Pelvic floor physical therapy combined with biofeedback electrical stimulation for postoperative fecal incontinence in children with Hirschsprung’s disease

Abstract

BACKGROUND

Postoperative fecal incontinence after Hirschsprung’s disease (HD) surgery is a common problem affecting the quality of life in affected children. Pelvic floor physical therapy (PFPT) combined with biofeedback electrical stimulation (BES) offers an innovative, non-invasive rehabilitation treatment for this issue, but the clinical efficacy remains unclear.

AIM

To study the efficacy of PFPT combined with BES for fecal incontinence in children after HD surgery.

METHODS

Clinical data of children with fecal incontinence after HD surgery, who underwent BES and PFPT at the Department of Pediatric Surgery of Anhui Provincial Children’s Hospital from January 2018 to June 2025, were collected, including symptom duration, anal pressure parameters, Fecal Incontinence Scores, etc. Children treated with BES alone from January 2018 to May 2022 were designated as the single treatment group; children treated with PFPT combined with BES from June 2022 to June 2025 were designated as the combined treatment group.

RESULTS

A total of 56 children were collected, including 40 males and 16 females. Among them, 31 children were in the single treatment group and 25 in the combined treatment group. There were no statistical differences between the two groups in terms of age, gender (P > 0.05). At the initial evaluation stage, there were no statistical differences in clinical indicators. After three treatment courses, both groups showed significant improvement in anal resting pressure, initial sensation threshold, defecation sensation threshold, defecation urgency threshold, and Fecal Incontinence Scores (P < 0.05). The P value for defecation urgency threshold after treatment in both groups was 0.077 (P > 0.05), showing no statistical significance, while the P values for anal resting pressure, initial sensation threshold, and defecation sensation threshold were < 0.001, and Fecal Incontinence Score showed P = 0.013, with statistical significance (P < 0.05).

CONCLUSION

PFPT combined with BES is a safe and effective treatment for fecal incontinence in children after HD surgery, and the combined treatment group shows better results than the single treatment group, making it worthy of clinical promotion and application.

Key Words: Pelvic floor physical therapy; Biofeedback electrical stimulation; Hirschsprung’s disease; Fecal incontinence; Anorectal manometry parameters; Children

Core Tip: Pelvic floor physical therapy combined with biofeedback electrical stimulation is a safe and effective treatment for fecal incontinence in children after Hirschsprung’s disease surgery, and the combined treatment group shows better results than the single treatment group, making it worthy of clinical promotion and application.

INTRODUCTION

Pelvic floor physical therapy (PFPT) is a non-invasive physical therapy that directly stimulates the pelvic floor nerves, enhances nerve excitability, and strengthens pelvic floor muscle contractions. Studies have shown that fecal incontinence significantly improves after PFPT[1]. There are many studies on biofeedback electrical stimulation (BES) for fecal incontinence, with a success rate of 75%-80%[2]. Currently, BES has become an effective option for treating defecation disorders after Hirschsprung’s disease (HD) surgery[3]. However, there are few reports in the literature on pelvic floor magnetic therapy for fecal incontinence, and the clinical efficacy of PFPT combined with BES for fecal incontinence after HD surgery in children is unclear. There is a lack of evaluation of the techniques used for this disease and the results of combined treatment. From January 2018 to May 2022, 31 children with fecal incontinence after HD surgery were treated with BES at our hospital. From June 2022 to June 2025, 25 children received PFPT combined with BES for fecal incontinence after HD surgery. This study will analyze the efficacy of these treatments in these children.

MATERIALS AND METHODS

Clinical data

Children who received BES alone from January 2018 to May 2022 were collected as the single treatment group, including 23 boys and 8 girls, with an average age of 3 (3.00, 5.00) years. Pathological classifications included 1 case of short segment type, 22 cases of common type, and 8 cases of long segment type. From June 2022 to June 2025, children who received PFPT combined with BES were designated as the combined treatment group, including 17 boys and 8 girls, with an average age of 3 (3.00, 6.50) years. Pathological classifications included 1 case of short segment type, 19 cases of common type, and 5 cases of long segment type. There were no statistically significant differences between the two groups in terms of age, gender, surgical age, symptom duration, and pathological classification (P > 0.05), as shown in Table 1.

Table 1 Comparison of baseline data between the two groups.

Factors/groups		Combined treatment group	Single treatment group	χ2/t/Z value	P value
Age (year), median (IQR)		3(3.00, 6.50)	3 (3.00, 5.00)	-0.314	0.754
Gender	Male	17	23	0.26	0.61
	Female	8	8
Surgical age, median (IQR)		0.7 (0.46, 2.00)	0.7 (0.42, 1.00)	-0.099	0.921
Symptom duration, median (IQR)		2 (1.00, 2.25)	2 (1.50, 2.50)	-0.296	0.767
Pathological type	Short segment	1	1	-0.513	0.608
	Common type	19	22
	Long segment	5	8

IQR: Interquartile range.

Inclusion criteria

Children diagnosed with HD undergoing laparoscopic-assisted Soave modification surgery based on preoperative imaging, rectal mucosal biopsy, and intraoperative and postoperative pathological examination.

Exclusion criteria

Children who are uncooperative, children with metal or electronic devices implanted near the stimulation site, children with congenital heart disease, pulmonary hypoplasia, epilepsy, rib or spinal development abnormalities, and congenital diseases such as urinary system disorders. To ensure the objectivity of the study results and minimize measurement bias, blinding was implemented for the outcome assessors. All healthcare professionals involved in the evaluation of outcome indicators (including those responsible for performing anorectal manometry and analyzing the Wexner scores) were unaware of the patient’s group allocation. Throughout the assessment process, the assessors were unable to determine whether the patients belonged to the combined treatment group or the single treatment group, thereby maximizing the reliability and authenticity of the evaluation results.

After treatment, the follow-up period for patients was 3 months. Informed consent was obtained from the children's families, and the study was approved by the Ethics Committee of Anhui Provincial Children’s Hospital.

Fecal incontinence scoring table

The Wexner Fecal Incontinence Score, as shown in Table 2[4], was used.

Table 2 Wexner Fecal Incontinence Score[4].

Score/frequency	Never occurred	Occasionally (< 1 time/month)	Sometimes (> 1 time/month, < 1 time/week)	Frequently (≥ 1 time/week)	Daily (≥ 1 time/day)
Solid fecal incontinence	0	1	2	3	4
Liquid fecal incontinence	0	1	2	3	4
Gas incontinence	0	1	2	3	4
Need to alter lifestyle	0	1	2	3	4
Need for protective tools	0	1	2	3	4

Never occurred: Did not occur in the past four weeks; Occasionally occurred: Occurred once in the past four weeks; Sometimes occurred: Occurred more than once in the past four weeks, but less than once per week; Frequently occurred: Occurred more than once per week in the past four weeks, but less than once per day on average; Occurred daily: Occurred once or more per day on average in the past four weeks. Minimum score of 0: No fecal incontinence; Maximum score of 20: Complete fecal incontinence.

BES treatment

The Canadian LABORIE BES device was used for neuroelectrostimulation (20 minutes) + Kegel training (15 minutes) for children with fecal incontinence after HD surgery. A complete treatment consists of 20 minutes of neuroelectrostimulation followed by 15 minutes of Kegel training, performed once daily. Ten complete treatments constitute one course, with a total of 6 courses, lasting 3 months. The current intensity range is (0-20) mA, starting from 0 mA and gradually increasing the intensity until the child feels stimulation without pain. During the treatment, the children's responses were closely monitored, and treatment parameters were promptly adjusted to ensure safety.

PFPT

In the combined treatment group, after receiving BES treatment, children with fecal incontinence after HD surgery were treated with the VISHEE Pelvic Floor Magnetic Therapy Device produced by Nanjing WISE Medical Technology Co., Ltd, which was operated in fecal incontinence mode for 20 minutes per session.

The frequency was 50 Hz, stimulation duration was 5 seconds, rest time was 5 seconds, number of pulses was 120, and intensity was 22%. During the treatment, the children's responses were closely monitored, and treatment parameters were promptly adjusted to ensure safety.

Anorectal manometry procedure

Anorectal manometry was performed using the Canadian LABORIE anorectal dynamometer. Two to four hours prior to the procedure, the child underwent a cleansing enema with a suppository until the stool was clear. The procedure involved the child being positioned in the left lateral or lithotomy position, using a catheter with an inflatable tip to detect and record relevant parameters. Anorectal manometry was performed before and after treatment.

Statistical analysis

SPSS 29.0 was used to perform the corresponding statistical analysis of clinical data. Continuous data (e.g., age) were expressed as means ± SD or as medians and interquartile ranges, and comparisons between groups were made using independent sample t-tests (for normally distributed data with equal variances) or Wilcoxon rank-sum tests (for non-normally distributed data or unequal variances). Comparisons of categorical data (e.g., gender, complications) were made using the χ² test; Fisher’s exact test was used when the sample size n < 40 or if any cell in the contingency table had a frequency T < 1. A P value < 0.05 was considered statistically significant.

Follow-up

All children in this study were successfully followed up using a combination of outpatient visits and telephone follow-ups, with follow-up durations 3 months.

RESULTS

After three treatment courses, the symptoms of all 56 children significantly improved. In the initial assessment stage, the Fecal Incontinence Scores for the two groups were 9.56 ± 2.63 and 9.70 ± 2.22, respectively; the anal resting pressures were 25.44 ± 3.94 mmHg and 24.55 ± 3.04 mmHg, respectively; the initial sensation thresholds were 55.40 ± 3.12 mL and 54.71 ± 3.93 mL, respectively; the defecation sensation thresholds were 121.24 ± 10.61 mmHg and 121.58 ± 8.38 mL, respectively; the defecation urgency thresholds were 148.44 ± 6.14 mL and 148.00 ± 4.36 mL, After treatment, the biofeedback current intensities were 4.20 ± 0.42 mA and 4.15 ± 0.51 mA, with no statistically significant difference (P > 0.05), as shown in Table 3. respectively. There were no statistical differences in these parameters between the two groups (P > 0.05), as shown in Table 3.

Table 3 Comparison of anorectal manometry parameters and Fecal Incontinence Scores between the two groups before treatment, mean ± SD.

Factors/groups		Combined treatment group	Single treatment group	χ2/t/Z value	P value
Anorectal manometry parameters	Anal resting pressure (mmHg)	25.44 ± 3.94	24.55 ± 3.04	0.956	0.343
	Initial sensation threshold (mL)	55.40 ± 3.12	54.71 ± 3.93	0.715	0.478
	Defecation sensation threshold (mL)	121.24 ± 10.61	121.58 ± 8.38	-0.131	0.896
	Defecation urgency threshold (mL)	148.44 ± 6.14	148.00 ± 4.36	0.313	0.755
Biofeedback current intensity (mA)		4.20 ± 0.42	4.15 ± 0.51	0.232	0.819
Fecal Incontinence Score		9.56 ± 2.63	9.70 ± 2.22	-0.231	0.818

Regarding anal resting pressure, initial sensation threshold, defecation sensation threshold, defecation urgency threshold, and Fecal Incontinence Scores, significant improvements were observed before and after treatment in both groups (P < 0.05; Table 4).

Table 4 Comparison of anorectal manometry parameters and fecal incontinence scores between the two groups before and after treatment, mean ± SD.

Factors/groups			Before treatment	After treatment	t value	P value
Combined treatment group	Anorectal manometry parameters	Anal resting pressure (mmHg)	25.44 ± 3.94	35.08 ± 1.23	-11.662	< 0.001a
		Initial sensation threshold (mL)	55.40 ± 3.12	41.16 ± 2.73	17.156	< 0.001a
		Defecation sensation threshold (mL)	121.24 ± 10.61	101.60 ± 5.82	8.117	< 0.001a
		Defecation urgency threshold (mL)	148.44 ± 6.14	154.00 ± 4.46	-3.606	< 0.001a
	Fecal Incontinence Score		9.56 ± 2.63	4.16 ± 0.94	9.659	< 0.001a
Single treatment group	Anorectal manometry parameters	Anal resting pressure (mmHg)	24.55 ± 3.04	34.45 ± 0.81	-17.514	< 0.001a
		Initial sensation threshold (mL)	54.71 ± 3.93	47.03 ± 2.39	9.303	< 0.001a
		Defecation sensation threshold (mL)	121.58 ± 8.38	110.29 ± 4.89	6.481	< 0.001a
		Defecation urgency threshold (mL)	148.00 ± 4.36	151.42 ± 5.81	-2.622	0.011a
	Fecal Incontinence Score		9.70 ± 2.22	4.90 ± 1.16	10.659	< 0.001a

^aP < 0.05 indicates statistical significance.

Regarding anal resting pressure, initial sensation threshold, defecation sensation threshold, defecation urgency threshold, and Fecal Incontinence Scores, a comparison after treatment showed that there were statistically significant differences between the two groups in anal resting pressure, initial sensation threshold, defecation sensation threshold, and Fecal Incontinence Scores (P < 0.05). However, the defecation urgency threshold showed no statistically significant difference between the two groups after treatment (P > 0.05; Table 5).

Table 5 Comparison of anorectal manometry parameters and fecal incontinence scores between the two groups after treatment, mean ± SD.

Factors/groups		Combined treatment group	Single treatment group	χ2/t/Z value	P value
Anorectal manometry parameters	Anal resting pressure (mmHg)	35.08 ± 1.23	34.45 ± 0.81	2.265	0.028a
	Initial sensation threshold (mL)	41.16 ± 2.73	47.03 ± 2.39	-8.577	< 0.001a
	Defecation sensation threshold (mL)	101.60 ± 5.82	110.29 ± 4.89	-6.007	< 0.001a
	Defecation urgency threshold (mL)	154.00 ± 4.46	151.42 ± 5.81	1.803	0.077
Fecal Incontinence Score		4.16 ± 0.94	4.90 ± 1.16	-2.579	0.013a

^aP < 0.05 indicates statistical significance.

Follow-up results

After discharge, all children were followed up for 3 months. During the follow-up period, 7 cases in the combined treatment group and 18 cases in the single treatment group still experienced occasional incontinence. During the follow-up period, 2 cases in the combined treatment group relapsed, with a recurrence rate of 8%, while 4 cases in the single treatment group relapsed, with a recurrence rate of 12.9%. All 6 patients who relapsed had the long-segment type of the condition.

DISCUSSION

PFPT and BES

HD is a common congenital intestinal malformation, with an incidence rate of approximately 1/5000[5]. The current preferred surgical method is laparoscopic-assisted Soave modification. Although the affected bowel segment is surgically removed, some patients still experience fecal incontinence and soiling symptoms postoperatively. Saleem et al[6] and others conducted long-term follow-up on children after megacolon surgery and found that 35.5% of the children had fecal incontinence, with 25% of them having persistent symptoms. Long-term fecal incontinence brings many inconveniences to patients in daily life and socializing, and it may affect the psychological well-being of children to some extent[7,8].

Therefore, surgery is not the endpoint of treatment for this disease. For children with postoperative fecal incontinence, appropriate defecation training and rehabilitation can improve symptoms. Currently, PFPT and BES have been widely accepted in the treatment of fecal incontinence. PFPT, with its non-invasive and sustained stimulation of the sacral nerve roots and pelvic floor muscles, is widely used for pelvic floor muscle rehabilitation, fecal incontinence, stress urinary incontinence, and other areas[9,10]. For example, Brusciano et al[11] in a retrospective study, and Barba et al[12] in a prospective study, both concluded that PFPT is a safe and reliable treatment for fecal incontinence. BES has also been recommended as a non-surgical treatment for fecal incontinence by the American Society of Colon and Rectal Surgeons clinical practice guidelines[13]. The combined treatment of PFPT and BES is becoming increasingly accepted in clinical practice. Song and Zhou[14] found in a study of 200 postpartum stress urinary incontinence patients treated with PFPT combined with BES that after treatment, the bladder trigone, urethral rotation angle, and bladder neck mobility decreased, and the electromyographic values of rapid contraction and tonic contraction increased. The study concluded that combined treatment could improve pelvic floor muscle electromyographic signals and pelvic function. Gao et al[15] in a comparative study on PFPT combined with BES for uterine prolapse patients found that the combined treatment group had better pelvic muscle strength grading and pelvic organ prolapse staging compared to the single BES group. The study concluded that PFPT combined with BES has a good therapeutic effect on uterine prolapse patients, improving pelvic muscle strength and the degree of prolapse. Therefore, we hypothesize that combined treatment can better improve pelvic floor muscle function and enhance defecation control in children. However, there are few studies on the application of PFPT combined with BES for fecal incontinence after HD surgery, and its clinical efficacy in children remains unclear.

Efficacy study of pelvic floor magnetic stimulation combined with BES vs BES alone

In this study, children with fecal incontinence after HD surgery were assessed using the Wexner scale before and after treatment. In the combined treatment group, the Fecal Incontinence Score before treatment was 9.56 ± 2.63, and after treatment, it was 4.16 ± 0.94 (P < 0.05). In the single treatment group, the Fecal Incontinence Score before treatment was 9.70 ± 2.22, and after treatment, it was 4.90 ± 1.16 (P < 0.05). The differences between the two groups were statistically significant, and both groups showed improvement in Fecal Incontinence Scores after treatment. After treatment, both groups showed improvements in anal resting pressure, initial sensation threshold, and defecation urgency threshold (P < 0.05), with statistically significant differences. The anorectal manometry parameters improved in both groups after treatment. Brusciano et al[10] in a study of 30 fecal incontinence patients treated with PFPT found a significant reduction in the frequency of fecal incontinence. Ng et al[16] in a study of 137 fecal incontinence patients treated with BES found that 68.6% of patients had improved Wexner scores, and 65% had improved Fecal Incontinence Quality of Life (FIQL) scores. 47.4% of patients showed improvements in both Wexner scores and FIQL. These results are consistent with those of the current study.

After treatment, the Fecal Incontinence Scores in the two groups were 4.16 ± 0.94 and 4.90 ± 1.16, respectively, with a statistically significant difference (P < 0.05). The initial sensation thresholds after treatment were 41.16 ± 2.73 mL and 47.03 ± 2.39 mL for the combined and single treatment groups, respectively; the defecation sensation thresholds were 101.60 ± 5.82 mL and 110.29 ± 4.89 mL, with P < 0.05, showing a statistically significant difference, indicating that PFPT combined with BES has better effects than BES alone. This conclusion is consistent with the findings of Deng et al[17] and Wang et al[18] on the treatment of fecal incontinence with PFPT combined with BES. Meanwhile, after treatment, the anal resting pressures in the two groups were 35.08 ± 1.23 mmHg and 34.45 ± 0.81 mmHg, respectively (P = 0.028), with a statistically significant difference. Anal resting pressure is the most critical pressure for maintaining anal continence and preventing involuntary leakage of feces, gas, and liquid[19]. This difference in changes may be an important factor leading to the differences in Fecal Incontinence Scores after treatment between the two groups, which requires further exploration by future researchers. Filippini et al[20] have confirmed in related studies that PFPT can promote the recovery of pelvic floor muscle and nerve injuries. The primary somatic and autonomic nerve supplies for the pelvic floor muscles and rectum come from the sacral nerve roots S2-S4. Stimulating these roots is an effective way to control pelvic organs and regulate the pelvic floor. Magnetic stimulation treatment for incontinence patients can promote the growth of myofibrils and the development of new protein filaments and muscle fibers, directly leading to muscle hypertrophy, which increases muscle strength and endurance. In this study, the combined group showed better recovery of the initial sensation threshold and defecation sensation threshold than the single treatment group, which may be because the PFPT promoted the repair of pelvic floor muscle and nerve injuries in the combined group, improving sensitivity to rectal stimulation and further enhancing pelvic floor muscle contraction, thus improving defecation control in children.

During the follow-up period, 7 children in the combined treatment group and 18 children in the single treatment group occasionally experienced incontinence. In the combined treatment group, 2 patients experienced relapse, with a relapse rate of 8%, while in the single treatment group, 4 patients relapsed, resulting in a relapse rate of 12.9%. All 6 relapsed patients had the long-segment type of the condition. Based on this, we hypothesize that relapse may be related to the type of HD, possibly because longer segments of the bowel are resected, leading to poorer physiological function of the remaining bowel and more extensive damage to the pelvic and abdominal tissues and structures, which further impairs bowel function. Of course, this hypothesis needs to be confirmed by subsequent studies. For children who occasionally experience incontinence, we recommend performing pelvic floor exercises, focusing on diet, and establishing regular bowel habits. If the effect is not satisfactory, we suggest an additional course of rehabilitation training. For children who relapse, we will extend the treatment duration.

CONCLUSION

PFPT combined with BES is a safe and effective treatment for fecal incontinence in children after HD surgery, and the combined treatment shows better results than single treatment. This method is worthy of clinical promotion and application. The limitations of this study include given the small sample size in this study, and multicenter controlled trials are necessary to confirm its value.