Background: obstructed defecation is one of the most com-
mon subtypes of constipation, and it is frequently responsive to
Aims: since a history of sexual and physical abuse may be pre-
sent in patients with obstructed defecation, we assessed the inci-
dence of abuse history in patients with obstructed defecation re-
ferred to a general gastroenterology practice, and whether such a
history may lead to a different outcome of biofeedback training in
Patients and methods: one hundred and twenty-one pa-
tients (17 men, 104 women, age 53 ± 15 years) with obstructed
defecation were studied by retrospective chart review. Their histo-
ry of sexual, physical and psychological abuse was obtained by a
standard interview, and biofeedback training was carried out by
means of a three-balloon technique.
Results: a history of sexual/physical or psychological abuse
was present in 12.4% patients. Biofeedback training yielded a
successful improvement of obstructed defecation in 93% patients
without abuse and in 100% of patients with abuse; this difference
was not statistically different (p = 0.53).
Conclusions: the prevalence of sexual/physical or psycholog-
ical abuse in a population of patients with obstructed defecation
referred to a general gastroenterology practice is relatively low;
such a history seems not to affect the outcome of biofeedback
training in these patients.
Key words: Abuse. Biofeedback. Constipation. Obstructed defe-
Chronic constipation is a frequent complaint in clinical
practice, and affects 3 to 30% of the general population in
Western countries, particularly women (1). However, re-
cent studies have shown that similar figures are also pre-
sent in other countries, such as Latin America (2).
The pathophysiological basis of chronic idiopathic
constipation may basically be reconducted to two main
subtypes, slow-transit constipation (STC) and constipa-
tion due to obstructed defecation (OD) (3). The latter, af-
ter excluding anatomical or mechanical causes, may be
often due to paradoxical contraction or failure to relax of
the pelvic floor muscles during attempts to defecate,
which impedes the outflow of feces (4,5).
The prevalence of OD in different series varies be-
tween 25 and 70% (6,7). This probably reflects different
population samples, with a prevalence of 7% in the gen-
eral population (8). In many of these patients biofeedback
treatment is very effective (9,10).
Even though behavioral or psychological disturbances
are frequently encountered in OD, it is still controversial
whether these abnormalities are the cause or the conse-
quence of this often disabling symptom (11).
Physical and/or psychical abuse are described with rel-
ative frequency in some functional gastrointestinal disor-
ders, particularly in patients with irritable bowel syn-
drome (IBS) (12,13); less data are available for
constipated, non-IBS patients. Two recent studies report-
ed that more than 32% of patients with OD had a history
of physical and/or psychical abuse (14,15). However, no
data on the treatment of such patients are available.
The purpose of this study was: a) to establish the preva-
lence of sexual/physical or psychological abuse in a general
gastroenterology practice of a Latin American population;
and b) to assess whether patients with OD and a history of
abuse respond differently to biofeedback treatment when
compared to those without such a history of abuse.
Prevalence of sexual and physical abuse in patients with
obstructed defecation: impact on biofeedback treatment
L. I. Solé, M. C. Bolino, M. Lueso, L. Caro, C. Cerisoli, N. Castiglia1and G. Bassotti2
Diagnostic and Therapeutic Gastroenterology Practice (GEDYT). 1Methodology Institute. Buenos Aires, Argentina.
2Gastroenterology and Hepatology Section. Department of Clinical & Experimental Medicine. University of Perugia.
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
Copyright © 2009 ARÁN EDICIONES,S. L. REV ESP ENFERM DIG (Madrid)
Vol. 101. N.° 7, pp. 464-467, 2009
Correspondence: Gabrio Bassotti. Clinica di Gastroenterologia ed Epatolo-
gia. Ospedale Santa Maria della Misericordia. Piazzale Menghini, 1. 06156
San Sisto (Perugia), Italy. e-mail: firstname.lastname@example.org
Solé LI, Bolino MC, Lueso M, Caro L, Cerisoli C, Pastiglia N,
G. Bassotti. Prevalence of sexual and physical abuse in pa-
tients with obstructed defecation: impact on biofeedback treat-
ment. Rev Esp Enferm Dig 2009; 101: 464-467.
06. OR 1507 SOLE:Maquetación 1 28/7/09 16:36 Página 464
We retrospectively reviewed the charts of all patients
of a general gastroenterology practice – the Diagnostic
and Therapeutic Gastrointestinal practice, GastroEn-
terología Diagnóstica y Terapéutica (GEDYT) – evaluat-
ed for OD that underwent biofeedback training during the
period January 2004-January 2006. To be classified as
OD the patients had: a) to fulfill Rome II criteria for con-
stipation (16), i.e. two or more of six symptoms present
for at least 12 weeks of the preceding 12 months: strain-
ing, lumpy or hard stools, sensation of incomplete evacu-
ation, sensation of anorectal obstruction/blockage, or
manual maneuvers to facilitate defecation on more than
one fourth of bowel movements, or less than three evacu-
ations per week; and b) paradoxical contraction or failure
to relax pelvic floor muscles during attempts to defecate,
as shown by anorectal manometry and defecography. It is
worth noting that according to these criteria patients also
met the recently published Rome III criteria for function-
al defecation disorder (17). Secondary causes of consti-
pation were excluded by clinical and drug history taking,
physical examination, blood chemistry, and colonoscopy
or barium enema.
Diagnostic criteria of sexual, physical, and
All patients were evaluated for sexual and physical
abuse according to previously described criteria by
means of a standard, previously validated questionnaire
(18). This was done in a trustful clinical setting that en-
sured confidentiality and the patients’ right not to dis-
close such information if unable or unwilling.
Sexual abuse criteria
Sexual abuse was defined as any of three types of sex-
ual experiences: those involving attempts; those involv-
ing forced sexual touching with hand, mouth, or objects;
and lastly, those in which vaginal or anal intercourse
(rape) occurred (19,20). Briefly, the questionnaire includ-
ed the paraphrased items below. When you did not want
it, has anyone ever: threatened to have sex with you,
touched the sex organs of your body, made you touch the
sex organs of their body, forced you to have sex, or have
you had any other unwanted sexual experience?
Physical abuse criteria
Using the same interview for sexual abuse, we also in-
cluded questions concerning physical abuse. We counted
physical abuse only when it occurred as an event outside
the sexual abuse incident. Thus, physical abuse in this
study was counted only if the incident did not involve
sexual abuse. Physical abuse was divided into two cate-
gories: beaten, hit, or kicked, and life threat (19,20), and
was evaluated by a multiple-choice answer given to the
following question: when you were a child or nowadays,
have you ever been beaten, hit or kicked by someone old-
er than you or by other adult, respectively?: never; some-
times; occasionally; frequently. We considered physical
abuse when “frequently” was answered, or when a brutal
attack required medical aid or resulted in squeals.
Psychological abuse criteria
Psychological abuse was considered to be present
when at least one affirmative response was given to the
following questions: have you ever felt that someone in
your family or at work made you feel that you had no val-
ue on several occasions? Have you ever been accused un-
justifiably by a member of your family or at work on sev-
eral occasions? Have you ever been asked too much of
you by a member of your family or at work on several oc-
casions? Have you ever been forced to attend family
conflicts or difficult situations without being involved by
a member of your family or at work on several occa-
sions? For both sexual and physical abuse, yes/no re-
sponses were obtained.
Biofeedback training (six weekly sessions of 30 min-
utes’ duration) was carried out by means of a three-bal-
loon manometric system (21). Biofeedback treatment in-
volved measuring internal anal sphincter (IAS) relaxation
and external anal sphincter (EAS) contraction by record-
ing pressure changes in two intra-anal balloons, and us-
ing a third balloon for rectal distension. By gradually and
progressively inflating the balloons located at the IAS
and EAS levels, while simultaneously asking the patient
to bear down, allowed the investigator and the patient to
visualize on a computer screen the effects of simulated
defecation. If during this maneuver a paradoxical con-
traction (i.e., increased pressure instead of relaxation dur-
ing straining) of the sphincter was observed, the patient
was instructed to relax in order to obtain a tracing similar
to that of a normal subject, also displayed on the screen.
Constant visual (by recording) and verbal reinforcements
were given to patients by the therapist when correct re-
sponses were made, and the patients were encouraged to
try harder or to modify their efforts in order to produce
normal tracings (i.e., avoiding paradoxical contraction of
Patients were considered to have a successful biofeed-
back treatment if at the end of the training session they
Vol. 101. N.° 7, 2009 PREVALENCE OF SEXUAL AND PHYSICAL ABUSE IN PATIENTS WITH OBSTRUCTED 465
DEFECATION: IMPACT ON BIOFEEDBACK TREATMENT
REV ESP ENFERM DIG 2009; 101 (7): 464-467
06. OR 1507 SOLE:Maquetación 1 28/7/09 16:36 Página 465
were able to normalize paradoxical contraction at
manometry, to have at least two bowel movements per
week without (or with sporadic, i.e. once or less per
week) use of laxatives, and to refrain from the use of dig-
ital maneuvers to help defecation.
Since this was a retrospective study, no study-driven
clinical intervention was performed; therefore only a
simplified Institutional Review Board approval for retro-
spective studies was necessary.
Pre- and post-treatment data were compared by means
of Fisher’s exact test. p values < 0.05 were chosen for re-
jection of the null hypothesis.
Chart review showed that 121/131 (92%) patients (17
men, 104 women, age 53 ± 15 years) were eligible for the
study. The ten patients excluded were so for incomplete
data (5 patients), and inability to fulfill the entry criteria
A history of abuse was found in 15/121 (12.4%) pa-
tients (5 sexual; 10 physical or psychological). Once OD
was diagnosed, all patients were treated with high-fiber
diet and/or laxatives, and this regimen did not resolve the
symptoms in 70 patients. These latter subjects were re-
ferred for biofeedback training.
Biofeedback treatment was thus carried out in 60 pa-
tients without a history of abuse and in 10 of those with a
history of abuse. At the end of the biofeedback training,
56/60 (93%) of the former and 10/10 (100%) of the latter
had a successful response, according to the criteria de-
scribed above: this difference was not significant (p =
0.53) between the two groups. No differences between
manometric or defecographic findings and between types
of abuse were found concerning the response to biofeed-
In this study we report that the prevalence of
sexual/physical or psychological abuse in patients re-
ferred to a general gastroenterology practice is slightly
higher than 10%, and lower than that reported by other
authors (14,15). However, the latter studies recruited pa-
tients referred to tertiary centers, more likely to be highly
selected and having more associated pathologies. Of
course, due to the peculiar, intimate, and difficult topic to
face, which requires some deep and trusty relationship
between patient and physician, there is the possibility that
a history of abuse could have not been reported or elicit-
ed in some of the patients during their evaluation. Studies
on patients with IBS, for instance, show different health
seeking behaviors in patients with and without a history
of abuse (22).
Biofeedback treatment is an effective option for pa-
tients with OD (5,6,23), as was also recently demonstrat-
ed by controlled trials (9,10,24), and the present study
confirmed this. In fact, 94% of our patients undergoing
this training had a successful response, al least in the
short term; however, there is evidence of a sustained re-
sponse of up to two years in up to 80% of patients (9).
The efficacy of biofeedback training for OD is influenced
by the skills of the biofeedback therapist and the tech-
nique used for training (9,10). We feel that the good re-
sults we obtained were due to the treatment being admin-
istered by the same physician with a long-standing
experience in such training, as shown in sexually abused
women with anismus (25). Of course, different results
may be obtained in different settings (26).
This study has limitations. We were unable to detect
differences in the response to biofeedback treatment be-
tween patients with and without a history of abuse; this
might be due to the small sample size of patients with
such a history that underwent this treatment, even though
it has been claimed that an abuse history has no relevant
role in the pathogenesis of either functional or organic
chronic gastrointestinal disorders, but it can affect their
clinical expression irrespective of functional or organic
diagnosis (27). Moreover, colonic transit was not evaluat-
ed; previous studies have shown reduced response rates
to biofeedback training in patients with coexistent OD
and slow transit compared to those with normal transit
(28). This potential confounding factor was not assessed
here. Finally, the period of observation of the results was
limited to the treatment period; long-term data are needed
to establish whether this treatment is effective in abused
patients even in the long term, as demonstrated in pa-
tients with OD without a history of abuse (9).
However, we feel that these results might be of inter-
est, since as far as we know there are no other such stud-
ies from South America evaluating the effect of biofeed-
back training in patients with OD and a history of abuse.
Since there is literature evidence of strong and consistent
relationships of sexual and physical abuse history with
functional GI symptoms and disorders (29), further stud-
ies in larger cohorts of patients are needed to establish the
proper effect of abuse on the effectiveness of biofeedback
training in OD patients.
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Vol. 101. N.° 7, 2009 PREVALENCE OF SEXUAL AND PHYSICAL ABUSE IN PATIENTS WITH OBSTRUCTED 467
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