centers and medical professionals operating or administering the biofeedback (home or office), as it is very operator-dependent [28].
Although uncritical appraisal is sporadically voiced for biofeedback [29], its effectivity is based on personal/individual patient adherence, among other prognostic factors such as the duration and intensity of training and patient education [30].
There is also an uneven number of relevant studies regarding the efficacy of biofeedback in different circumstances. Based on one older review of 74 qualified studies, 33 were trials for fecal incontinence, 38 were for pelvic floor dyssynergia or functional constipation, and only 3 were for anorectal pain [31].
Although the biofeedback method in gastroenterology is primarily used in defecation disorders, there are scarce scientific data on using biofeedback therapy in other functional gastrointestinal disorders (now more precisely called disorders of gut–brain interactions, DGBIs), foremost, irritable bowel syndrome and functional dyspepsia [12].

2. Biofeedback Training for Fecal Incontinence

The first references of biofeedback training for fecal incontinence come from the 1970s [32]. Recently published European Guidelines (a joint effort of the United European Gastroenterology (UEG), European Society of Neurogastroenterology and Motility (ESNM), European Society of Clinical Pharmacy (ESCP), European Society For Primary Care Gastroenterology (ESPCG)) for the diagnosis and treatment of fecal incontinence consider biofeedback therapy as a first-line treatment option for this condition [33], although the effect of home biofeedback has not been evaluated. It was also concluded that biofeedback combined with pelvic floor physiotherapy resulted in fewer days with incontinence episodes per week and possibly a reduction in FI severity compared to physiotherapy alone. However, no difference in the quality of life (QoL) index was found (based on the meta-analysis and RCTs considered in these guidelines), and there is no significant evidence that biofeedback is superior to education procedures only in this regard [33].
Biofeedback is also suitable for patients whose other means of conservative treatment failed and who are not able or willing to undergo more invasive procedures [34]. Compliance and after-treatment follow-up are important in ensuring the long-term sustainability of positive treatment benefits [35].
If appropriate patient compliance is secured, biofeedback therapy for fecal incontinence has the potential to introduce long-term sustainability of good bowel movement and anorectal function [36].
The Cochrane analysis concluded that in patients who failed to improve after the more prevalent conservative therapies, biofeedback could be more beneficial than pelvic floor exercises alone [37]. This could be mainly effective in patients with moderate symptoms of fecal incontinence [38]. The combination of conservative therapy (e.g., loperamide and stool bulking agents) with biofeedback is superior to individual therapy modalities alone [39].
Results of some older studies suggest that in addition to the positive physiological influence of biofeedback on the pelvic floor reinforcement, the placebo effect could also play a non-negligible role [40].

3. Home Biofeedback Training for Fecal Incontinence

Several randomized controlled studies [41] reported the efficacy of home biofeedback in treating fecal incontinence, and further studies are focusing on developing an appropriate home biofeedback protocol [42].
Based on results of known studies published to this day, home biofeedback is suggested to be more beneficial than electric stimulation alone or biofeedback in an office setting when performed two times daily [43]. The response rate to biofeedback may vary and is based on several factors, including age and sex. Therefore, it is suitable to consider the management of each patient individually (e.g., the duration of biofeedback and intensity) [24].
Results of a randomized controlled study by Bertlett and colleagues show that home biofeedback is well tolerated, leads to a significant improvement in quality of life, and reduces overall embarrassment, particularly in younger patients [44].
Recently published results of a randomized controlled study by Xiang and colleagues show that home biofeedback is non-inferior to standard office-based biofeedback therapy and is a safe and effective way to improve patients’ quality of life with considerably better adherence to treatment [22]. This was assessed using stool diaries, validated questionnaires, and anorectal manometry.
Another study comparing standard biofeedback protocol versus home electrical stimulation in women showed that home electrical stimulation may provide an alternative to general office biofeedback training [19].

4. Biofeedback Training for Constipation

As in the case of fecal incontinence, biofeedback training has been used for decades to treat constipation [45,46,47,48,49,50,51].
Considering different causes of constipation, biofeedback therapy is primarily used to treat constipation due to pelvic floor dyssynergia, not constipation due to slow transit or functional constipation [52], and it is therefore important to obtain a diagnosis of dyssynergia with a very high proof level (e.g., using anorectal manometry in combination with a balloon expulsion test). However, the concomitant presence of a slow transit colon pattern is not a contraindication for biofeedback therapy, which has been proven effective in patients with overlapping pathophysiological factors of constipation [53]. Both the European Society of Neurogastroenterology and Motility [52] and the Korean Society of Neurogastroenterology and Motility [54] strongly recommend using biofeedback for treating constipation with pelvic floor dyssynergia with a moderate-to-high level of evidence [52,54].
The main goal of biofeedback training in pelvic dyssynergia is to restore a regular pattern of defecation. This goal has two pivotal parts: (1) correction of the dyssynergia and/or incoordination of muscles that have specific roles in the defecation maneuver (musculus abdominalis, musculus puborectalis, and musculi ani sphincteri); and (2) enhancement of rectal sensory perception mainly in those patients with impaired rectal sensation [55]. Therefore, it is essential to rule out structural abnormalities and other main reasons for constipation besides pelvic floor dyssynergia before administering biofeedback therapy [56]. From a technical point of view, there are three main kinds of biofeedback training [57].
Sensory training is performed by introducing and then slowly withdrawing a balloon filled with water while the patient is instructed to concentrate on the sensation evoked by the balloon, simultaneously trying to ease the passage [58].
Electromyography is based on recording patient electromyographic activity of the pelvic floor muscles during training, obtained from either intraluminal or skin electrodes (using perianal placement). The patient receives visual feedback by looking at the recording and trying to gradually relax their pelvic floor muscles while obtaining sufficient intra-abdominal pressure [59,60].
The third option is using data obtained by anorectal manometry, which is a technique that measures the pressure (and more importantly changes in the pressure) in the anal canal and rectum [61,62].
Studies comparing the effect of feedback provided by electromyography to manometry concluded that both techniques lead to similar improvements in pelvic floor dyssynergia [61], the number of spontaneous bowel movements, and the physiological state of patients [63].
Several studies have shown that biofeedback therapy for dyssynergia leads to sustained good clinical response to therapy for 12 to 44 months [64], with a 55–82% overall patient response [65,66]. A post-analysis of two prospective studies showed that factors significantly associated with the positive outcome of biofeedback are the need for manual evacuation and low baseline satisfaction with bowel movements before training [66].
Several randomized studies also reported the long-term efficacy of biofeedback treatment with no side effects [67].
The considerable limitation of biofeedback for pelvic floor dyssynergia is its limited availability, restriction to specialized centers, and the need for multiple sessions in an outpatient setting [68].
Although most published data focuses on adult patients, several studies have been performed on the pediatric population. However, a meta-analysis by Wegh and colleagues concluded that biofeedback has no additive effect in children with functional constipation, and that there is inconclusive evidence for a positive effect in patients with dyssynergic defecation [68].
The slightly outdated Cochrane analysis performed in 2012 identified seventeen studies with a total of 931 patients that explored the effect of biofeedback therapy on patients with chronic constipation regardless of (but mostly with) the presence of dyssynergic defecation. They found low and very low qualities of evidence from studies supporting the effectiveness of biofeedback in the treatment of chronic constipation, with most of these studies compromised by poor methodological quality and a recognizable risk of bias [69].
Therefore, there is a long-term need for a sufficient number of high-quality studies investigating the effectiveness of biofeedback in treating dyssynergic defecation [25].
A group from Chapel Hill in North Carolina, USA, performed a prospective, randomized study comparing biofeedback to placebo and to diazepam in the treatment of pelvic floor dyssynergia. Although all patients in all three groups received the same professional rehabilitation management (six bi-weekly, one-hour sessions), patients receiving biofeedback presented with significantly more spontaneous bowel movements at the end of the study compared to the other methods. These results show that biofeedback has a possible pivotal role in the treatment of defecation disorders resulting from pelvic floor dyssynergia [25].
The relatively recent systematic review and meta-analysis by Moore and Young in 2020 concluded that biofeedback is recommended for patients who failed to respond to conservative therapy [70]. However, there is still a problem with the heterogeneity of trials considered in meta-analysis and high risks of bias. However, home biofeedback therapy could lead to improved accessibility of treatment, and thus a higher recruitment rate in future clinical trials, providing additional relevant data.
A study in a Singapore tertiary care center specializing in defecation disorders showed that biofeedback therapy is significantly effective in improving the quality of life of patients with dyssynergic defecation based on the Gastrointestinal Quality of Life Index (GIQLI) measurement developed by Eypasch and colleagues [71]. What is more important, this positive effect tended to persist in 71% of patients over the course of the follow-up period, with a median of 20 months, although the objective’s parameters (as for anorectal manometry) were not measured [72].
There are several considerable limitations when considering biofeedback, regardless of the home or office setting. First and foremost, no unified and widely accepted algorithm is backed by sufficient data from relevant studies. This leads to various protocols, a different number of sessions (usually four to six), and different durations of individual sessions (usually from 30 to 60 min). There are no generally consensual criteria regarding the basic requirements for a health care professional to be able to administer biofeedback properly [73]. This is even more pronounced in terms of home biofeedback, as there are scarcely published (albeit convincing in terms of efficacy) data regarding the procedure algorithm in the treatment of dyssynergic defecation.

5. Home Biofeedback Training for Constipation

The prospective study by Heymen and colleagues focused on comparing different biofeedback protocols, including home training, as follows: (1) outpatient intra-anal electromyographic biofeedback training; (2) electromyographic biofeedback training plus intrarectal balloon training; (3) electromyographic biofeedback training plus home training; and (4) electromyographic biofeedback training, balloon training, and home training. All patients in all groups reported significant improvement in bowel movements, with no differences between these methods. This means that electromyographic biofeedback administered alone once weekly in an outpatient office setting is as effective as a combination of electromyographic training and home training [74].
The significant single-blinded randomized study performed by Rao and colleagues compared the efficacy of home-based (HB) versus office-based (OB) biofeedback on various aspects of bowel movements and motility patterns in patients with constipation [23]. The duration of the intervention was 3 months. Overall satisfaction with bowel movements was substantially increased in both groups, with increased spontaneous bowel movements in the HB group almost five times greater compared to the baseline, and four times greater in the OB group compared to the baseline. Although stool consistency improved only slightly in both groups, there were significant improvements in the straining sensation, both in patients with home and office biofeedback. Regarding objective measurements consisting of data from anorectal manometry, the dyssynergia pattern was corrected or significantly improved in 72% of patients with home biofeedback and 80% of patients receiving office biofeedback. Parameters of rectoanal coordination were considerably enhanced in both groups, and sensory thresholds for the first sensation were significantly shortened. The balloon expulsion test also showed improved (decreased) time of expulsion in both groups. And finally, rather interestingly, even the proportion of patients with slow colon transit was significantly reduced in patients with home biofeedback, but it was not reduced in the group of patients with office biofeedback. Overall, the results of this study show that 68% of patients responded to home biofeedback compared to 70% responders to office biofeedback, proving that home biofeedback is not inferior to a more traditional office setup [23].
In a consecutive analysis, the same group focused on the quality of life and cost-effectiveness of home biofeedback compared to office biofeedback [75]. QoL was significantly improved in both groups, with better cost-effective performance in the group with home biofeedback.
Although these are promising results, it is important to note that all aforementioned studies were performed on relatively small samples of patients. Accordingly, reported outcomes could not be considered with great confidence as proof of the definite superiority of home biofeedback training compared to an office setting. This is true for fecal incontinence and constipation alike.

6. Biofeedback Training for Anorectal Pain

As presented in a recent systematic review by Wagner and colleagues, only a limited number of trials have focused on the effect of biofeedback on anorectal pain, and none considered home biofeedback as a treatment option [76]. Of these trials, the majority were designed as non-randomized (n = 5), and only one was randomized. All trials reported the positive effect of biofeedback, but the level of treatment success varied substantially, which could be explained by a significant heterogeneity of design in these trials (the number of patients, inclusion and exclusion criteria, and comparison of interventions).
Probably the first report on biofeedback treatment in chronic proctalgia was from Grimaud and colleagues in 1991, who reported that all 12 patients in the group stated significant pain alleviation after eight sessions [77]. However, several other studies did not replicate the same level of positive effect [78,79] of this therapy, although results showed a beneficial impact in a significant percentage of patients [80,81]. Chiarioni and colleagues presented results of a three-arm randomized controlled trial comparing biofeedback, electrogalvanic stimulation, and levator ani massage for pain relief in patients without constipation [81]. BFB was proven superior to other trial therapeutic modalities, and the effect lasted for 12 months. This effect was observed only in patients who manifested tenderness on rectal examination.
A biofeedback protocol for pelvic dyssynergia could be applied to patients with anorectal pain with concomitant obstructive defecation syndrome, as it was observed that the vast majority of these patients reported significant improvement in their condition during the two-year follow-up [82]. Based on the current state of the evidence, patients with anorectal pain who benefit most from biofeedback are those with tenderness of the musculus levator ani and pelvic floor dyssynergia, which are generally considered to be related to striated muscle tension [83].

7. Home Biofeedback Training for Anorectal Pain

As mentioned above, there are no currently published studies regarding biofeedback training for anorectal pain in the home environment.

8. Conclusions

Implementation of home biofeedback training presents a highly personalized approach to patients with pelvic floor disorders. The outcome of this review, which is also observed in our unpublished experience with home biofeedback in various indications, is that the best results, both in improving clinical symptoms and objective manometry results, are obtained from patients with fecal incontinence. Patients with pelvic floor dyssynergia, constipation, and functional anorectal pain report less satisfaction with the treatment, though the results of several trials are promising.
Although further studies are needed to evaluate the proper approach and development of various treatment protocols for different kinds of pelvic floor disorders, home biofeedback therapy offers an emerging and effective tool in the personalized management of these conditions (Figure 2).

Author Contributions

Conceptualization, P.L. and P.B.; writing—original draft preparation, P.L., M.D., J.H. and M.V.; writing—review and editing, P.L. and P.B.; supervision, P.B. All authors have read and agreed to the published version of the manuscript.

Funding

Funded by the EU NextGenerationEU through the Recovery and Resilience Plan for Slovakia under the project No: 09I03-03-V04-00761.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. The NeuroTrac© MyoPlus device for home biofeedback training used at the authors’ motility lab. This device provides various modes of visual feedback to patients during training. In this example, patients control the airplane’s movement by voluntarily changing the anal tone (sqeezing and relaxing). The presented mode is used for fecal incontinence rehabilitation.
Figure 1. The NeuroTrac© MyoPlus device for home biofeedback training used at the authors’ motility lab. This device provides various modes of visual feedback to patients during training. In this example, patients control the airplane’s movement by voluntarily changing the anal tone (sqeezing and relaxing). The presented mode is used for fecal incontinence rehabilitation.
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Figure 2. A schematic visualization of the conclusion of this review.
Figure 2. A schematic visualization of the conclusion of this review.
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Table 1. Clinical trials evaluating the effect of home biofeedback training for the treatment of pelvic floor disorders.
Table 1. Clinical trials evaluating the effect of home biofeedback training for the treatment of pelvic floor disorders.
Type of StudyInterventionControl GroupNumebr of Patients/
Controls		Measured OutcomeResults
Fecal Incontinence
Xiang et al. [22]RCT (Randomized Controlled Trial)Home biofeedback + electrical stimulationOffice biofeedback alone20/10Number of weekly FI episodes Home biofeedback is non-inferior to office biofeedback.
Bertlett el al. [24]RCTSupplementary BFB (biofeedback)Office biofeedback alone39/36Quality of lifeSupplementary home biofeedback is superior to office biofeedback. No difference in overall clinical improvement. Younger patients tend to have better results.
Constipation
Heymen et al. [25]RCT1. Supplementary BFB
2. Supplementary BFB + balloon training		1. Office intraanal electromyographic biofeedback training
2. Office electromyographic biofeedback training plus intrarectal balloon training		8 + 10/9 + 9Number of unassisted bowel movements (days per week)Supplementary home biofeedback does not lead to better results.
Rao et al. [23]RCTHome biofeedback aloneOffice biofeedback alone38/45Number of bowel movements per week, dyssynergia pattern, balloon expulsion time, digital maneuver use, and bowel satisfactionHome biofeedback is non-inferior to office biofeedback. Both methods led to significant improvement of measured parameters.
Anorectal pain
No studies published to this date
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Vojtko, M.; Banovcin, P.; Duricek, M.; Hoferica, J.; Liptak, P. Home Biofeedback Training for Pelvic Floor Disorders: Is There Hope for Hopeless Patients? Gastrointest. Disord. 2025, 7, 35. https://doi.org/10.3390/gidisord7020035

AMA Style

Vojtko M, Banovcin P, Duricek M, Hoferica J, Liptak P. Home Biofeedback Training for Pelvic Floor Disorders: Is There Hope for Hopeless Patients? Gastrointestinal Disorders. 2025; 7(2):35. https://doi.org/10.3390/gidisord7020035

Chicago/Turabian Style

Vojtko, Marek, Peter Banovcin, Martin Duricek, Jakub Hoferica, and Peter Liptak. 2025. "Home Biofeedback Training for Pelvic Floor Disorders: Is There Hope for Hopeless Patients?" Gastrointestinal Disorders 7, no. 2: 35. https://doi.org/10.3390/gidisord7020035

APA Style

Vojtko, M., Banovcin, P., Duricek, M., Hoferica, J., & Liptak, P. (2025). Home Biofeedback Training for Pelvic Floor Disorders: Is There Hope for Hopeless Patients? Gastrointestinal Disorders, 7(2), 35. https://doi.org/10.3390/gidisord7020035

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