Effect of Biofeedback Training on Paradoxical Pelvic Floor Movement in Children with Dysfunctional Voiding

doi:10.1016/j.urology.2007.05.005

Urology

Volume 70, Issue 4, October 2007, Pages 790-793

https://doi.org/10.1016/j.urology.2007.05.005 Get rights and content

Objectives

Dynamic perineal ultrasonography to assess the function of the pelvic floor muscles in children with micturition complaints shows that many children with daytime incontinence or recurrent urinary tract infections use their pelvic floor paradoxically. They strain when asked to withhold urine, or they have no voluntary control of the pelvic floor muscles at all. The aim of this study was to record the pelvic floor function and evaluate the physical therapy regimens for children with dysfunctional voiding (DV) and paradoxical pelvic floor function.

Methods

A total of 65 patients with DV, many who also had constipation, were diagnosed with paradoxical movement of the pelvic floor. The patients were asked to contract their pelvic floor muscles during a perineal dynamic ultrasound investigation. Of the 52 patients treated by physical therapists, 32 had a single 1-hour biofeedback session with rectal examination and anal balloon expulsion. In the remaining 20 patients, this was followed by 2 weeks of biofeedback balloon expulsion training at home. Forty control patients were observed.

Results

In 13 of the 65 patients, the diagnosis could not be confirmed by the physical therapists. At 6 to 10 months after training, 50 of the 52 other patients had normal voluntary pelvic floor muscle control. Of the 40 control patients, 39 had normal pelvic floor control.

Conclusions

The results of this study have demonstrated that pelvic floor dysfunction occurs frequently in children with DV and can be cured by dedicated physical therapy. The clinical importance of this phenomenon is not yet clear. Prospective studies will teach us more about the true incidence and therapeutic effect of pelvic floor dysfunction on DV.

Section snippets

Material and Methods

Dynamic perineal ultrasonography to assess the function of the pelvic floor muscles in children with micturition complaints and/or UTIs is part of the standard protocol at our outpatient clinic. With the patient in the supine position, a 7-MHz ultrasound probe (Hitachi) is put on the perineum, and the child is asked to contract the pelvic floor muscles. The urethra, bladder neck, and distal rectum can be observed using ultrasound examination. With a normally functioning pelvic floor, elongation

Results

The diagnosis of pelvic floor paradox could not be confirmed by the physical therapists in 13 of the 65 patients. In these patients, the physical therapist found normal command of the pelvic floor muscles during the examination. Of the remaining 52 patients, 32 (62%) were able to correct the abnormal pelvic floor control during the 1-hour training session, and 20 (38%) needed a 2-week training program at home with the anal balloon device. Of the 52 patients, all had normal control over the

Comment

The results of this study have proved that the pelvic floor paradox occurs in children with DV and that it can be cured successfully by training as determined by follow-up examination at 6 to 10 months after training. In adults, the relationship between incontinence and pelvic floor function is well-known, and magnetic resonance imaging and ultrasonography are used to deliniate the anatomy and function.9, 10, 11 In a published study of a control group of 22 female physical therapists who were

Conclusions

A considerable number of children with DV have inadequate command of their pelvic floor muscles. This can be shown by perineal dynamic ultrasound examination of the pelvic floor and urethra. Biofeedback anal balloon expulsion training can successfully treat the condition. The exact clinical value of these findings must be clarified in the future by additional studies.

References (15)

L.M. de Kort et al.
Lower urinary tract dysfunction in children with generalized hypermobility of joints
J Urol
(2003)
T.P. de Jong et al.
Ultrasound imaging of sacral reflexes
Urology
(2006)
W.F. Bower et al.
Normative pelvic floor parameters in children assessed by transabdominal ultrasound
J Urol
(2006)
R.N. van der Plas et al.
Biofeedback training in treatment of childhood constipation: a randomised controlled study
Lancet
(1996)
A.J. Klijn et al.
Home uroflowmetry biofeedback in behavioral training for dysfunctional voiding in school-age children: a randomized controlled study
J Urol
(2006)
A.L. Hellstrom et al.
Micturition habits and incontinence in 7-year-old Swedish school entrants
Eur J Pediatr
(1990)
R. Tunn et al.
Introital and transvaginal ultrasound as the main tool in the assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical approach
Ultrasound Obstet Gynecol
(2003)

There are more references available in the full text version of this article.

Cited by (37)

Pelvic floor rehabilitation in children with functional LUTD: does it improve outcome?
2019, Journal of Pediatric Urology
Citation Excerpt :
Adequate command of the pelvic floor is present when a displacement of the bladder neck towards the inferoposterior margin of the symphysis pubis and a simultaneous elongation of the urethra is observed [7,19]. A combined downward movement of the bladder neck towards the sacrum and shortening of the urethra is defined as the pelvic floor paradox [7]. If a displacement cannot be sustained for several seconds, is of insufficient force (i.e. < 50 mmHg) or is completely absent, the presence of inadequate pelvic floor control is diagnosed.
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.
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.
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.
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.
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.
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.
Pelvic floor electrical stimulation and muscles training: a combined rehabilitative approach for management of non-neuropathic urinary incontinence in children
2019, Journal of Pediatric Surgery
To assess the efficacy of combined transcutaneous interferential (IF) electrical stimulation and pelvic floor muscle training through biofeedback on non-neuropathic urinary incontinence in children.
This prospective study comprised of 46 anatomically and neurologically normal children (9 boys, 37 girls; mean age of 8.4 ± 2.2 years old) with non-neuropathic urinary incontinence. All children were evaluated by kidney and bladder ultrasounds, uroflowmetry with electromyography (EMG), a complete voiding diary and a dysfunctional voiding scoring questionnaire at the baseline. Children were randomly allocated into two treatment groups including group A (n = 23) who underwent biofeedback therapy in addition to IF electrical stimulation and group B (n = 23) who received only biofeedback therapy. Re-evaluation was performed 6 months and one year after completion of the treatment sessions.
Improvement of non-neuropathic urinary incontinence was significantly higher in group A in comparison to group B at two follow ups (P < 0.05). Daytime incontinence was improved in 19/23(82%) and 13/23(56.5%) of children in groups A and B respectively after the treatment (P < 0.01). There was no significant difference in uroflowmetry measures between two groups after the treatment.
Combination of biofeedback therapy and transcutaneous IF electrical stimulation is a potential effective modality in treating non-neuropathic urinary incontinence in children.
Type of study: Treatment study.
Level I: Randomized controlled trials with adequate statistical power to detect differences (narrow confidence intervals) and follow up > 80%.
Breaking the vicious circle: Onabotulinum toxin A in children with therapy-refractory dysfunctional voiding
2015, Journal of Pediatric Urology
Citation Excerpt :
It involves a multidisciplinary approach and usually starts with behavioural and standard therapy, including: biofeedback therapy, often called urotherapy. Various retrospective studies have shown success rates for urotherapy between 60 and 90% [6–9]. This leaves a substantial group of children with therapy-refractory DV.
An increased activity of the external urethral sphincter or pelvic floor muscles during voluntary voiding leads to dysfunctional voiding. Frequently reported symptoms are urinary incontinence, urinary tract infections and high post-void residuals. Dysfunctional voiding is a common problem in school-aged children and despite various treatment options, 10–40% of the children remain therapy-refractory.
The aim of this study is to evaluate the effectiveness of Onabotulinum toxin-A (BTX-A) injections in the external urethral sphincter in children with therapy-refractory dysfunctional voiding.
Patients with therapy-refractory dysfunctional voiding who have received BTX-A injections in the external urethral sphincter from 2010 to 2013 were analysed. Children with known neuropsychiatric disorders were excluded. All children had abnormal flow patterns and increased pelvic floor tone during uroflowmetry/EMG studies. They had received at least five sessions of urotherapy and two sessions of pelvic floor physical therapy prior to treatment. A total of 100 IU of BTX-A was injected in the external urethral sphincter at the 3, 9 and 12 o'clock positions. Our main outcome measures were urinary incontinence, recurrent urinary tract infections and post-void residual.
A total of twenty patients, of whom 16 girls, with a median age of 9 years (range 5–14) were treated with BTX-A. The median follow-up was 13 months (range 5–34). Post-void residual decreased by 75% after BTX-A, from a median of 47.5 ml (16.3–88.5 ml) to 0 ml (0.0–28.0 ml) (p = 0.001) Six patients had a post-void residual < 20 ml prior to treatment. After BTX-A sixteen patients had a post-void residual <20 ml (Figure). No significant changes in uroflowmetry results was seen. Sixteen children are no longer daily incontinent, of whom 9 became completely dry (p = 0.0001). Eleven patients suffered from recurrent urinary tract infections prior to treatment. After BTX-A five children remained infection free, while the other six experienced only one urinary tract infection during follow-up (p = 0.003). Fourteen patients received additional urotherapy after BTX-A. Repeat injections were necessary in four patients after initial satisfactory results, with repeated good clinical responses. Two children showed no improvement after first BTX-A injection. No serious adverse events were reported.
The results in this homogenous group of patients confirm the conclusions of previous studies in opting BTX-A in the external urethral sphincter to be a viable treatment option for the therapy-refractory group of patients with dysfunctional voiding. What is new, is that in most of our patients post-injection urotherapy was used to amplify the BTX-A effect. During our long-term follow-up the satisfactory results were sustained, similar to the results of the long-term follow-up presented by Vricella et al. [1]. The retrospective character and relative small sample size are limitations of this study.
This study shows safe and persistent satisfactory results during our average 13-month follow-up in 90% of our patients with therapy-refractory dysfunctional voiding. A prospective study using validated and standardized measurements will be performed to affirm our results and evaluate the exact role of post-injection urotherapy.
1. Vricella GJ, Campigotto M, Coplen DE, Traxel EJ, Austin PF: Long-term efficacy and durability of botulinum-a toxin for refractory dysfunctional voiding in children. J Urol 2014;191:1586–1591.
Management of non-neuropathic underactive bladder in children with voiding dysfunction by animated biofeedback: A randomized clinical trial
2015, Urology
To assess the efficacy of animated biofeedback and pelvic floor muscle (PFM) exercise in managing children with non-neuropathic underactive bladder (UB).
A total of 50 children with UB without underlying neuropathic disease, aged 5-16 years, were included in this study. They were randomly divided into 2 equal treatment groups comprising standard urotherapy (hydration, scheduled voiding, toilet training, and diet) with (group A) or without (group B) animated biofeedback and PFM exercise. The follow-up period for each participant was 1 year. A complete voiding and bowel habit diary was recorded by participants' parents before and after 2 evaluations. In addition, uroflowmetry with electromyography and bladder ultrasound were performed before, 6 months, and 1 year after treatment. Results were compared between the 2 cohorts.
Mean number of voiding episodes was significantly increased in group A after biofeedback therapy compared with group B with only standard urotherapy (6.6 ± 1.6 vs 4.5 ± 1 times a day; P <.000). Urinary tract infection did not relapse in 9 of 11 (81%) and 8 of 15 (38%) patients in groups A and B, respectively (P <.02). Postvoid residual volume and voiding time decreased considerably, whereas maximum urine flow increased significantly in group A compared with group B (17.2 ± 4.7 vs 12.9 ± 4.6 mL/s; P <.01).
Combination of animated biofeedback and PFM exercise effectively improves sensation of bladder fullness and contractility in children with UB due to voiding dysfunction.
Urodynamic pattern distribution among aged male patients with lower urinary tract symptoms suggestive of bladder outlet obstruction
2014, Urology
To develop a urodynamic study (UDS) pattern system for aged male patients who complained of non-neurogenic lower urinary tract symptoms (LUTS) to create a reference guideline for their diagnosis and treatment by a retrospective analysis.
A retrospective analysis of UDS data was carried out in 1984 male patients neurologically intact with symptoms suggestive of bladder outlet obstruction (BOO) aged older than 45 years (2002-2013). On the basis of their UDS characteristic findings, the patients were classified into 1 of 7 subgroups: equivocal or mild BOO with sphincter synergia with or without idiopathic detrusor overactivity (pattern A); equivocal or mild BOO with idiopathic sphincter overactivity (B); classic BOO with sphincter synergia (C) or overactivity (D); BOO with only detrusor low compliance (E); BOO with both detrusor underactivity and low compliance (F); and equivocal BOO with detrusor underactivity (G). The follow-up data were reviewed and analyzed thereafter.
The feasibility and rationality of this system were confirmed. The distribution of 7 patterns (pattern, case number, %) was A 158, 8%; B 59, 3%; C 1059, 53.3%; D 277, 14%; E 120, 6%; F 93, 4.7%; and G 218, 11%. A-G numbers in pattern C, D, and E were 103.1-141.4, higher than other patterns (P <.001), and functional pressure lengths of pattern C and D were 7.0-7.2 cm, longer than other patterns (P <.001).
A practical UDS pattern system for aged male patients with lower urinary tract symptoms suggestive of BOO was constructed, which can be used to optimize the diagnosis and treatment of these patients.
Dynamic pelvic floor ultrasound for lower urinary tract symptoms in children - Initial report on normative values
2013, Journal of Pediatric Urology
Lower urinary tract symptoms (LUTS) are common in children. The aim of this study was to determine normal values for pelvic floor movement in asymptomatic controls to allow comparison with symptomatic children with dysfunctional voiding (DV) in the next phase of the study.
One hundred children between the ages of 5–17 years were recruited prospectively as controls. All were asked to perform a voluntary pelvic floor contraction manoeuvre with a full bladder. All scans were performed on a Vivid I GE ultrasound machine with a 4–9 MHz curvilinear probe. M Mode was used to determine the direction of pelvic floor (levator plate-LP) movement, the distance in cms and the endurance in seconds. Each measurement was taken 3 times.
Six children were unable to understand and perform the manoeuvre and were excluded. The median age was 10 years (range 4–17). The median LP movement was 0.3 cm (range 0.1–1.6) and cranial in 86/94 (91%). The median endurance time was 5.8 s (range 2.3–15.5). For the (n = 59) younger children aged 4–11, the 95% normal reference range for LP movement was 0.1 cm–1.4 cm and for endurance was 2.5–13.5 s. For the (n = 33) older children aged 12–17, the 95% normal reference range for LP movement was 0.2 cm–1.2 cm and for endurance was 2.3–15.5 s. There was a significant correlation (Pearson r = 0.39, P = 0.001) between average LP movement and endurance.
This study gives the normal reference ranges for the variables measured. A further study is currently underway examining the same variables in children with dysfunctional voiding (DV) and comparing these with the reference range.

View all citing articles on Scopus

View full text

Pediatric urologyEffect of Biofeedback Training on Paradoxical Pelvic Floor Movement in Children with Dysfunctional Voiding

Objectives

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Conclusions

J Urol

Urology

J Urol

Lancet

J Urol

Micturition habits and incontinence in 7-year-old Swedish school entrants

Eur J Pediatr

Introital and transvaginal ultrasound as the main tool in the assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical approach

Ultrasound Obstet Gynecol

Pediatric urology
Effect of Biofeedback Training on Paradoxical Pelvic Floor Movement in Children with Dysfunctional Voiding