Animated biofeedback yields more rapid results than nonanimated biofeedback in the treatment of dysfunctional voiding in girls

The effect of duration between sessions on biofeedback treatment in children with dysfunctional voiding

OBJECTIVE

Biofeedback is an effective treatment in children with standard urotherapy-resistant dysfunctional voiding (DV). However, the duration of the session intervals is not standardized. We aimed to compare the effectiveness of daily and weekly sessions of biofeedback treatments.

METHODS

The data of children who received biofeedback due to DV between March 2018 and May 2019 were retrospectively evaluated. The children were divided into two groups, one with daily and the other with weekly sessions. The voiding patterns in uroflowmetry (UF), maximum flow rate (Qmax), electromyography activity, postvoid residual volume (PVR), the ratio of voided volume to expected bladder capacity (EBC) (%), and Dysfunctional Voiding and Incontinence Scoring System (DVISS) were compared between the two groups.

RESULTS

A total of 45 children (39 girls [86.6%] and 6 boys [13.3%]) were included in the study. The daily group consisted of 27 (60%) children and the weekly group of 18 (40%). Qmax, PVR, number of abnormal UF patterns, voiding volume/EBC, and DVISS scores were similar between the two groups before treatment. Voiding parameters improved statistically significantly in both groups following biofeedback, but there was no difference between the two groups. A statistical difference was found between the results of DVISS after treatment (P = .03).

CONCLUSION

Both types of biofeedback treatment (daily and weekly) are effective methods that improve voiding parameters and DVISS values in children with DV. Therefore, the duration between sessions can be determined according to the suitability of the patient and the biofeedback unit.

Dysfunctional voiding: update on evaluation and treatment

PURPOSE OF REVIEW

This review will be covering dysfunctional voiding, its diagnosis, and treatment options. This will focus primarily on dysfunctional voiding rather than all lower urinary tract dysfunction and we will focus on some of the newer findings and progress within this disease.

RECENT FINDINGS

Dysfunctional voiding is the inappropriate sphincter and pelvic floor constriction during voiding in an otherwise neurologically normal child. This has a wide spectrum of symptoms and can lead to a number of complications such as chronic kidney disease and poor quality of life if not appropriately addressed. Dysfunctional voiding is diagnosed with a careful examination and history with further imaging including a renal ultrasound and uroflowmetry to confirm the diagnosis. Urotherapy and biofeedback are the first and second-line treatments respectively and lead to significant improvement or cure in the majority of patients. For refractory patients, additional therapy options include use of α-blockers, botulinum injection, and electroneurostimulation, though the majority of the literature surrounding the use of these therapies consists of small studies with heterogenous causes of voiding dysfunction.

SUMMARY

Dysfunctional voiding is a common urologic complaint that has many excellent options for improving the patient's voiding issues and should be considered in patients with voiding dysfunction.

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.

Effectiveness of Intra-anal Biofeedback and Electrical Stimulation in the Treatment of Children With Refractory Monosymptomatic Nocturnal Enuresis: A Comparative Randomized Controlled Trial

Purpose

To compare the effects of intra-anal biofeedback (BF) and intra-anal electrical stimulation (ES) on pelvic floor muscles (PFMs) activity, nocturnal bladder capacity, and frequency of wet night episodes in children with refractory primary monosymptomatic nocturnal enuresis (PMNE).

Methods

Ninety children of both sexes aged 8–12 years with refractory PMNE participated in this study. They were randomly assigned to 3 groups of equal number: control group (CON) that underwent behavioral therapy and PFM training, and 2 study groups (BF and ES) that underwent the same program in addition to intra-anal BF training and intra-anal ES, respectively. PFMs activity was assessed using electromyography, nocturnal bladder capacity was evaluated by measuring the first morning voided volume, and a nocturnal enuresis diary was used for documenting wet night episodes before treatment and after 3 months of treatment.

Results

After training, all groups showed statistically significant improvements in all measured outcomes compared to their pretreatment findings. The ES group showed significantly greater improvements in all measured outcomes than the CON and BF groups.

Conclusions

Both intra-anal BF training and ES combined with behavioral therapy and PFMs training were effective in the treatment of PMNE, with intra-anal ES being superior to BF training.

Animated versus non-animated biofeedback therapy for dysfunctional voiding treatment: Does it change the outcome?

PURPOSE

The aim of this study is to evaluate and compare the effectiveness of animated vs. non-animated biofeedback therapy in the treatment of dysfunctional voiding (DV) in the pediatric age group.

METHODS

In this study, children with DV were randomly assigned for animated and non-animated biofeedback therapy. Age, voiding dysfunction symptom scores (VDSS), urinary ultrasound and uroflowmetry parameters such as electromyography (EMG) activity, voided volumes, post voiding residual urine volume (PVR) and maximum flow rate (Qmax) were evaluated. At the end of treatment, clinical success was regarded as the cessation of EMG activity during voiding, resolution of symptoms (reduction in VDSS, frequency, intermittency, urgency and incontinence), and improvements in uroflowmetry parameters.

RESULTS

A total of 40 children were included in the study. There were 20 children in the non-animated group (16 girls, 4 boys; mean age: 10.5±3.2years) and 20 children in the animated group (15 girls, 5 boys; mean age: 9.5±3.63years). Patients received a mean of 5.2±1.9 sessions in both groups. Cessation of pelvic muscle activity on EMG was 75% in the non-animated group and 90% in the animated group (p=0.407). Reduction in VDSS was clinically significant in both groups (p=0.001 for both). There was no significant difference between the clinical success rates of the nonanimated and animated groups (80% vs. 70% respectively, p=0.125). PVR decreased by 68% in the non-animated group (p=0.015) while a 60% decrease was observed in the animated group (p=0.001).

CONCLUSION

In our study, there was no difference between animated and non-animated biofeedback therapy in terms of clinical success rates.

TYPE OF STUDY

Prospective comparative study LEVEL OF EVIDENCE: Level II.

Dysfunctional voiding: the importance of non-invasive urodynamics in diagnosis and treatment

In Dysfunctional voiding, failure of the external sphincter-pelvic floor complex to relax during micturition results in bladder outflow obstruction with a spectrum of presentation from more benign lower urinary tract dysfunction including recurrent urinary tract infections, to significant upper tract pathology and end-stage renal failure. There is no underlying neurological or anatomical cause and the condition is postulated to be a largely learnt behavior. Diagnosis relies on non-invasive urodynamics and in particular uroflowmetry, plus or minus EMG, which is also used in biofeedback, the mainstay of treatment. The etiology, presentation, diagnosis, and treatment with particular emphasis on non-invasive urodynamics are covered.

The management of childhood urinary incontinence

The International Children's Continence Society (ICCS) has undertaken an enormous effort to standardize both the terminology and management of various aspects of incontinence in children, including enuresis, bladder overactivity, dysfunctional voiding and psychological comorbidities. A number of guidelines have been published to aid those involved in the care of children with lower urinary tract symptoms. This review addresses a number of recommended diagnostic and therapeutic strategies, including urotherapy and pharmacological treatment, with emphasis on a focused medical history, information acquired from bladder diaries and uroflow evaluations. The major role of urotherapy is underlined with supportive pharmacotherapy, when indicated. The article provides both a summary of ICCS guidelines and a brief review of recently published papers related to the contemporary management of childhood incontinence, a health issue still underestimated by both the child's caregivers and healthcare providers.

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.

Objective versus subjective outcome measures of biofeedback: what really matters?

OBJECTIVE

Clinical epidemiologic studies suggest that once established, voiding dysfunction can become a lifelong condition if not treated correctly early on in life. Biofeedback is one component of a voiding retraining program to help children with voiding dysfunction. Our goal was to compare objective non-invasive urodynamic data obtained during office biofeedback sessions with patient reported voiding symptom scores.

METHODS

Charts of 55 children referred in 2010 for pelvic floor muscle biofeedback therapy for urinary incontinence were retrospectively reviewed. Patients with any anatomic diagnoses were excluded. Forty-seven (86%) females and eight males (14%) with a mean age of 8.2 years made up the cohort. Uroflow curves, voided volumes, and post-void residuals were recorded at each visit and served as objective data. Volumes were normalized as a percentage of expected bladder capacity according to age. The patient reported symptom score and patient reported outcome (improved, no change or worse) served as subjective measures of intervention.

RESULTS

The primary referral diagnoses were day and night wetting in 37 (67%) and daytime incontinence in 18 (33%) children. A history of urinary tract infection (UTI) was noted in 32 (64%) patients, and 25% were maintained on antibiotic prophylaxis during the study period. Twenty-nine percent were maintained on anticholinergic medication. Patients attended an average of 2.5 biofeedback sessions. Voided volumes and post void residual volumes were unchanged, 50% of the abnormal uroflow curves normalized over the course of treatment (p < 0.05). Patient reported symptom score decreased from 12.8 ± 5.6 to 8.0 ± 6.5 (p < 0.002) over an average follow-up time of 276 days reflecting fewer daytime voiding symptoms. There was no significant change in the patient symptom score component for the night-time wetting. Patient-reported outcomes at the final session of biofeedback were rated an improved in 26 (47%), no change in 15 (27%), worse in three (5%) patients, and not rated in 11 patients (21%).

CONCLUSIONS

Pelvic floor muscle biofeedback is associated with patient-reported improvement in symptoms, reduction in voiding symptom score, and normalization of uroflow curves, but these improvements are not correlated with objective parameters of voided volumes and post-void residual urine obtained during office visits for biofeedback. It is important to identify the most relevant outcome measures for BFB, as insurance coverage for medical interventions that cannot offer outcomes analysis that demonstrates a benefit for the patient will eventually be eliminated.

Vesicoureteral reflux--the role of bladder and bowel dysfunction

Vesicoureteral reflux (VUR) is a significant risk factor for clinical pyelonephritis and renal scarring. In 2010, the American Urological Association (AUA) reported that bladder and bowel dysfunction (BBD), which is common in patients with VUR, increases the risk of breakthrough UTI in children receiving antibiotic prophylaxis, reduces the success rate for endoscopic injection therapy, and increases the risk of postoperative UTI, irrespective of the surgical success rate for VUR. Accordingly, physicians are strongly recommended to investigate BBD in their patients with VUR. Symptoms and signs of BBD include urinary frequency and urgency, prolonged voiding intervals, daytime wetting, perineal and penile pain, holding manoeuvres (posturing to prevent wetting), constipation, and encopresis. Primary assessment tools include the Pediatric Symptom Checklist, urinalysis, urine culture, bladder diary, measurement of the postvoid residual urine volume, Dysfunctional Voiding Symptom Score, uroflow with electromyography, and Bristol Stool Form Score. The Rome III criteria can also be used for diagnostic assessment of bowel function. Treatment of BBD should be individualized, directed at symptomatic and objective improvement, and can include behavioural modification, biofeedback, selective use of anticholinergics and α-blockers, and bowel management.

Evaluation and treatment of nonmonosymptomatic nocturnal enuresis: a standardization document from the International Children's Continence Society

PURPOSE

This document represents the consensus guidelines recommended by the ICCS on how to evaluate and treat children with nonmonosymptomatic nocturnal enuresis (NMNE). The document is intended to be clinically useful in primary, secondary and tertiary care.

MATERIALS AND METHODS

Discussions were held by the board of the ICCS and a committee was appointed to draft this document. The document was then made available to the members of the society on the web site. The comments were vetted and amendments were made as necessary to the document.

RESULTS

The main scope of the document is the treatment of NMNE with drugs other than desmopressin-based therapy. Guidelines on the assessment, and nonpharmacologic and pharmacologic management of children with NMNE are presented.

CONCLUSIONS

The text should be regarded as an expert statement, not a formal systematic review of evidence-based medicine. It so happens that the evidence behind much of what we do in the care of enuretic children is quite weak. We do, however, intend to present what evidence there is, and to give preference to this rather than to experience-based medicine, whenever possible.

Bladder control training in girls with lower urinary tract dysfunction

PURPOSE

To evaluate the efficacy of standard and biofeedback bladder control training (BCT) on the resolution of dysfunctional elimination syndrome (primary outcome), and on the reduction of urinary tract infections (UTI) and the use of medications such as antibacterial prophylaxis and/or anticholinergic/alpha-blockers (secondary outcome) in girls older than aged least 5 years.

MATERIALS AND METHODS

72 girls, median age of 8 years (interquartile range, IQR 7-10) were subjected to standard BCT (cognitive, behavioural and constipation treatment) and 12 one-hour sessions of animated biofeedback using interactive computer games within 8 weeks. Fifty patients were reevaluated after median 11 (IQR, 6-17) months. Effectiveness of BCT was determined by reduction of dysfunctional voiding score (DVS), daytime urinary incontinence (DUI), constipation, UTI, nocturnal enuresis (NE), post void residual (PVR), and improvements in bladder capacity and uroflow/EMG patterns.

RESULTS

BCT resulted in significant normalization of DUI, NE, constipation, bladder capacity, uroflow/EMG, while decrease of PVR didn't reach statistical significance. In addition, the incidence of UTI, antibacterial prophylaxis and medical urotherapy significantly decreased. There were no significant differences in DVS, DVI, NE, bladder capacity and voiding pattern at the end of the BCT and at the time of reevaluation. The success on BCT was supported by parenteral perception of the treatment response in 63.9% and full response in additional 15.3% of the patients.

CONCLUSION

Combination of standard and biofeedback BCT improved dysfunctional elimination syndrome and decreased UTI with discontinuation of antibacterial prophylaxis and/or anticholinergic/alpha-blockers in the majority of the patients. Better training results are expected in patients with higher bladder wall thickness as well as in those with vesicoureteral reflux, while presence of nocturnal enuresis may be a negative predictor of the training effect.

High efficacy of biofeedback therapy for treatment of dysfunctional voiding in children

Introduction

Dysfunctional voiding is a frequent condition in children associated with symptoms of incontinence. The aim of this study was to present the efficacy of biofeedback treatment on the resolution of clinical symptoms in a large cohort of children with urodynamically confirmed dysfunctional voiding.

Material and methods

81 children (75 girls and 6 boys) aged 6-18 years (mean: 10.32 ±3.17 yrs.) with a dysfunctional voiding pattern are presented. 74/81 (92.6%) of children were unresponsive to standard urotherapy and prior pharmacotherapy. Symptoms of bladder dysfunction were evaluated by questionnaire, bladder diary and an urodynamic study according to definitions and standards set by ICCS. The biofeedback training was planned for 2 months. Each session consisted of about 30 repeats of 5 s contraction and 30 s relaxation of pelvic floor muscles and external urethral sphincter. Biofeedback was performed together with standard urotherapy.

Results

67 (82.72%) of the 81 children declared wetting during the day and 41 (50, 62%) – wetting during the night. 32/81 (39.5%) children had increased voiding frequency and 43 (53.08%) had decreased bladder capacity. Following 2 months of biofeedback therapy daytime incontinence resolved in 34/67 (50.7%) children and nighttime incontinence in 22/41 (53.65%). A further 40,3% declared partial improvement in daytime and 26.7% in nighttime wetting.

Conclusions

Biofeedback treatment is an effective therapeutic option for children with dysfunctional voiding. Pelvic floor therapy with biofeedback should be offered to children with dysfunctional voiding resistant to standard urotherapy.

Animated biofeedback: an ideal treatment for children with dysfunctional elimination syndrome

PURPOSE

Animated biofeedback is an established treatment for pediatric dysfunctional voiding. Bowel dysfunction is closely associated with dysfunctional voiding. We evaluated the efficacy of animated biofeedback urotherapy in bowel and voiding dysfunction in children with dysfunctional elimination syndrome.

MATERIALS AND METHODS

A total of 80 children with dysfunctional elimination syndrome were randomly assigned to undergo animated biofeedback (group A, 40 patients) or conservative therapy (group B, 40 patients). Group A underwent animated biofeedback along with pelvic floor muscle exercises and behavioral modification (hydration, high fiber diet, scheduled voiding). Group B underwent behavioral modification only. Dysfunctional voiding symptom score, constipation and fecal soiling episodes per week (according to Paris Consensus on Childhood Constipation Terminology criteria), and uroflowmetry parameters were evaluated before and 6 and 12 months after treatment in both groups.

RESULTS

Subjective and objective voiding problems were significantly improved. Vesicoureteral reflux resolved in 7 of 9 children (78%) and urinary tract infection did not recur in 10 of 14 children (71%) within 1 year. Bladder capacity and voided volume did not significantly improve. Post-void residual and voiding time decreased considerably, while maximum and average urine flow increased significantly. All children with fecal soiling and 17 of 25 with constipation (68%) in group A were symptom-free within 1 year after treatment. Animated biofeedback therapy was more efficient than nonbiofeedback management regarding objective and subjective voiding problems and bowel dysfunction (p <0.05).

CONCLUSIONS

Animated biofeedback effectively treats bowel and voiding dysfunction in children with dysfunctional voiding. Pelvic floor muscle exercises coordinate breathing and pelvic floor muscle contractions, and are beneficial in improving bowel dysfunction.

Dysfunctional voiding: A review of the terminology, presentation, evaluation and management in children and adults

Dysfunctional voiding (DV) is a voiding disorder characterized by dyssynergic striated sphincteric activity in the absence of a proven neurological etiology. It can present at any age with a spectrum of storage and voiding symptoms that may resemble florid neurogenic bladder. There is a striking lack of clarity regarding what this entity represents, the diagnostic methodology and treatment. The limitations of existing guideline documents are analyzed. Specifically, use of the term "habitual", the assumption that bladder changes are secondary to the outlet, the emphasis on "staccato" voiding and the implication of striated urethral sphincter are discussed. Literature shows that DV may also present with continuous slow flow or normal flow. Dyssynergia may be at the level of the striated urethral sphincter, the pelvic floor or both, better termed "striated urethral sphincter-pelvic floor complex" (SUS-PFC).A diagnostic algorithm is provided so that patients are evaluated on merit rather than on the basis of different philosophies of individual centers. High-risk markers such as hydronephrosis, vesicoureteral reflux, renal failure or marked voiding difficulty should prompt a formal urodynamics evaluation and imaging for neurological etiology. Patients with predominantly storage symptoms with incidental staccato voiding can be managed initially, on the basis of non-invasive evaluation. Conservative urotherapy including biofeedback is appropriate initial management for patients without high risk factors. Treatment and evaluation should be escalated based on response. Patients with severe DV will need treatment similar to neurogenic bladder including clean intermittent catheterization and measures to control storage pressures.

The evaluation of combined standard urotherapy, abdominal and pelvic floor retraining in children with dysfunctional voiding

PURPOSE

The aim of the study was to compare the treatment outcome of two urotherapy programs in children with dysfunctional voiding (DV) through analyzing the clinical manifestations and uroflowmetry parameters.

MATERIALS AND METHODS

Eighty-six children with DV were randomly divided into two groups (A and B). Children in both groups were educated about the importance of regular voiding and hydratation, and about the appropriate posture during voiding. Simple voiding instructions were provided. In group A diaphragmatic breathing and pelvic floor muscles (PFM) retraining were additionally assigned to children. Constipation and recurrent urinary tract infections (UTIs) were treated in both groups. Selected children from both groups received pharmacotherapy (anticholinergics or desmopressin). Uroflowmetry with pelvic floor electromyography and ultrasound residual urine volumes were obtained before and at the end of the 12-month treatment period.

RESULTS

After one year of therapy, urinary incontinence and nocturnal enuresis were cured in a significantly larger number of children in group A than in group B (P < 0.001; P < 0.05). Although more children with UTIs were cured in group A, the difference was not statistically significant compared to group B. There was a significant recovery constipation-wise in both groups. Post-treatment uroflowmetry parameters and curve pattern were markedly improved only in group A.

CONCLUSIONS

Carefully planned and regularly controlled abdominal and PFM retraining is beneficial in children with DV for curing urinary incontinence, nocturnal enuresis, UTIs and normalizing urinary function. Further trials are needed to define the most effective treatment program for achieving the best treatment outcome.

Characterization and management of voiding dysfunction in children with attention deficit hyperactivity disorder

OBJECTIVES

To investigate whether voiding dysfunction (VD) in children with attention deficit hyperactivity disorder (ADHD) could be treated successfully using individualized therapy. We also sought to describe the spectrum of voiding symptoms experienced by children with ADHD. ADHD is diagnosed in 3-5% of children. These children have a greater incidence of VD than non-ADHD controls, and it is less amenable to treatment.

METHODS

A comprehensive history assessed the nature of the voiding disorder. A physical examination, screening urologic ultrasonography, and urinalysis were routinely performed, with electromyography combined with uroflowmetry performed for certain cases. Treatment was individualized to include behavioral modification, bowel and diet management, biofeedback, pharmacotherapy, and close follow-up.

RESULTS

A total of 75 children with ADHD were referred because of VD. The 75 children (39 boys and 36 girls) were 5-16 years old. Of the 75 children, 60 were taking medication for ADHD. All the children had daytime wetting (>1/d, 5-7 d/wk) and urgency. In addition, 88% had frequency and 87% had sleep enuresis. Of the 75 families, 56 proceeded with our prescribed program. Of the 56 children, 47 (83.9%) had complete resolution or improvement of the daytime symptoms. Of the 17 patients (30.4%) with complete resolution, 9 responded to behavior modification and anticholinergics and 8 needed biofeedback. Of the 30 patients with a partial response (53.6%), 9 responded to behavior modification alone, 15 to behavior modification and anticholinergics, and 6 required all 3 modalities. Of the 56 children, 9 failed to respond to any of the 3 modalities.

CONCLUSIONS

Diurnal symptoms constituted the most common referred complaint in children with ADHD. VD can be successfully treated if the treatment is individualized. Multimodal treatment, including behavior modification combined with anticholinergic agents and/or biofeedback, appears to be effective in managing VD in most of these challenging cases.

The management of dysfunctional voiding in children: a report from the Standardisation Committee of the International Children's Continence Society

PURPOSE

We present a consensus view of members of the International Children's Continence Society on the management of dysfunctional voiding in children.

MATERIALS AND METHODS

Discussions were held by the board of the International Children's Continence Society and a multi-disciplinary core group of authors was appointed. The draft document review process was open to all International Children's Continence Society members via the web site. Feedback was considered by the core authors and, by agreement, amendments were made as necessary.

RESULTS

Guidelines on the assessment, and nonpharmacological and pharmacological management of dysfunctional voiding are presented.

CONCLUSIONS

The final document is not a systematic literature review. It includes relevant research when available as well as expert opinion on the current understanding of dysfunctional voiding in children.

Management of abnormal postvoid residual urine in children with dysfunctional voiding

OBJECTIVES

To evaluate the effect of biofeedback therapy on the residual urine volume in children with dysfunctional voiding.

METHODS

This prospective study was conducted in children with dysfunctional voiding associated with abnormal postvoid residual urine (PVR) from June 2002 to 2007. The children were divided randomly into 2 groups. Group 1 was treated with standard urotherapy combined with biofeedback therapy and group 2 was treated with only standard urotherapy. The outcomes of uroflow-electromyography pattern, urinary tract infection (UTI), and PVR were recorded before and at the end of sixth month of treatment.

RESULTS

A total of 94 patients were enrolled in this study. Groups 1 and 2 consisted of 62 and 32 patients, respectively. The voiding pattern became normal in 80.6% (50/62) and 56.2% (18/32) of patients in groups 1 and 2, respectively. The PVR resolved in 40 of 62 (64.5%) patients in group 1 and in 11 of 32 (34.4%) children in group 2. Before the treatment, UTI was noted in 22.5% of patients (14/62) in group 1 and 21.8% of patients (7/32) in group 2. After the treatment, UTI was observed in 3.2% of patients (2/62) and in 9.3% (3/32) of patients in groups 1 and 2, respectively. Although both treatment modalities changed the voiding pattern, rate of febrile UTI, and PVR positively, these outcomes were better in a combination group.

CONCLUSIONS

The combination of standard urotherapy with the biofeedback therapy improved the results significantly.

Successful treatment for giggle incontinence with biofeedback

PURPOSE

Giggle incontinence is the involuntary and often unpredictable loss of urine during giggling or laughter in the absence of other stress incontinence. The pathophysiology is unclear, urodynamics are seldom helpful, and the efficacy of timed voiding and pharmacotherapy is limited. We postulated that improving sphincter tone and muscle recruitment using biofeedback techniques might be helpful in children with giggle incontinence.

MATERIALS AND METHODS

The charts of 12 patients with giggle incontinence were reviewed. Giggle incontinence severity, voiding patterns, associated symptoms and medical history including prior treatment were reviewed. Children were evaluated with uroflowmetry-electromyography and ultrasound measurement of post-void residual urine. They were assessed by the ability to isolate, contract and relax perineal muscles. They were taught Kegel exercises and instructed to perform them at home between weekly-biweekly sessions. Clinical success was characterized as a full or partial response, or nonresponse as defined by the International Children's Continence Society.

RESULTS

The 10 females and 2 males were 6 to 15 years old. Only 1 child had a partial response to first line therapy with timed voiding and bowel management. Seven children were treated with anticholinergic agents and/or pseudoephedrine with a partial response in 3. The 9 children with refractory giggle incontinence underwent biofeedback with a median of 4.5 sessions per child (range 2 to 8). The 6 patients who underwent 4 or more sessions had a full response that endured for at least 6 months and the 3 with fewer than 4 sessions had a partial response.

CONCLUSIONS

Patients with giggle incontinence can heighten external urinary sphincter awareness and muscle recruitment using biofeedback techniques. Treatment with education and pharmacotherapy only led to a partial response in some cases. Biofeedback supplemented this treatment or avoided pharmacotherapy when at least 4 sessions were performed. Biofeedback therapy should be incorporated in the treatment algorithm for giggle incontinence in children and it should be considered before pharmacotherapy.