골반저 근실조에서 전기자극 치료와 바이오피드백 병합 치료의 효과 = Combined Therapy with Electrical Stimulation and Biofeedback for Treating Pelvic Floor Dyssynergia골반저 근실조에서 전기자극 치료와 바이오피드백 병합 치료의 효과

국문 초록 (Abstract)

목적 : 바이오피드백은 골반저 근실조에서 높은 치료 효과를 보이지만 일부 환자는 증상의 호전을 경험하지 못한다. 최근 변실금에서 효과가 알려진 전기자극 치료가 만성변비에서도 효과가 있을 가능성이 제기되고 있다. 저자들은 골반저 근실조에서 전기자극 치료와 바이오피드백 병합 요법의 효과에 대해 알아보고, 이들 치료의 효과에 있어 substance P의 역할에 대해서도 알아보고자 하였다. 대상 및 방법: 골반저 근실조로 진단된 변비 환자를 무작위로 분류하여 EB군은 전기자극 치료 후 바이오피드백을, BE군은 바이오피드백 후 전기자극 치료를 시행하였다. 두 군에 대해 치료 전, 첫 치료 후 및 두 번째 치료 완료 후 증상 및 배변 만족도, 항문직장 내압검사와 직장 점막 조직 생검에서 substance P 면역화학염색 결과 등을 분석하였다. 결과: 40명의 환자가 포함되었으며 EB 군이 20명(21-77세, 남:여=8:12), BE 군이 20명(24-70세, 남:여=7:13)이었고, 치료 전 주관적 증상, 대장통과시간, 항문직장 내압검사와 substance P 발현은 두 군에서 차이가 없었다. EB 군 및 BE 군 모두 각각의 치료 후 배변 만족도 및 증상의 호전을 보였으며, 첫 치료 후 호전율(60% vs. 60%; p=1.000)과 두 번째 치료 완료 후 최종 호전율(85% vs. 80%; p=0.681)에 있어 차이는 없었다. 항문직장 내압검사에서 휴식기 항문괄약근압이 치료 후 감소하는 경향을 보인 이외에 다른 변수의 유의한 변화는 없었다. Substance P의 발현도 두 군 모두에서 치료 전후에 유의한 차이가 없었다. 결론: 전기자극 치료와 바이오피드백은 각각 단독으로 골반저 근실조 환자에서 치료 효과를 보여주었을 뿐 아니라 병합하여 시행했을 때 추가적 증상의 호전을 보여주었다. 따라서, 골반저 근실조 환자에서 전기자극은 표준 치료인 바이오피드백에 반응하지 않거나 충분한 호전을 보이지 않는 경우에 추가함으로써 부가적 치료 효과를 기대할 수 있는 방법으로 생각된다.

다국어 초록 (Multilingual Abstract)

Background/Aims: Although electrical stimulation therapy (EST) has been tried for treating fecal incontinence, there are only limited reports concerning the application of EST to pelvic floor dyssynergia (PFD). We aimed to evaluate the efficacy of combined EST and biofeedback therapy (BFT) for treating PFD. We also checked the substance P expression in the rectum for evaluating the underlying mechanism. Methods: Constipated patients who were diagnosed with PFD were randomly divided into two groups. In the EB group, the patients first underwent EST and then BFT. In the BE group, BFT was applied first and then EST was performed. In both groups, the measurement the symptoms and performing anorectal manometry and immunohistochemical staining for substance P in the rectal mucosa were done before and after administering therapies. Results: Forty patients were analyzed. The baseline characteristics and substance P expression were not different between the EB and BE groups. The patient`s symptoms were improved after the first and second therapy, and the proportion of improved patients after both therapies did not differ between the two groups. The anorectal manometric parameters with the patient resting anal the sphincter pressure were significantly decreased in the BE group, but, these tended to show decreases in the EB group. The expression of substance P also did not change before and after the therapies. Conclusions: EST alone showed therapeutic efficacy for treating PFD and it produced additional improvement of symptoms when combined with BFT. (Kor J Neurogastroenterol Motil 2006;12:108-116)

참고문헌 (Reference)

1 "Tissue localization and relative distribution of regulatory peptides in separated layers from the human bowel" 777-786, gastroenterology1983;84

2 "The effects of biofeedback on rectal sensation and distal colonic motility in patients with disorders of rectal evacuation evidence of an inhibitory rectocolonic reflex in humans?" 94 : 751-756, 1999

3 "Substance P in rectal mucosa of children with chronic constipation" 31 : 41-45, 2001

4 "Slow transit constipation in children" 37 : 426-430, 2001

5 "Sacral nerve stimulation for faecal incontinence" 22 : 1-5, 2005

6 "Sacral nerve stimulation as a treatment for fecal incontinence" 121 : 536-541, 2001

7 "Projections of substance P- containing neurons within the guinea-pig small intestine" 411-424, neuroscience1981;6

8 "Patterns of anismus and the relation to biofeedback therapy" 39 : 768-773, 1996

9 "Patient satisfaction after biofeedback for constipation and pelvic floor dyssynergia" 131 : 152-156, 2001

10 "Obstructive defecation: a failure of rectoanal coordination" 93 : 1042-1050, 1998

11 "Long-term study on the effects of visual biofeedback and muscle training as a therapeutic modality in pelvic floor dyssynergia and slow-transit constipation" 47 : 90-95, 2004

12 "Long-term effectiveness of sacral nerve stimulation for refractory urge incontinence" 39 : 101-106, 2001

13 "Isolated anal sphincter hypertension as a cause of obstruction to defecation" 120 : 2001

14 "Is paradoxical contraction of puborectalis muscle of functional importance?" 667-670,

15 "Innervation of the muscularis mucosa in the canine stomach and colon" scandjgastroenterol1982;17

16 "Gastrointestinal transit and anorectal manometry in children with colonic substance P deficiency" 16 : 624-630, 2001

17 "Electromyography of the pelvic floor musculature in the assessment of obstructed defecation symptoms" 44 : 1168-1175, 2001

18 "Electrical stimulation for the treatment of urinary incontinence" 51 : 24-26, 1998

19 "Efficacy and safety of sacral nerve stimulation for urinary urge incontinence: a systematic review" 175 : 835-841, 2006

20 "Effects of biofeedback therapy on anorectal function in obstructive defecation" 42 : 2197-2205, 1997

21 "Effect of sacral nerve stimulation in patients with fecal and urinary incontinence" 44 : 779-789, 2001

22 "Effect of electrical stimulation in constipated patients with impaired rectal sensation" 18 : 433-438, 2003

23 "Dyssynergic defecation" 30 : 97-114, 2001

24 "Distributions of substance P- and VIP-immunoreactive nerve fibres in the colonic circular muscle in children" 14 : 66-70, 1998

25 "Decreased substance P levels in rectal biopsies from patients with slow transit constipation" 8 : 1207-1211, 1996

26 "Clinical results of sacral neuromodulation for chronic voiding dysfunction using unilateral sacral foramen electrodes" 16 : 313-321, 1998

27 "Clinical characteristics of patients with chronic constipation after radical hysterectomy or delivery" 44 : 267-274, 2004

28 "Clinical and physiologic effects of biofeedback in outlet obstruction constipation" 39 : 520-524, 1996

29 "Chronic idiopathic slow transit constipation: pathophysiology and management" 5 : 288-296, 2003

30 "Cholinergic stimulation and nonadrenergic, noncholinergic relaxation of human colonic circular muscle in idiopathic chronic constipation" 43 : 2719-2726, 1998

31 "Biofeedback treatment for functional anorectal disorders: a comprehensive efficacy review" 29 : 153-174, 2004

32 "Biofeedback for pelvic floor dysfunction in constipation" 328 : 393-396, 2004

33 "A new technique for sacral nerve stimulation a percutaneous method for urinary incontinence caused by spinal cord injury" 81 : 315-318, 1998

34 "A case of constipation with decreased rectal sensation improved by electrical stimulation therapy alone" 7 : 245-250, 2001