The effect of biofeedback treatment for children with non-neurogenic voiding dysfunction: A systematic review and meta-analysis

The effect of biofeedback on nonneurological dysfunctional voiding in children: A meta-analysis and systematic review

OBJECTIVE

This study was conducted to investigate the effect of biofeedback (BF) on the rehabilitation of children with nonneurological dysfunctional voiding (NDV).

METHODS

RCTs were retrieved from various databases (published from inception to February 29, 2024). The effects of the BF and non-BF treatments were compared. A random-effects model was used to evaluate the combined data.

RESULTS

Meta-analysis revealed that BF increased the maximum urinary flow rate (SMD = 3.78, 95% CI 1.33∼6.22), improved urination time (SMD = 5.88, 95% CI 3.75∼8.01), and reduced the postvoid residual (SMD = -19.18, 95% CI -27.03∼-11.33) and urinary tract infection incidence (RR = 0.43, 95% CI 0.21∼0.87). Electromyogram activity (RR = 0.46, 95% CI 0.25∼0.84) and abnormal urination patterns (RR = 0.51, 95% CI 0.35∼0.74) improved, with effects persisting for more than 1 year. However, the effect of BF on the mean urinary flow rate in children with NDV was significant only after 1 year of follow-up (SMD = 1.90, 95% CI 0.87∼2.92).

CONCLUSION

Existing evidence indicates that BF can enhance urinary parameters and patterns in children with NDV. However, its effectiveness in addressing constipation, daytime urinary incontinence, and nocturnal urinary incontinence is not substantial. High-quality randomized controlled trials can offer additional insights.

Updates of Overactive Bladder in Pediatrics

Overactive bladder (OAB) is clinically defined as urinary urgency with or without urinary incontinence. It is associated with daytime frequency or constipation and has a prevalence of approximately 5%-12% among 5- to 10-year-olds. The appropriate functional exchange between the pontine micturition center, periaqueductal gray matter, and prefrontal cortex is important for proper micturition control. Several studies on pediatric cases observed a link between OAB and neuropsychiatric problems, such as anxiety, depression, and attention deficit, and treatment of these comorbidities improved patient symptoms. In this review, we present the pathophysiology of OAB, its associated conditions, and aspects related to updates in OAB treatment, and we propose a step-by-step treatment approach following this sequence: behavioral therapy, medical treatment, and invasive treatment. Although anticholinergic drugs are the mainstay of OAB medical treatment, beta-3 agonists and alpha-blockers are now recommended as a result of significant advancements in pharmacologic treatment in the last 10 years. Electrical stimulation techniques and botulinum toxin are also effective and can be used, especially in conventional treatment-refractory cases.

Long-Term Follow-Up of Lower Urinary Tract Outcome in Children with Dysfunctional Voiding

Objective: To investigate the long-term clinical and urodynamic outcomes of a small cohort of children who received short-term urotherapy for confirmed dysfunctional voiding (DV) and lower urinary tract symptoms (LUTS). Materials and Methods: This study included 26 children with confirmed LUTS and DV via video urodynamic study (VUDS) and received standard urological therapy, pelvic floor muscle training, or surgical intervention in childhood. Their current lower urinary tract conditions were assessed by chart review and direct and telephone interviews. Charts of 14 patients who underwent follow-up VUDS were reviewed to investigate their bladder and voiding dysfunction or follow-up on previous treatment results. The satisfaction of lower urinary tract status was assessed using the global response assessment (GRA) scale. Results: At initial enrolment, the mean age was 9.54 ± 3.88 years, and urological treatment was performed during the first 1−5 years thereafter. Most patients were not regularly followed in the urology clinic. Among the 14 children available for follow-up, a GRA score of 3 was reported by 10 (71.4%) after a mean follow-up period of 10.3 ± 6.74 (range, 2−20) years, indicating satisfactory bladder and voiding conditions. Four children with less favorable outcomes (GRA score of <3) had significantly more post-void residual urine volume at baseline, and 75% of these patients had central nervous system diseases. Daytime incontinence and enuresis rates were significantly decreased at follow-up compared with the baseline. Significantly increased bladder capacity and sensation and significantly decreased voiding detrusor pressure were found on follow-up VUDS. Conclusions: Children with DV who received standard urotherapy upon diagnosis exhibited improved LUTS at a 10-year follow-up. Of the 14 children available for follow-up, 10 (71.4%) reported satisfactory bladder and voiding status without further medication or urotherapy, with significantly decreased voiding detrusor pressure.