Combined functional pelvic floor muscle exercises with Swiss ball and urotherapy for management of dysfunctional voiding in children: a randomized clinical trial

The Role of Secondary Conservative Management Strategies in Bladder and Bowel Dysfunction: A Systematic Review and Meta-analysis

OBJECTIVE

We sought to determine the effect of secondary management strategies in addition to urotherapy on bowel bladder dysfunction outcomes.

STUDY DESIGN

The review protocol was prospectively registered (CRD42023422168). MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and Scopus (database initiation until June 2023) were searched. Comparative studies of secondary management strategies vs conventional urotherapy alone were included. Two authors independently screened titles, abstracts, and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results.

RESULTS

In this systematic review and meta-analysis of 18 studies and 1228 children, secondary management strategies (home-based education, biofeedback, and physical therapy) were associated with reduced symptom burden, fewer recurrent urinary tract infections, and improved uroflowmetry findings than children treated solely with urotherapy for conservative management.

CONCLUSIONS

Although there is significant reporting heterogeneity, secondary conservative management strategies such as home education, biofeedback or cognitive behavioral therapy, and physiotherapy-based education are associated with less urinary incontinence, fewer infections, and fewer abnormal uroflowmetry findings.

The applicability of the urine color scale in pediatric urology

AIMS

To determine the level of agreement between healthcare professionals, patients and their parents/guardians in the interpretation of the urine color scale (UCS) in cases of urinary dysfunction, analyzing the applicability of the scale as a diagnostic tool determining the hydration status.

METHODS

This was a cross-sectional study involving 5-17-year-old patients with lower urinary tract symptoms (LUTS) and enuresis. The study was conducted in a public healthcare referral center for pediatric urology in the Brazilian state of Bahia between October 2019 and March 2020. The Kolmogorov-Smirnov test was used to assess the distribution of the variables. Agreement was assessed using the kappa coefficient and weighted kappa. The z-test was used to determine significant differences between the kappa and weighted kappa. The statistical analysis was conducted using SPSS, version 14, and significance was established at p < 0.05.

RESULTS

Forty-four patients were included. The kappa value was 32.4% (p = 0.000) for the agreement between healthcare professionals and patients, 41.9% (p = 0.000) for agreement between healthcare professionals and parents/guardians, and 25.0% (p = 0.001) for agreement between patients and parents/guardians. The weighted kappa was 70.6% (p = 0.000) for agreement between healthcare professionals and patients, 82.4% (p = 0.000) for agreement between healthcare professionals and parents/guardians, and 51.5% (p = 0.001) for agreement between patients and parents/guardians. There was a statistically significant difference in kappa values when the healthcare professionals were compared with the other groups.

CONCLUSIONS

Although there were some inconsistencies in interpretation, the UCS proved to be a useful tool with which to evaluate patients' hydration status.

Evaluation of the results of urodynamic studies in patients with vesicoureteral reflux

BACKGROUND

To investigate urodynamic abnormalities associated with vesicoureteral reflux (VUR) in toilet-trained children.

METHODS

The data of 157 children who were diagnosed with vesicoureteral reflux and referred to our hospital between 2013 and 2022 were retrospectively examined. The urodynamic parameters were analyzed and correlated with age, gender, lower urinary tract symptoms (LUTS), reflux severity, and laterality.

RESULTS

Overall, 131 (83.4%) patients had abnormal urodynamic findings with a male-to-female ratio of 1:1.4. The most common pathological finding was detrusor overactivity (DO), identified in 101 (64.3%) patients, followed by dysfunctional voiding (DV) in 74 (50.3%) patients. Children with VUR grades II and III exhibited a greater percentage of abnormal urodynamic findings than children with grades IV and V. The prevalence of DO was higher in children younger than 10 years old with unilateral and lower-grade VURs. DV was more frequent in children older than 10 years, with bilateral VUR, and higher grade VUR. The prevalence of LUTS, bowel and bladder dysfunction (BBD), and urinary tract infection (UTI) was higher among children with abnormal urodynamic findings.

CONCLUSIONS

Children with VUR have a high incidence of urodynamic disorders. Urodynamic dysfunction may contribute to the pathogenesis of VUR, especially in mild cases.

Home pelvic floor exercises in children with non-neurogenic Lower Urinary Tract Symptoms: Is fitball an alternative to classic exercises?

INTRODUCTION

Biofeedback with home pelvic floor exercises were recommended as non-pharmacologic treatment for non-neurogenic Lower Urinary Tract Symptoms (LUTS) in children. Fitball is recommended to improve all-over flexibility, balance, and coordination, especially for pelvic floor. Aim of the study was to investigate efficacy of standard home pelvic floor exercises versus exercises using fitball.

METHODS

From April 2021 to February 2022 to all children arrived in our clinic with non-neurogenic LUTS nonresponder at urotherapy, our pelvic floor rehabilitative program was proposed. During the rehabilitation children performed: standard urotherapy, pelvic floor animated biofeedback therapy and pelvic floor exercises in a standard way and using a fitball. After the first session, patients received prescription to repeat at home the same exercises performed at hospital. Children who chose classic exercises were enrolled in group A and they who chose fitball in group B. Continence rate, pelvic floor muscles activity, adherence and satisfaction were evaluated by means of bladder diary, external pubococcygeus test and Likert-type psychometric scale (from 1 = very unsatisfied to 5 = very satisfied) respectively.

RESULTS

Twenty-six children affected by LUTS were enrolled: 13 in group A and 13 in B. At 4th control urinary incontinence was reduced by 72,5% in A and 71.4% in B. Pubococcygeus test increased in both groups. Adherence at home was 92% in group A and 62% in group B. Satisfaction with the treatment (4 or 5 points) was 95% in both groups. Four patients of group A and all of group B decided to maintain home exercises including fitball.

CONCLUSIONS

Our preliminary study shows that efficacy of home exercises, with or without fitball, is comparable. Satisfaction with fitball is high, regardless results obtained, because parents and children have learned a new, interesting and stimulating way to manage urinary problems. The opportunity to perform these exercises using fitball, it's an important finding for pediatric population.

Effectiveness of game-based core exercise in children with non-neuropathic bladder dysfunction and comparison to biofeedback therapy

OBJECTIVES

This study was planned to evaluate the effectiveness of game-based core exercises in children diagnosed with non-neuropathic bladder dysfunction and compare this effectiveness to that of the biofeedback treatment method.

METHODS

The study included 48 children, aged 6-13 years, who were diagnosed with non-neuropathic bladder dysfunction. The children satisfying the inclusion criteria were selected by drawing lots from the population with the method of nonprobability random sampling. The patients were divided into three groups: group I, "game-based core stabilization exercise training"; group II, "biofeedback program"; and group III, "game-based core stabilization exercise training in addition to the biofeedback program." The Dysfunctional Voiding and Incontinence Symptom Scale (DVISS) scores and uroflowmetry values of the patients were evaluated before and after the treatment.

RESULTS

The mean age of the participants was 8.81 ± 2.08 years. There was a statistically significant difference between the pretreatment and post-treatment DVISS scores in all three groups (p < .05). However, no significant difference was found among the groups. There was no statistically significant difference in the uroflowmetry results of the patients in group I and II before and after the treatment. In group III, the time to maximum flow rate after treatment was significantly reduced, and the average flow rate was significantly increased.

CONCLUSIONS

According to the results of this study, the use of game-based exercises along with biofeedback treatment may reduce DVISS scores in children with non-neuropathic bladder dysfunction. A combination of the two methods may have positively affected the uroflowmetry results of the patients. We think that game-based exercises will contribute to the literature as a new treatment option in the treatment of non-neuropathic bladder dysfunction.

Uroterapia y mindfulness en el tratamiento de niños con disfunción vesical e intestinal: protocolo para un ensayo clínico

Objetivo:

Presentar un protocolo para ensayo clínico controlado y aleatorizado que estudie los resultados de la asociación entre técnicas de uroterapia estándar y mindfulness en la adhesión al programa y reducción de síntomas de disfunción vesical e intestinal en escolares.

Método:

Presentación descriptiva del protocolo.

Resultados:

El grupo de control deberá recibir orientaciones de medidas comportamentales gradualmente en visitas semanales, durante cuatro semanas. Tales medidas deberán contemplar: control de la ingesta de agua, intervalo de evacuación, ingestión de potenciales irritantes de la vejiga, y entrenamiento muscular del fondo pélvico. El grupo experimental deberá ser sometido al mismo protocolo, además de las técnicas de atención plena (mindfulness), previamente al inicio de cada consulta de uroterapia.

Conclusión:

Se espera estimular la aplicación de este protocolo en diferentes escenarios y así evaluar la contribución de la práctica de atención plena en la adhesión al tratamiento y en la reducción de síntomas.

Pelvic Floor Muscle Resting Tone in Children With Dysfunctional Voiding Symptomology Following Simple Gross Motor Exercises

PURPOSE

The study aimed to understand the effects of a set of simple gross motor exercises on pelvic floor muscle (PFM) resting tone (RT) in children with dysfunctional voiding symptomology.

METHODS

The study compared PFM RT for a single-sample before and after 2 protocols: exercise versus relaxation (metric standard).

RESULTS

Participants included 27 children ages 5.00 to 10.92 years. Preintervention PFM RT was similar between the interventions: 63% (exercise) and 78% (relaxation) of children decreased PFM RT following intervention. Between-intervention post-minus-prechanges in PFM RT were compared. Between-intervention differences were similar.

CONCLUSIONS

Exercise and relaxation protocols were comparable in lowering PFM RT in children with voiding dysfunction. Findings are clinically worthy in that either exercises or relaxation prior to toileting may assist with more complete emptying in children with symptoms.

Non-pharmacologic approach to pediatric constipation

Functional constipation (FC) is a pervasive problem in pediatrics. Although pharmaceuticals are commonly used for FC, parents and patients show reluctance or find dissatisfaction with available medications at times. Further, patients often have interest in utilizing nutraceutical supplements and botanicals that are available over the counter. This literature review aims to summarize research studies performed on non-pharmacologic approaches to constipation and to evaluate the safety and efficacy of these modalities. Overall data on non-pharmacologic treatments for childhood constipation were sparse, and though some studies were available for adult populations, pediatrics studies were generally limited, lacking or flawed. Certain supplements, such as prebiotics, probiotics and fiber, are safe and are without significant side effects. Though fiber supplements such as glucomannan, green banana mass, cocao husk and various fiber blends have emerging evidence in children, evidence for psyllium, cellulose and flaxseed only have supportive studies in adults. Other than senna, studies of botanicals indicate significant safety concerns (in particular with Aloe vera with aloin and Cascara sagrada) and insufficient evidence. For patients with a significant behavioral or anxiety component to their FC and exhibit dyssynergia, mind-body interventions (e.g. diaphragmatic breathing, biofeedback, cognitive behavioral therapy, and behavioral modifications) are certainly safe and effective. Finally, movement and manipulative interventions such as abdominal massage, reflexology, acupuncture and transcutaneous nerve stimulation show promise in the field of pediatric constipation, and data is accumulating for efficacy. These modalities require further study to determine mechanisms of action and which populations may benefit the most from these therapies.

Urotherapy in the treatment of children and adolescents with bladder and bowel dysfunction: a systematic review

OBJECTIVE

To identify and describe the protocols and clinical outcomes of urotherapy interventions in children and adolescents with bladder bowel dysfunction.

METHOD

Systematic review carried out in June 2018 on Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL),Excerpta Medica dataBASE (EMBASE), Scientific Electronic Library Online (SciELO), Cochrane Library, and PsycInfo databases. Clinical trials and quasi-experimental studies carried out in the last ten years in children and/or adolescents with bladder and bowel symptoms and application of at least one component of urotherapy were included.

RESULTS

Thirteen clinical trials and one quasi-experimental study were included, with moderate methodological quality. The heterogeneity of the samples and of the methodological design of the articles prevented the performance of a meta-analysis. The descriptive analysis through simple percentages showed symptom reduction and improvement of uroflowmetry parameters. The identified urotherapy components were: educational guidance, water intake, caffeine reduction, adequate voiding position, pelvic floor training, programmed urination, and constipation control/management.

CONCLUSION

This review indicates positive results in terms of symptom reduction and uroflowmetry parameter improvement with standard urotherapy as the first line of treatment for children and adolescents with bladder bowel dysfunction. It is recommended that future studies bring contributions regarding the frequency, number, and time of urotherapy consultations.

Pelvic floor rehabilitation in children with functional LUTD: does it improve outcome?

INTRODUCTION

If children do not experience satisfactory relief of lower urinary tract dysfunction (LUTD) complaints after standard urotherapy is provided, other treatment options need to be explored. To date, little is known about the clinical value of pelvic floor rehabilitation in the treatment of functional voiding disorders.

OBJECTIVE

Therefore, we compared pelvic floor rehabilitation by biofeedback with anal balloon expulsion (BABE) to intensive urotherapy in the treatment of children with inadequate pelvic floor control and functional LUTD.

STUDY DESIGN

A retrospective chart study was conducted on children with functional incontinence and inadequate pelvic floor control. All children referred for both intensive inpatient urotherapy and pelvic floor rehabilitation between 2010 and 2018 were considered for inclusion. A total of 52 patients were eligible with 25 children in the group who received BABE before inpatient urotherapy, and 27 children in the group who received BABE subsequently to urotherapy. Main outcome measurement was treatment success according to International Children's Continence Society criteria measured after treatment rounds and follow-up.

RESULTS

Baseline characteristics demonstrate no major differences between the BABE and control group. There was a significant difference in improvement between BABE and inpatient urotherapy after the first and second round of treatment (round 1: BABE vs urotherapy; 12% vs 70%, respectively, round 2: urotherapy vs BABE; 92% vs 34%, respectively, both P < .001). In both cases, the urotherapy group obtained greater results (Fig. 1). When the additional effect of BABE on urotherapy treatment is assessed, no significant difference is found (P = .355) in the children who received BABE; 30 (58%) showed improvement on pelvic floor control.

DISCUSSION

Our findings imply that training pelvic floor control in combination with inpatient urotherapy does not influence treatment effectiveness on incontinence. Intensive urotherapy contains biofeedback by real-time uroflowmetry; children receive direct feedback on their voiding behaviour. Attention offered to the child and achieving cognitive maturity with corresponding behaviour is of paramount importance. It is known that combining several kinds of biofeedback does not enhance the outcome. However, our results do not provide a conclusive answer to the effectiveness of pelvic floor physical therapy in the treatment of children with LUTD because we specifically investigated BABE.

CONCLUSION

In this study, we could not prove that pelvic floor rehabilitation by BABE has an additional effect on inpatient urotherapy on incontinence outcomes. Considering the invasive nature of BABE, the use of BABE to obtain continence should therefore be discouraged.

Conservative interventions for treating functional daytime urinary incontinence in children

BACKGROUND

In children, functional daytime urinary incontinence is the term used to describe any leakage of urine while awake that is not the result of a known underlying neurological or congenital anatomic cause (such as conditions or injuries that affect the nerves that control the bladder or problems with the way the urinary system is formed). It can result in practical difficulties for both the child and their family and can have detrimental effects on a child's well-being, education and social engagement.

OBJECTIVES

To assess the effects of conservative interventions for treating functional daytime urinary incontinence in children.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains studies identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 11 September 2018). We also searched Chinese language bibliographic databases: Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and Wanfang. No language restrictions were imposed.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised, multi-arm studies, cross-over studies and cluster-randomised studies that included children aged between 5 and 18 years with functional daytime urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened records and determined the eligibility of studies for inclusion according to predefined criteria. Where data from the study were not provided, we contacted the study authors to request further information. Two review authors assessed risk of bias and processed included study data as described in the Cochrane Handbook for Systematic Reviews of Interventions. Where meta-analysis was possible, we applied random-effects meta-analysis using the Mantel-Haenszel method for dichotomous outcomes.

MAIN RESULTS

The review included 27 RCTs involving 1803 children. Of these, six were multi-arm and one was also a cross-over study. Most studies were small, with numbers randomised ranging from 16 to 202. A total of 19 studies were at high risk of bias for at least one domain. Few studies reported data suitable for pooling due to heterogeneity in interventions, outcomes and measurements.Individual conservative interventions (lifestyle, behavioural or physical) versus no treatmentTranscutaneous electrical nerve stimulation (TENS) versus sham (placebo) TENS. More children receiving active TENS may achieve continence (risk ratio (RR) 4.89, 95% confidence interval (CI) 1.68 to 14.21; 3 studies; n = 93; low-certainty evidence).One individual conservative intervention versus another individual or combined conservative interventionPelvic floor muscle training (PFMT) with urotherapy versus urotherapy alone. We are uncertain whether more children receiving PFMT with urotherapy achieve continence (RR 2.36, 95% CI 0.65 to 8.53, 95% CI 25 to 100; 3 studies; n = 91; very low-certainty evidence).Voiding education with uroflowmetry feedback and urotherapy versus urotherapy alone. Slightly more children receiving voiding education with uroflow feedback and urotherapy may achieve continence (RR 1.13, 95% CI 0.87 to 1.45; 3 studies; n = 151; low-certainty evidence).Urotherapy with timer watch versus urotherapy alone. We are uncertain whether urotherapy plus timer watch increases the number of children achieving continence compared to urotherapy alone (RR 1.42, 95% CI 1.12 to 1.80; 1 study; n = 58; very low-certainty evidence).Combined conservative interventions versus other combined conservative interventionsTENS and standard urotherapy versus PFMT with electromyographic biofeedback and standard urotherapy. We are uncertain whether there is any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 1.11, 95% CI 0.73 to 1.68; 1 study; n = 78; very low-certainty evidence).PFMT with electromyography biofeedback and standard urotherapy versus PFMT without feedback but with standard urotherapy. We are uncertain whether there is any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 1.05, 95% CI 0.72 to 1.52; 1 study; n = 41; very low-certainty evidence).Individual conservative interventions versus non-conservative interventions (pharmacological or invasive, combined or not with any conservative interventions)PFMT versus anticholinergics. We are uncertain whether more children receiving PFMT than anticholinergics achieve continence (RR 1.92, 95% CI 1.17 to 3.15; equivalent to an increase from 33 to 64 per 100 children; 2 studies; n = 86; very low-certainty evidence).TENS versus anticholinergics. We are uncertain whether there was any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 0.81, 95% CI 0.05 to 12.50; 2 studies; n = 72; very low-certainty evidence).Combined conservative interventions versus non-conservative interventions (pharmacological or invasive, combined or not with any conservative interventions)Voiding education with uroflowmetry feedback versus anticholinergics. We are uncertain whether there was any evidence of a difference between treatment groups in the proportion of children achieving continence (RR 1.02, 95% CI 0.58 to 1.78; 1 study; n = 64; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The review found little reliable evidence that can help affected children, their carers and the clinicians working with them to make evidence-based treatment decisions. In this scenario, the clinical experience of individual clinicians and the support of carers may be the most valuable resources. More well-designed research, with well-defined interventions and consistent outcome measurement, is needed.

Traditional Biofeedback vs. Pelvic Floor Physical Therapy-Is One Clearly Superior?

PURPOSE OF REVIEW

Pelvic floor physical therapy is a worldwide accepted therapy that has been exclusively used to manage many pelvic floor disorders in adults and children. The aim of this review is to suggest to clinicians an updated understanding of this therapeutic approach in management of children with non-neuropathic voiding dysfunction.

RECENT FINDINGS

Today, pelvic floor muscle training through biofeedback is widely used as a part of a voiding retraining program aiming to help children with voiding dysfunction which is caused by pelvic floor overactivity. Biofeedback on its own, without a pelvic floor training component, is not an effective treatment. Biofeedback is an adjunct to the pelvic floor training. In the current review, we develop the role of pelvic floor physical therapy in management of children with non-neuropathic voiding dysfunction and compare it with biofeedback therapy alone.

EMG biofeedback or parasacral transcutaneous electrical nerve stimulation in children with lower urinary tract dysfunction: A prospective and randomized trial

AIMS

Evaluate the efficacy of biofeedback and parassacral electric nerve stimulation (TENS) for the treatment of children with lower urinary tract (LUT) dysfunction.

METHODS

A prospective, randomized study was approved by our Hospital Ethics Committee. We enrolled 64 children, 43 girls and 21 boys, average age of 9.39 years. The initial evaluation consisted of history, physical examination, urine analyses, voiding diary, uroflow, and ultrasound. Dysfunction voiding symptom score (DVSS) questionnaires were applied pre- and post-treatment. The children were divided into two treatment groups independent of the predominant type of voiding dysfunction (dysfunctional or overactive bladder): biofeedback group and TENS group. The criteria for assessing the effectiveness of the techniques was the resolution of daytime and nighttime symptoms including urinary leakage, improvements in voiding diary, DVSS, and changes in uroflow. After 6 months, the children were reassessed with the same work-up of baseline.

RESULTS

Regarding daytime symptoms, results for complete response were similar between the two groups (P = 0.483); 54.9% of children treated by the biofeedback group and 60.6% in the TENS group. The same have been observed in the nighttime incontinence with complete resolutions in 29.6% and 25%, respectively ( P = 0.461). Analyzing the voiding diary, uroflow and DVSS questionnaires both groups had significant improvement ( P = 0.001) after treatment. The biofeedback group required fewer sessions than TENS group, 10.9 and 18.1, respectively ( P < 0,001).

CONCLUSIONS

Both biofeedback and the TENS are equally effective for treating non-neurogenic voiding dysfunction. Biofeedback seems to require a lower number of sessions to obtain similar results of the TENS.

Physiotherapist management of a patient with spastic perineal syndrome and subsequent constipation: a case report

Background and Purpose: The purpose of this case report is to describe the benefits of manual therapy techniques, including mobilization and stretching, in the management of a patient with chronic constipation. Case Description: A 17-year-old male with an 8-month history of constipation and complaint of incomplete evacuation after defecation was referred for therapy. The patient was diagnosed with a spastic perineal syndrome. Isolated puborectalis relaxation exercise was not successful in alleviating constipation. Physical examination showed tightness of left side piriformis, thoracic kyphosis, apparent limb shortening on the left side, and a right-on-right sacrum forward torsion. The patient was treated with stretching of left piriformis and mobilization of thoracic and lumbar vertebrae and sacroiliac joints along with puborectalis relaxation exercises. Outcomes: After 4 weeks of treatment, there was a reduction in Bowel Function Index (BFI) from 74.6 to 27.2. The patient also reported spending less time (<3 minutes) during defecation. The patient maintained his improvement at 7 months. Discussion: A detailed neuromuscular examination assisted in identifying the pathophysiology related to obstructive defecation for this patient. Controlled studies regarding the effectiveness of various physiotherapy interventions in the treatment of obstructive constipation are warranted.

Pelvic floor electromyography and urine flow patterns in children with vesicoureteral reflux and lower urinary tract symptoms

OBJECTIVE

To determine the different urine flow patterns and active pelvic floor electromyography (EMG) during voiding in children with vesicoureteral reflux (VUR) as well as presenting the prevalence of lower urinary tract symptoms in these patients.

MATERIALS AND METHODS

We retrospectively reviewed the charts of children diagnosed with VUR after toilet training from Sep 2013 to Jan 2016. 225 anatomically and neurologically normal children were included. The reflux was diagnosed with voiding cystourethrography. The study was comprised an interview by means of a symptom questionnaire, a voiding diary, uroflowmetry with EMG and kidney and bladder ultrasounds. Urine flow patterns were classified as bell shape, staccato, interrupted, tower and plateau based on the current International Children's Continence Society guidelines.

RESULTS

Of 225 children with VUR (175 girls, 50 boys), underwent uroflowmetry + EMG, 151 (67.1%) had an abnormal urine flow pattern. An active pelvic floor EMG during voiding was confirmed in 113 (50.2%) children. The flow patterns were staccato in 76 (33.7 %), interrupted in 41 (18.2%), Plateau in 26 (11.5%), tower in 12 (5.3%) and a bell shape or normal pattern in 70 (31.5%). Urinary tract infection, enuresis and constipation respectively, were more frequent symptoms in these patients.

CONCLUSIONS

Bladder/bowel dysfunction is common in patients with VUR that increases the risk of breakthrough urinary tract infections in children receiving antibiotic prophylaxis and reduces the success rate for endoscopic injection therapy. Therefore investigation of voiding dysfunction with primary assessment tools can be used prior to treating VUR.

Bladder and bowel dysfunctions in 1748 children referred to pelvic physiotherapy: clinical characteristics and locomotor problems in primary, secondary, and tertiary healthcare settings

The aims of this study are to evaluate in a pragmatic cross-sectional study, the clinical characteristics of childhood bladder and/or bowel dysfunctions (CBBD) and locomotor problems in the primary through tertiary health care setting. It was hypothesized that problems would increase, going from primary to tertiary healthcare. Data were retrieved from patient-records of children (1-16 years) presenting with CBBD and visiting pelvic physiotherapists. Prevalence's of dysfunctions were compared between healthcare settings and gender using ANOVA and chi-square test. Agreement between physicians' diagnoses and parent-reported symptoms was evaluated (Cohen's Kappa). One thousand seventy hundred forty-eight children (mean age 7.7 years [SD 2.9], 48.9% boys) were included. Daytime urinary incontinence (P = 0.039) and enuresis (P < 0.001) were more diagnosed in primary healthcare, whereas constipation (P < 0.001) and abdominal pain (P = 0.009) increased from primary to tertiary healthcare. All parent-reported symptoms occurred more frequently than indicated by the physicians. Poor agreement between physicians' diagnoses and parent-reported symptoms was found (k = 0.16). Locomotor problems prevailed in all healthcare settings, motor skills (P = 0.041) and core stability (P = 0.015) significantly more in tertiary healthcare.

CONCLUSIONS

Constipation and abdominal pain (physicians' diagnoses) and the parent-reported symptoms hard stools and bloating increased from primary to tertiary healthcare. Discrepancies exist between the prevalence's of physicians' diagnoses and parent-reported symptoms. Locomotor problems predominate in all healthcare settings. What is Known: • Childhood bladder and/or bowel dysfunctions (CCBD) are common. • Particularly tertiary healthcare characteristics of CBBD are available What is New: • Characteristics of CBBD referred to pelvic physiotherapy are comparable in primary, secondary, and tertiary healthcare settings. • Concomitant CBBD appeared to be more prevalent than earlier reported. • Discrepancies exist between referring physicians' diagnoses and parent-reported symptoms.

Transcutaneous interferential electrical stimulation for the management of non-neuropathic underactive bladder in children: a randomised clinical trial

OBJECTIVES

To assess the efficacy of transcutaneous interferential electrical stimulation (IFES) and urotherapy in the management of non-neuropathic underactive bladder (UAB) in children with voiding dysfunction.

PATIENTS AND METHODS

In all, 36 children with UAB without neuropathic disease [15 boys, 21 girls; mean (sd) age 8.9 (2.6) years] were enrolled and then randomly allocated to two equal treatment groups comprising IFES and control groups. The control group underwent only standard urotherapy comprising diet, hydration, scheduled voiding, toilet training, and pelvic floor and abdominal muscles relaxation. Children in the IFES group likewise underwent standard urotherapy and also received IFES. Children in both groups underwent a 15-session treatment programme twice a week. A complete voiding and bowel habit diary was completed by parents before, after treatment, and 1 year later. Bladder ultrasound and uroflowmetry/electromyography were performed before, at the end of treatment course, and at the 1-year follow-up.

RESULTS

The mean (sd) number of voiding episodes before treatment was 2.6 (1) and 2.7 (0.76) times/day in the IFES and control groups, respectively, which significantly increased after IFES therapy in IFES group, compared with only standard urotherapy in the control group [6.3 (1.4) vs 4.7 (1.3) times/day, P < 0.002). The mean (sd) bladder capacity before treatment was 424 (123) and 463 (121) mL in the control and IFES groups, respectively, which decreased significantly at 1 year after treatment in the IFES group compared with the controls, at 227 (86) vs 344 (127) mL (P < 0.01). Maximum urine flow increased and voiding time decreased significantly in the IFES group compared with controls at the end of treatment sessions and 1 year later (P < 0.05). All the children had abnormal flow curves at the beginning of the study. The flow curve became normal in 14/18 (77%) of the children in the IFES group and six of 18 (33%) in the control group by the end of follow-up (P < 0.007). At the end of the treatment course, night-time wetting was improved in all children who had this symptom before the treatment in the IFES group (P < 0.01).

CONCLUSION

Combining IFES and urotherapy is a safe and effective therapy in the management of children with UAB.

Can a four-session biofeedback regimen be used effectively for treating children with dysfunctional voiding?

OBJECTIVE

To compare the outcomes of the open-ended six to ten sessions of biofeedback against a novel regime of four sessions of biofeedback to treat children with dysfunctional voiding.

MATERIALS AND METHODS

Patients from two centers using different methods were retrospectively analyzed. Group 1 comprised 20 patients treated with four sessions of biofeedback. Group 2 comprised 20 patients treated with six to ten sessions of biofeedback. Each group was evaluated with subjective and objective parameters pre-treatment, immediately post-treatment and 6 months post-treatment.

RESULTS

All patients in Group 1 were treated with four sessions of biofeedback and in Group 2 the mean number of sessions was 7.35±1.30 (range 6-10). Normalized voiding flow curves after treatment were determined in 18 patients in Group 1 (90%) and 19 patients in Group 2 (95%) (p=0.553). There were seven patients (35%) in Group 1 and eight patients (40%) in Group 2 with reflux. When units were compared, there were 11 units (4 bilateral) in Group 1 and 13 units (5 bilateral) in Group 2 with reflux (p=0.747). At 6 months post-treatment, in Group 1, seven had resolved (63.6%), three had improved (27.2%) and one persisted (9.01%). In Group 2, ten had resolved (76.9%) and three had improved (23.1%) (p=0.553).

CONCLUSIONS

Biofeedback therapy is one of the most widely used techniques in dysfunctional voiding in children. The regime of use has not been well defined, and the results of this study showed that a regime of four sessions of biofeedback therapy may be as safe and effective as the previously defined open-ended six to ten sessions.