Urodynamic biofeedback: a new approach to treat vesical sphincter dyssynergia

Urodynamic biofeedback training for children with bladder-sphincter dyscoordination during voiding

Neurologically normal children with recurrent urinary tract infections (UTIs), night- and daytime wetting, and urge and painful voiding may have staccato voiding due to pelvic floor contractions. The immediate effect of non-invasive urodynamic biofeedback (BF) therapy was assessed using a historical follow-up study in 31 children aged 5-15 years suffering from urodynamically proven overactive urethra during voiding. A long-term follow-up study was performed to investigate whether improvement was maintained. Twenty-four children (77.5%) benefited from the treatment. Of these 16 (51.5%) were cured, while 8 (26%) had a pronounced reduction in their symptoms. Although the flow was normalized in 17 (55%) and nearly normalized in 7 (22.5%), there was no significant correlation between subjective and objective criteria of improvement. Similarly, no relationship was found between the initial urodynamic characteristics and the treatment outcome. During a mean follow-up time of 4 years (range: 1-7.5 years) two of the initially cured patients relapsed. They were recurred with a refresher course. Three had had a single or a few episodes of cystitis in the course of several years. Of the patients with pronounced reduction in their symptoms, three relapsed. A refresher course was attempted in two patients; one was successful. It can thus be concluded that BF is an effective way of treating this disturbance and the beneficial effect is to a wide degree maintained.

A psychophysiological evaluation of female urethral syndrome: evidence for a muscular abnormality

This is a preliminary investigation into a recently defined urological disorder occurring in a subgroup of women with "urethral syndrome" suggestive of pelvic floor muscular (PFM) dysfunction. Symptoms include straining to void, urgency, frequency, hesitation, incontinence and/or retention, and subpubic pain. Finding neither bladder nor urological abnormalities, urologists may consider these women emotionally unstable without organic cause for their symptoms. However, their distress may be a consequence rather than a cause of their voiding problems. Sixteen female urological patients were matched with 16 asymptomatic controls to investigate PFM functioning, psychological status, and symptomatology. Results showed heterogeneity of symptomatology and little elevation of depression or anxiety when comparing patients with controls. Hypotheses of muscular abnormality were confirmed. Patients evidence poor control over testing and relaxing PFM, elevations of PFM activity under various conditions, and chronic pain as a prominent symptom. Treatment approaches specifically designed to address PFM dysfunction are discussed.

An effective treatment for functional urinary incoordination

Twenty women diagnosed with functional urinary incoordination were randomly assigned to one of two treatment groups: biofeedback or progressive muscle relaxation. Ten subjects who were placed on a waiting list prior to treatment allocation served as a comparison group. The biofeedback intervention focused specifically on retraining of pelvic floor musculature (PFM). Patients were assessed pretreatment, posttreatment, and at 2-month follow-up. Outcome measures included self-reported symptomatology, psychological functioning, psychophysiological assessment of the PFM, and urologist ratings of problem severity and treatment efficacy. Both treatment approaches proved effective in improving symptomatology and psychological state. Subjects on the waiting list demonstrated no change in urological difficulties. No differences were found between the two treatment groups on any of the outcome measures. Theoretical and practical implications of the results are discussed.

Biofeedback therapy technique for treatment of urinary incontinence

Biofeedback treatment of urinary incontinence is a management method that has low risk and therapeutic efficacy for selected patients. Biofeedback therapy techniques vary widely and have not been well described or standardized. A technique for biofeedback therapy is described that allows accurate signal monitoring and assures appropriate biofeedback to the patient. External anal sphincter electromyographic performance is presented to the patient as a color line graph with pitch variable audio feedback. The method has complete flexibility in providing biofeedback training according to patient performance level and is one that can be easily interpreted by patients who have voiding dysfunctions.

Use of biofeedback in treatment of psychogenic voiding dysfunction

A young man with psychologic problems and a long history of social inadequacy presented with voiding dysfunction. Videocystometrography revealed a normal filling phase and normal initiation of voiding interrupted by considerable straining by the patient and marked sphincter electromyographic (EMG) activity. Temporary amelioration was achieved by infiltration of the sphincter with lignocaine hydrochloride and by biofeedback therapy. In such cases optimal results are expected from long-term behavioral therapy.

Terodiline in the treatment of children with unstable bladders

A double-blind study of terodiline compared with placebo was performed in 58 children aged 6 to 14 years with urgency or urge incontinence. All had an unstable bladder at cystometry. A bladder regimen was emphasised during the study. Continence was improved according to micturition charting and a pad test in both groups. Terodiline at 25 mg/day, however, gave significantly better results than placebo. In patients with a subnormal bladder capacity (less than or equal to 150 ml), a significant increase in capacity was recorded on cystometry during medication with terodiline but not with placebo. The improved continence seen in the placebo group was probably due to the non-specific bladder training achieved by the child's increased awareness and adult involvement during treatment. The even better results attained in the terodiline group shows this drug to be a valuable adjunct to a bladder regimen in children with urge incontinence, particularly since no important adverse effects were noted during an 8-week period.

Biofeedback in treatment of urinary incontinence in stroke patients

Urinary incontinence can occur poststroke owing to weakness or incoordination of sphincter muscles, impaired bladder sensation, or hyperreflexic, neurogenic bladder. Four male subjects who had urinary incontinence associated with a stroke that had occurred 8 months to 10 years earlier, and who averaged 1.6 to 7.5 accidental voidings per week, participated in an outpatient study with a 4-week scheduled-voiding baseline, 2 to 5 sessions of biofeedback-assisted bladder retraining, and 6- to 12-month follow-up. Training sessions included stepwise filling of the bladder and manometric feedback display of bladder pressure, abdominal pressure, and external anal sphincter pressure. Training procedures were designed to teach subjects to attend to bladder sensations, inhibit bladder contractions, and improve voluntary sphincter muscle control. All four subjects achieved and maintained continence regardless of substantial differences in subject characteristics, including laterality of stroke, degree of sensory impairment, and independence in daily activities.

Behavioral training for post-prostatectomy urinary incontinence

We treated 20 men with persistent post-prostatectomy incontinence by biofeedback-assisted behavioral training procedures. Initially, scheduled 2-hour voiding resulted in a mean 33.1 per cent increase in urge incontinence, a mean 28.5 per cent decrease in stress incontinence and no change in continual leakage. Subsequently, biofeedback was used to teach selective control of the sphincter muscles and/or inhibition of detrusor contractions. Individualized home practice included a voiding schedule, sphincter exercises, active use of the sphincter to prevent urine loss and strategies to manage urgency. After 1 to 5 biofeedback sessions patients with urge incontinence demonstrated an average 80.7 per cent decrease in incontinence, while stress incontinence was decreased an average 78.3 per cent and patients with continual leakage were less successful, with a mean 17.0 per cent improvement. The findings indicate that biofeedback training is an effective intervention for episodic stress or urge incontinence after prostatectomy. However, its usefulness appears to be limited in patients with postoperative incontinence characterized by continual leakage.

The use of biofeedback in a behavioral program designed to teach an anxious child self-catheterization

This paper presents a case study of a 7-year-old girl with a noncompliant bladder who was trained to self-catheterize using biofeedback and behavior therapy techniques. Initial attempts to train her to self-catheterize were unsuccessful owing to excessive amounts of fear, muscle tension, and refusal. After seven treatment sessions in which she was instructed in proper self-catheterization technique by a urology nurse clinician and coached in biofeedback-assisted relaxation by a clinical psychologist, the child successfully learned to self-catheterize. EMG readings showed a decrease in quadriceps muscle tension levels across sessions. Eight additional sessions were held in order to train the child's parents in proper technique and coaching procedures. Through the use of portable biofeedback equipment during actual training sessions, the biofeedback served as a cue--first to the child and coach, and later to the child and parents--for when the child needed to stop and relax. This case illustrates the usefulness of biofeedback in a comprehensive behavioral program designed to teach self-catheterization to fearful children.

Rehabilitation of the dysfunctional bladder in children: method and 3-year followup

A rehabilitation program has been developed for children with functional, nonneurogenic bladder disturbance. The basis for the program is a bladder regimen supplemented by biofeedback training if needed. Results in the first 70 children (64 girls and 6 boys) are presented. After 1 and 3 years 36 and 53 children, respectively, had completely normalized voiding patterns, that is they were continent, had no urgency, voided 3 to 6 times a day and emptied the bladder completely in 1 portion with a normal flow rate. The training program is applicable in children with varying urodynamic diagnoses and it has been used in children as young as 4 years old.

Biofeedback training for children with bladder sphincter incoordination

We studied 35 children with voiding dysfunction and detrusor-sphincter incoordination. More than 90 per cent of these patients had a history of repeat urinary tract infections, and medication and surgical treatment of the voiding dysfunction had failed. Of the patients 22 (63 per cent) experienced significant improvement or resolution of the voiding dysfunction when biofeedback was used to teach normal bladder sphincter coordination as part of the over-all treatment regimen. A review of our experience with these patients indicates that with proper patient selection an even higher rate of success may be possible.

Nonneurogenic neurogenic bladder (the Hinman syndrome)--15 years later

Every child with day and night wetting is a suspect for vesicourethral dysfunction on a behavioral basis, which, when severe, appears as a syndrome that we have called the nonneurogenic neurogenic bladder. Futile attempts by the child at sphincteric urinary control in the face of uncontrollable bladder contractions not only produce the symptoms but also the anatomical and functional changes: vesical trabeculation, distortion of the ureterovesical orifices and dilatation of the upper tracts, along with residual urine and consequent bacteriuria. These changes are indistinguishable from obstructive or, particularly, neurogenic factors, although these causes must be ruled out. Urodynamic investigations in these children show incoordination between detrusor contraction and the expected but not forthcoming urethral sphincteric relaxation. Since these children usually are toilet trained initially, the incoordination appears to be a learned behavior or habit, perhaps as a response to under-appreciated detrusor contractions. Reversal of the syndrome is achieved by suitable medication and by some form of suggestion or retraining. Reparative operations will fail if done before the system is balanced.

Innovations in behavioral medicine

The chapter begins with a brief history of the behavioral medicine movement along with an overview of contemporary activities in the field. Three subsequent sections review technical innovations in major areas of clinical behavioral medicine: treatment, health care delivery, and preventive health care. The final section describes the methodological characteristics of research in behavioral medicine, discusses the field in light of the psychosomatic medicine and behavior modification movements, and calls for a conceptual integration that is authentically behavioristic. Already the quality of research in behavioral medicine appears comparable to that of research in behavior therapy. Even so, when viewed in terms of contemporary methodological desiderata, most of the work is fairly unimpressive. Possibly needed are "hybrid" experimental approaches in which the inferential power of intrasubject phase manipulations and between-subject outcome comparisons are combined. There is good reason to believe that behavioral medicine will follow the historical course of behavior therapy/modification, not the course of psychosomatic medicine. Behaviorally knowledgeable psychologists can become major service providers in liaison with well-informed medical practitioners. Some potentially deleterious influences on the behavioral medicine movement are (inevitable) mentalistic and dualistic thinking and a retreat toward psychosomatic medicine. Field behaviorism as an organizing schema can, in principle, serve as a safeguard against such untoward influences.

Urodynamic biofeedback treatment of urinary incontinence in children with myelomeningocele

Eight children with myelomeningocele and chronic neurogenic urinary incontinence were provided urodynamic biofeedback training. During urodynamic biofeedback, six of the eight children demonstrated improved self-regulation of detrusor and/or sphincter functioning. However, substantial improvements in clinical symptomatology (i.e., urinary incontinence) were clearly shown by only one child. Unexpectedly, chronic neurogenic fecal incontinence was reduced in four children. Several methodological modifications are discussed which may improve clinical symptomatology and which may facilitate further urodynamic biofeedback research for these children with congenital neurogenic urinary incontinence.

EMG biofeedback for functional bladder-sphincter dyssynergia: a case study

The present study utilized EMG biofeedback in the treatment of functional bladder-sphincter dyssynergia, a learned incoordination of bladder and urethral sphincter activity during voiding. The condition is usually associated with a history of painful urination due to bladder infections, surgery, or harsh toilet training. The subject was an 8-year-old girl with chronic diurnal urinary frequency, urge incontinence, and nocturnal enuresis. Treatment consisted of intensive instruction in alternately tensing and relaxing her lower pelvic musculature, as well as relaxing during voiding. These exercises were accompanied by EMG biofeedback from perianal and perivaginal surface electrode sites. Home practice consisted of the tense-relax exercise, relaxation during voiding, and self-monitoring and record-keeping. There were 17 sessions over a period of 9 months. No medication was used. Marked reduction (to normal levels) in diurnal urgency and frequency occurred by the 3rd week of therapy, and complete recovery of normal function, including nocturnal continence without waking, occurred by the 13th therapy session, 5 months after therapy began. Follow-up 1 year after therapy revealed that these gains were being maintained. Pre- and posttherapy urodynamic studies corroborated the achievement of normal urinary function.

Urodynamic biofeedback: a new therapeutic approach for childhood incontinence/infection (vesical voluntary sphincter dyssynergia)

A major cause of urinary incontinence and/or recurrent urinary infections in neurologically intact children is vesical voluntary sphincter/urogenital diaphragm dyssynergia and/or "strain" dyssynergia. These acquired or learned mechanisms are characterized by increased striated muscle tone during micturition, residual urine, daytime wetting and/or urinary infections. Generally, pharmacotherapy is prescribed and manipulated to achieve modification of these dysfunctions. Recently, urodynamic biofeedback has surfaced as a suitable therapeutic alternative. We selected 10 children, between 6 1/2 and 16 years old, for biofeedback therapy because of age, intelligence, commitment and conviction to improve. Following inpatient biofeedback 8 of the 10 children demonstrated complete abatement of signs and symptoms in long-term surveillance (6 to 19 months after biofeedback), while 2 moderately improved. Our experience with biofeedback therapy demonstrated that all patients convert to synergistic voiding within 48 hours of therapy. Urodynamic biofeedback appears to be an extremely useful tool in the armamentarium of the urologist treating neurologically normal children with voiding disorders. The possibility that this modality may be useful for adults is intriguing.

Abdominal wall electromyography: a noninvasive technique to improve pediatric urodynamic accuracy

Abdominal wall electromyography, using sticky surface patch electrodes placed on the rectus abdominus muscles, was used during noninvasive urodynamic studies in 60 children to detect straining. Straining, which usually was imperceptible to the examiner, occurred in 64 per cent of neurologically normal children. Urodynamics identified detrusor-sphincter dyssynergia during straining to void but reverted to normal when the same children voided without straining. Because the urodynamic findings that characterize detrusor-sphincter dyssynergia are mimicked by straining and other common urologic entities, the potential for misdiagnosis is great unless some assessment of intra-abdominal pressure is made during neurourologic testing.

Voiding abnormalities in children: methods of evaluation and results of treatment

Recent advances in technology have fueled interest in the field of urodynamics and have made possible accurate diagnosis of voiding abnormalities in children. A thorough understanding of the underlying physiology and institution of the appropriate pharmacologic agents and/or teaching techniques results in correction of the underlying problems in 90% of the cases. Symptoms, techniques of diagnosis, therapeutic regimens, and results of therapy are presented.

Disposable (infant) surface electrocardiogram electrodes in urodynamics: a simultaneous comparative study of electrodes

Substantiated by the simultaneous comparison with wire and rectal catheter electrodes, disposable surface electrocardiogram electrodes developed for infants have proved to be easy to place, well tolerated and reliable for urodynamic testing in more than 400 clinical urodynamic evaluations.

Urodynamic evaluation of dysfunctional bladder neck obstruction in men

Dysfunctional bladder neck obstruction in young men has received increasing interest in recent years. The urodynamic characteristics of this disorder include elevated voiding pressure, normal reflex relaxation of the urethral rhabdosphincter, increased pressure gradient between the membranous urethra and the bladder, and inadequate radiographic bladder neck opening during detrusor activity. The functional changes occurring at the internal sphincter in 3 patients with dysfunctional bladder neck obstruction are described herein. It is demonstrated that the obstruction may result from either an active dyssynergic bladder neck contraction or failure of bladder neck relaxation. While the pathophysiology of dysfunctional bladder neck obstruction is uncertain possible mechanisms are discussed.

The female urethral syndrome: external sphincter spasm as etiology

Many women suffer a constellation of urinary and pelvic symptoms commonly referred to as the urethral syndrome. Numerous medical, surgical and psychological treatment modalities have been used to alleviate the symptoms. Urodynamic techniques were used to study a group of women with the urethral syndrome. Based on the findings of external urethral sphincter spasm and/or pelvic floor hyperactivity the institution of diazepam therapy not only has provided clinical relief but also sphincter synergy as demonstrated by post-treaatment urodynamics.