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

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.

Effectiveness of biofeedback for dysfunctional elimination syndrome in pediatrics: a systematic review

PURPOSE

Dysfunctional elimination syndrome is associated with an inability to effectively empty the bladder and may present with UTI, incontinence, intestinal constipation or other voiding symptoms. Biofeedback has emerged as one potentially effective and non-invasive treatment. We sought to analyze if biofeedback is an effective method to treat children less than 18 years of age.

METHODS

A literature search was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Database, AUA, CUA, AAP and ESPU abstracts. Copies of all relevant articles were retrieved for quality assessment and data abstraction by two independent reviewers. Primary outcomes were UTIs and daytime incontinence.

RESULTS

27 studies were included (1 RCT and 26 case-series). The pooled estimate showed 83% (95% CI: 79%-86%) and 80% (95% CI: 76%-85%) improvement in UTI and daytime incontinence respectively. I(2) statistic showed "Low" (7%) and "High" (77%) heterogeneity across studies results for UTI and daytime incontinence. The only included RCT favored biofeedback over standard therapy (RR 1.4, 95% CI: 0.98-2.00) but this was not statistically significant. On analysis of all included studies there was also improvement in constipation (18%-100%), frequency (67%-100%), urgency (71%-88%) and VUR (21%-100%). PVR improvement ranged from 26 ml to 99 ml and Q(max) improvement was from 3.1 ml/s-4.7 ml/s.

CONCLUSION

Based on this review, biofeedback is an effective, non-invasive method of treating dysfunctional elimination syndrome, and approximately 80% of children benefited from this treatment. However, most reports were of low level of evidence and studies of more solid design such as RCT should be conducted.

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.

Urinary incontinence

Urinary incontinence is a common primary care problem. With the proper understanding of normal and abnormal bladder function, pediatricians can create a protocol that will benefit most children seen with this condition. Emphasis should be placed on primary therapy: establishing healthy dietary habits, treating constipation, maintaining appropriate hygiene, and developing a regular voiding pattern. When the initial evaluation identifies an anatomic abnormality or when primary therapy fails, referral to a pediatric urologist is warranted.

[Biofeedback for urinary bladder dysfunctions in childhood. Indications, practice and the results of therapy]

In children, abnormal behavior during micturition, i.e. detrusor/sphincter dyscoordination, causes persistent voiding problems, urinary incontinence and/or recurrent urinary tract infections in up to 15% of cases. Contractions of the external urethral sphincter during micturition lead to functional subvesical obstruction. Nowadays, biofeedback training is the most suitable therapy. Biofeedback training for children is based on the assumption that relaxation and contraction of the urinary external sphincter is a habitual phenomenon and can be restored. With specially developed, computer-assisted biofeedback programs, sphincter contraction and relaxation can be transformed into acoustic or visual signals. Acoustic or optical feedback indicates relaxation and contraction control to the patient. The residual urine volume should subsequently be assessed. The results should be reviewed after each micturition. Poor compliance sometimes makes biofeedback training impossible. Further biofeedback training at home is a reasonable suggestion. Good results-a response rate of up to 90%-demonstrates that biofeedback training is successful in the treatment of detrusor-sphincter dyscoordination. After effective therapy, associated urinary tract infections and vesicoureterorenal reflux may disappear.

A modified biofeedback program for children with detrusor-sphincter dyssynergia: 5-year experience

PURPOSE

We reviewed our 5-year experience with a modified 4 to 6-session biofeedback program combining noninvasive urodynamic approaches with various psychological techniques, including externalizing the voiding problem, empowerment and praise, to treat children with detrusor-sphincter dyssynergia.

MATERIALS AND METHODS

Biofeedback was performed with a urodynamics processor that enables simultaneous recording of urine flow and electromyography, and visual display of flow/electromyography activity. Initially normal and abnormal voiding were explained in a unique way and the children observed relaxation and contraction of the pelvic floor muscles while visualizing the electromyography monitor. The bladders were filled naturally and surface electrodes were placed. Psychological strategies were used to engage and motivate the children to achieve maximal cooperation. The children voided while attempting relaxation and post-void residual urine volume was measured by bladder scan. Special and specific praise was provided for progress and increasing self-esteem. Patients returned monthly to review these concepts and practice voiding.

RESULTS

Of 87 children 77 completed the program, including 7 boys and 70 girls 3 to 17 years old (mean age 7.8) who required an average of 4.7 sessions (median 4). Results were achieved within 6 sessions in 82% of cases. Of the 77 children 59 (76%) had recurrent urinary tract infections, 38 (49%) had associated bladder instability, 19 (24%) had vesicoureteral reflux and 44 (58%) had constipation. Subjectively 47 patients (61%) reported pronounced improvement in urinary symptoms, while another 24 (32%) reported moderate improvement after biofeedback training. Objectively 47 children (61%) had normal flow with minimal electromyography activity during voiding and a normal post-void residual urine of less than 20% voided volume (p <0.002). In 28 cases (36%) flow studies improved (p <0.03) but post-void residual urine remained elevated. Vesicoureteral reflux resolved in 9 cases after biofeedback training. This approach was equally successful in children in all age groups. Those with more than a 2-year history of symptoms, poor bladder emptying and severe constipation had only moderate improvement.

CONCLUSIONS

The modified biofeedback program including appropriate explanations and psychological approaches appeared effective for treating 92% of children with detrusor-sphincter dyssynergia. It is less invasive and requires less time than traditional methods, and patients are more compliant with treatment.

Long-term efficacy of simple behavioral therapy for daytime wetting in children

PURPOSE

Behavioral therapy has proved benefit for children with daytime wetting but most studies have used biofeedback techniques and provide no long-term assessment of results. We previously reported similar results using simple behavioral therapy without biofeedback. We report the long-term efficacy of behavioral therapy for daytime wetting.

MATERIALS AND METHODS

Our program of behavioral therapy included timed voiding, modification of fluid intake, positive reinforcement techniques and pelvic floor (Kegel) exercises to promote pelvic floor strengthening and relaxation. Questionnaires to assess therapeutic efficacy were mailed to patients who had completed therapy more than 1 year previously.

RESULTS

A total of 48 patients responded. Mean ages at the time of the initial clinic visit and questionnaire were 8.2 and 12.9 years, respectively. Improvement in symptoms was noted in approximately 74% of the cases during the first year following therapy. At a mean of 4. 7 years after treatment 59.4% of the patients had improved daytime urinary control, 51.1% improved daytime urinary frequency and 45.6% improved daytime urinary urgency. The frequency of urinary tract infections decreased in 56.4% of the cases. Measures of psychological well-being were also noted to be improved in a majority of patients. A total of 77.3% of the patients stated that they would recommend the program to others.

CONCLUSIONS

Simple behavioral therapy without biofeedback techniques is an effective and durable first line therapy for children with daytime wetting.

Pelvic-floor therapy and toilet training in young children with dysfunctional voiding and obstipation

OBJECTIVE

To analyse experience in treating young children (4-5 years old) with urodynamically confirmed voiding dysfunction, using a noninvasive training programme.

PATIENTS AND METHODS

Between January 1996 and October 1997, 20 children (all < 5 years old, mean age 4.45 years, 18 girls and two boys, mean ages 4.44 and 4.5 years, respectively) with voiding dysfunction were treated. Three children showed filling phase dysfunction alone (bladder instability), six emptying phase dysfunction alone (dysfunctional voiding) and 11 showed both filling and emptying phase dysfunction. Sixteen children had incontinence problems (three diurnal, two nocturnal and 11 diurnal and nocturnal). Eight children had a history of recurrent urinary tract infections and 12 girls had vaginal irritation. Four children were referred for perineal pain caused by spasms of the pelvic floor. Eight children had encopresis based on chronic obstipation. Therapy consisted of keeping a voiding and drinking chart, instructions on proper toilet posture, daily rules for application at home, and if possible relaxation biofeedback of the pelvic-floor muscles. Therapy was considered successful if incontinence and other urological symptoms resolved. The treatment of encopresis is also discussed.

RESULTS

Of the 20 children, 13 had a good result; they all became dry during the day and night, and encopresis resolved. Six children had moderate success; in one, nocturnal incontinence persisted, and in two diurnal and nocturnal incontinence continued. In two children encopresis persisted and in one the faecal incontinence ameliorated. In one child the therapy was prematurely interrupted because of lack of motivation.

CONCLUSION

This experience suggests that a noninvasive training programme is applicable in very young children with symptoms of dysfunctional elimination of urine and faeces.

Evaluation and management of pediatric urinary tract infections

Urinary tract infections (UTIs) are relatively common in children. We describe the evaluation and management of children with UTIs, as well as the risks and consequences related to the UTI. This article describes a rational approach to the evaluation and management of childhood UTIs with the relation to the natural history and risk factors.

[Urodynamics in diagnosis and therapy of "enuresis"--relevance for child and adolescent psychiatry]

Enuresis and functional urinary incontinence are clinically and pathophysiologically heterogeneous disorders. They differ with regard to their urodynamics, i.e. with regard to the function or dysfunction of the urinary tract. In addition to general measures such as history, physical examination, urinalysis, questionnaires and flow charts, noninvasive sonography and uroflowmetry with pelvic-floor EMG play an important role in diagnosis and therapy. Rates of pathological findings are especially high among day-wetting children and nocturnal enuretics with micturition problems. This group requires a detailed diagnosis, especially children with detrusor-sphincter discoordination, which can be treated effectively by means of uroflow-biofeedback. The relevance of these methods in child and adolescent psychiatry are discussed in detail and practical recommendations are made.

Biofeedback therapy for children with dysfunctional voiding

OBJECTIVES

Biofeedback therapy has been recognized as a treatment option for children with classic dysfunctional voiding (DV) where there is inadequate pelvic floor relaxation during voiding. However, there are few articles that discuss methodology and limited sites where it is available. In the hope of making biofeedback a more practical and accessible option, we report our indications, easy to duplicate methodology, and results.

METHODS

Twenty-one consecutive children diagnosed with DV refractory to standard therapy were enrolled in our biofeedback program. Therapy consisted of extensive age-appropriate explanations of DV and demonstrations of normal and abnormal voiding patterns. Cyclic uroflow studies with pelvic floor electromyography are performed, which the child monitors on analog chart and audio recorders. The child returns weekly until consistent relaxation of the pelvic floor during voiding is demonstrated. Timing between sessions is then increased to monitor progress and retention of concepts previously taught.

RESULTS

An excellent clinical response was one in which there was consistent relaxation of the pelvic floor throughout voiding, normal flow pattern, and no residual urine volume (urodynamic response), coupled with profound resolution of voiding symptoms. Seventeen of 21 (81%) had an excellent response, 3 (14%) had a fair response, and 1 (5%) was too inconsistent to rate. The average number of sessions to achieve a consistent urodynamic response was 3.7 (range 2 to 14) and full clinical response somewhat longer. Average follow-up since beginning therapy has been 34 months (range 14 to 51).

CONCLUSIONS

Biofeedback therapy is an effective method for treating DV with poor pelvic floor relaxation. Although initially labor intensive, it yields sustained positive results in most patients in a short time.

Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood

OBJECTIVES

To evaluate the frequency of urinary incontinence and urinary tract infection in children with chronic constipation and report on the resolution of these with treatment of the underlying constipation.

METHODS

We evaluated the frequency of urinary incontinence and urinary tract infection in 234 chronic constipated and encopretic children before, and at least 12 months after, the start of treatment for constipation.

RESULTS

Twenty-nine percent complained of daytime urinary incontinence and 34% of nighttime urinary incontinence. Urinary tract infection was present in 11% and was more commonly present in girls than in boys (33% vs 3%). Vesicoureteral reflux was present in four and megacystis in four of the 25 children who had a voiding cystourethrogram because of urinary tract infection. One girl who came in had constipation and acute urinary retention. The treatment for constipation consisted of disimpaction and maintenance treatment, which included the prevention of reaccumulation of stools and reconditioning to normal bowel habits through timed toilet sitting. Follow-up, at least 12 months after start of treatment for constipation, revealed that the constipation was relieved successfully in 52%. Relief of constipation resulted in disappearance of daytime urinary incontinence in 89% and nighttime urinary incontinence in 63% of patients, and disappearance of recurrent urinary tract infections in all patients who had no anatomic abnormality of the urinary tract.

CONCLUSION

Urinary symptoms were found in a significant number of children who had functional constipation and encopresis. With treatment of the constipation, most patients became clean and dry and further recurrence of urinary tract infections was prevented.