Biofeedback in the treatment of detrusor instability

The effect of biofeedback pelvic floor training with ACTICORE1 on urinary incontinence: a multicenter randomized clinical pilot trial

Background

Pelvic floor training with biofeedback has been shown to significantly reduce symptoms of urinary incontinence. The present study aimed to evaluate the effectiveness of pelvic floor training with the ACTICORE1 biofeedback device, which uses a noninsertable pelvic floor sensor with a digital interface.

Materials and methods

A multicenter randomized controlled clinical pilot study in Germany was conducted between October 2021 and January 2022. The intervention group was instructed to use ACTICORE1 for 6 min daily to train the pelvic floor for 12 weeks. The control group was instructed not to do any pelvic floor training. Over 18-year-old men and women with urinary incontinence and an International Consultation on Incontinence Questionnaire score (ICIQ) of ≥5 were included in the study. The primary endpoint was the ICIQ score 12 weeks after enrollment. The secondary endpoints were the ICIQ score and quality of life using the EG-5D-3L questionnaire 4, 8, and 12 weeks after patients' enrollment.

Results

A total of 40 individuals with urinary incontinence were recruited for the present study (35 females, 5 males; 40% lost to follow-up). In terms of biometric data, both groups did not differ. At 4, 8, and 12 weeks, the ICIQ scores of those in the ACTICORE1 group decreased from 12.9 to 7.5. The ICIQ score in the control group decreased from 11.0 to 10.5. The intraindividual improvement of patients in the ACTICORE group was statistically significant.

Conclusion

Biofeedback training with ACTICORE1 significantly reduces symptoms of urinary incontinence after 12 weeks.

Cystodistension: Is there evidence to support its use in current practice for patients with overactive bladder?

Cystoscopy and cystodistension have been part of common treatment protocols for a variety of bladder conditions for many years. However, the science behind the procedure is not strong and continued use of the operation may not be justified. Much research is old and was not planned or executed with the current rigour demanded by current trial methods. Newer treatments such as intravesical botulinum toxin have been extensively researched and found to be effective. This review article aimed to review the evidence behind the use of cystodistension for overactive bladder (OAB) with the aim of identifying the weaknesses in the current evidence. The article aimed to identify whether a general anaesthetic cystoscopy and distension has sufficient evidence to recommend its continued use in current practice for patients with OAB resistant to conservative and drug therapies. Impact statement Cystodistension is often used in current practice in patients with overactive bladder (OAB) resistant to conservative and drug therapies. Older data suggested that this may be of benefit but there are no randomized controlled trails with appropriate assessment of symptoms and quality of life outcomes. This paper reviews the current evidence regarding the use of cystodistension in patients with OAB. There is no standardized method of cytodistension making direct comparisons difficult. The data consists of case series from individual units. Some series show benefit but in most cases this is not sustained. Initial improvement may fall to around 10-20% after 6 months. Urodynamic parameters may also fail to improve. The procedure is associated with a complication rate of 10-20%. A randomised controlled trial of cystodistension is needed to identify if this procedure should be performed for patients with OAB.

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.

What predicts and what mediates the response of urge urinary incontinence to biofeedback?

AIMS

To better target a behavioral approach for urge urinary incontinence (UUI) and enhance its efficacy by (1) identifying predictors of response to biofeedback-assisted pelvic muscle training (BFB), and (2) determining factors that mediate response.

METHODS

BFB (four biweekly visits) was administered to 183 women > 60 years (mean = 73.6). Before and after intervention, all underwent comprehensive evaluation and videourodynamic testing. Postulated predictors and mediators from four urodynamic domains, specified a priori, were correlated with reduction in UUI frequency.

RESULTS

Median UUI frequency decreased from 3.2/day to 1/day (P =0.0001). UUI improved by ≥50% in 55% of subjects and by 100% in 13% of subjects. Frequent UUI predicted poor response (P < 0.01). Of the urodynamic parameters, only high amplitude and briskness of detrusor overactivity (DO) predicted decreased response (P < 0.05 and P < 0.01) and these could be measured only in the 43% of subjects with elicitable DO. Decreased DO elicitability was the only urodynamic variable that changed in concert with improvement and thus was a candidate mediator. Response was neither predicted nor mediated by proprioception/warning, cystometric capacity, detrusor contractility, sphincter strength, or baseline DO elicitability.

CONCLUSIONS

Severe DO predicts poor response to BFB. Good response is mediated by reduction in DO elicitability. Other than baseline UUI frequency, there are no other clinically or urodynamically important predictors or mediators of BFB response in this population. BFB may be best for patients with less severe DO. Future research to enhance its efficacy might better focus on the brain than on the lower urinary tract.

Anticholinergic drugs versus non-drug active therapies for non-neurogenic overactive bladder syndrome in adults

BACKGROUND

Overactive bladder syndrome is defined as urgency with or without urgency incontinence, usually with frequency and nocturia. Pharmacotherapy with anticholinergic drugs is often the first line medical therapy, either alone or as an adjunct to various non-pharmacological therapies after conservative options such as reducing intake of caffeine drinks have been tried. Non-pharmacologic therapies consist of bladder training, pelvic floor muscle training with or without biofeedback, behavioural modification, electrical stimulation and surgical interventions.

OBJECTIVES

To compare the effects of anticholinergic drugs with various non-pharmacologic therapies for non-neurogenic overactive bladder syndrome in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 4 September 2012), which includes searches of the Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE, and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised, controlled trials of treatment with anticholinergic drugs for overactive bladder syndrome or urgency urinary incontinence in adults in which at least one management arm involved a non-drug therapy. Trials amongst patients with neurogenic bladder dysfunction were excluded.

DATA COLLECTION AND ANALYSIS

Two authors evaluated the trials for appropriateness for inclusion and risk of bias. Two authors were involved in the data extraction. Data extraction was based on predetermined criteria. Data analysis was based on standard statistical approaches used in Cochrane reviews.

MAIN RESULTS

Twenty three trials were included with a total of 3685 participants, one was a cross-over trial and the other 22 were parallel group trials. The duration of follow up varied from two to 52 weeks. The trials were generally small and of poor methodological quality. During treatment, symptomatic improvement was more common amongst those participants on anticholinergic drugs compared with bladder training in seven small trials (73/174, 42% versus 98/172, 57% not improved: risk ratio 0.74, 95% confidence interval 0.61 to 0.91). Augmentation of bladder training with anticholinergics was also associated with more improvements than bladder training alone in three small trials (23/85, 27% versus 37/79, 47% not improved: risk ratio 0.57, 95% confidence interval 0.38 to 0.88). However, it was less clear whether an anticholinergic combined with bladder training was better than the anticholinergic alone, in three trials (for example 74/296, 25% versus 95/306, 31% not improved: risk ratio 0.80, 95% confidence interval 0.62 to 1.04). The other information on whether combining behavioural modification strategies with an anticholinergic was better than the anticholinergic alone was scanty and inconclusive. Similarly, it was unclear whether these complex strategies alone were better than anticholinergics alone.In this review, seven small trials comparing an anticholinergic to various types of electrical stimulation modalities such as Intravaginal Electrical Stimulation (IES), transcutaneous electrical nerve stimulation (TENS), the Stoller Afferent Nerve Stimulation System (SANS) neuromodulation and percutaneous posterior tibial nerve stimulation (PTNS) were identified. Subjective improvement rates tended to favour the electrical stimulation group in three small trials (54% not improved with the anticholinergic versus 28/86, 33% with electrical stimulation: risk ratio 0.64, 95% confidence interval 1.15 to 2.34). However, this was statistically significant only for one type of stimulation, percutaneous posterior tibial nerve stimulation (risk ratio 2.21, 95% confidence interval 1.13 to 4.33), and was not supported by significant differences in improvement, urinary frequency, urgency, nocturia, incontinence episodes or quality of life.The most commonly reported adverse effect among anticholinergics was dry mouth, although this did not necessarily result in withdrawal from treatment. For all comparisons there were too few data to compare symptoms or side effects after treatment had ended. However, it is unlikely that the effects of anticholinergics persist after stopping treatment. 

AUTHORS' CONCLUSIONS

The use of anticholinergic drugs in the management of overactive bladder syndrome is well established when compared to placebo treatment. During initial treatment of overactive bladder syndrome there was more symptomatic improvement when (a) anticholinergics were compared with bladder training alone, and (b) anticholinergics combined with bladder training were compared with bladder training alone. Limited evidence from small trials might suggest electrical stimulation is a better option in patients who are refractory to anticholinergic therapy, but more evidence comparing individual types of electrostimulation to the most effective types of anticholinergics is required to establish this. These results should be viewed with caution in view of the different classes and varying doses of individual anticholinergics used in this review. Anticholinergics had well recognised side effects, such as dry mouth.

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

PURPOSE

Biofeedback is known to effect symptomatic and objective cure in children with dysfunctional voiding. While some authors advocate animation assisted biofeedback to achieve success, we previously demonstrated similar success without animation. We recently used animated biofeedback aimed at simplifying muscle isolation and encouraging patient interest. We compared the efficacy of biofeedback with and without animation in treating dysfunctional voiding, and its concomitant urinary symptoms.

MATERIALS AND METHODS

We compared our experience with the last 60 cases of biofeedback using electromyography tracing alone (nonanimated) with our first 60 cases using the Urostym Pediflow program (animated). All 120 girls presented with urinary complaints and exhibited dysfunctional voiding on electromyography uroflow. Post-void residual measurements were made by ultrasound. We compared the 2 groups with respect to time to resolution of symptoms and dysfunctional voiding, and improvement in post-void residual volume after treatment.

RESULTS

The nonanimated and animated groups were comprised of girls of similar ages (7.3 years vs 6.9 years). There was no significant difference between the 2 groups regarding symptom relief at a mean of 5.4 months after therapy, including daytime incontinence, nocturnal enuresis, urgency, frequency and hoarding. Three patients in each group experienced urinary tract infection following treatment, compared to 42 and 41 before treatment in the nonanimated and animated groups, respectively. Dysfunctional voiding resolved in 95% of patients in both groups. Post-void residual reduction was similar, namely from 35% to 9% of pre-void volume in the nonanimated group, and from 28% to 8% in the animated group. Children in the animated biofeedback group achieved success in significantly fewer sessions (3.6) than those undergoing nonanimated biofeedback (7.6, t test p <0.05).

CONCLUSIONS

Despite our proved experience with nonanimated biofeedback systems and our inexperience with an animated system, animated biofeedback systems yielded similar results in a significantly shorter time. Animated and nonanimated biofeedback is efficacious in the treatment of dysfunctional voiding and its symptoms.

Anticholinergic drugs versus non-drug active therapies for overactive bladder syndrome in adults

BACKGROUND

Overactive Bladder Syndrome (OAB) is defined as urgency, with or without urgency incontinence, usually with frequency and nocturia. Pharmacotherapy with anticholinergic drugs is often the first line medical therapy, either alone or as an adjunct to various non-pharmacological therapies. The commonest non-pharmacologic therapies are: bladder training, pelvic floor muscle training with or without biofeedback and electric stimulation to affect detrusor muscle activity.

OBJECTIVES

To compare the effects of various anticholinergic drugs with various non-pharmacologic therapies for idiopathic overactive bladder syndrome in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 29 November 2005), The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to September 2004), PREMEDLINE, Dissertation Abstracts and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised, or quasi-randomised, controlled trials of treatment with anticholinergic drugs for overactive bladder syndrome or urge urinary incontinence in adults, in which at least one management arm involved a non-drug new therapy. Trials amongst patients with neuropathic bladder dysfunction were excluded.

DATA COLLECTION AND ANALYSIS

Two authors evaluated the trials for appropriateness for inclusion and methodological quality. Three authors were involved in the data extraction. Data extracted was based on predetermined criteria. Data analysis was based on standard statistical approaches used in Cochrane reviews.

MAIN RESULTS

Thirteen trials with 1770 participants were included; all were designed as parallel groups except for one cross-over trial. Trial groups were well matched for baseline characteristics in all trials. Treatment duration was 3 to 12 weeks, with one trial carrying out a follow-up analysis at 24 weeks after starting treatment. During treatment, symptomatic improvement was more common amongst those on anticholinergic drugs compared with bladder training (RR 0.73; 95% CI 0.59 to 0.90). Combination of anticholinergics with bladder training was also associated with more improvement than bladder training alone but with wide confidence intervals (RR 0.55; 95% 0.32 to 0.93). Similarly, the limited data favoured a combination of anticholinergics with bladder training compared with anticholinergics during treatment but the difference was not statistically significant (RR for improvement 0.81; 95% CI 0.61 to 1.06). For all comparisons, there were too few data to compare symptoms after treatment had ended. Adverse effects, such as dry mouth, were reported by around a third of those taking anticholinergics.

AUTHORS' CONCLUSIONS

The use of anticholinergic drugs in the management of OAB is well established. During initial treatment there was more symptomatic improvement when (a) anticholinergics were compared with bladder training alone, and (b) anticholinergics combined with bladder training were compared with each modality alone. Anticholinergics have well recognised side effects, such as dry mouth. There were too few data to assess whether or not effects are sustained after stopping treatment.

Conservative management of overactive bladder in children: evaluation of clinical and urodynamic results

OBJECTIVE

Overactive bladder in children may indicate serious anatomic as well as functional changes in both the lower and upper urinary tracts. In order to prevent such problems, these patients should be diagnosed quickly and treated appropriately. In this study, children with diurnal and nocturnal enuresis symptoms (without any underlying neurological pathology) were evaluated and the long-term follow-up results are discussed.

MATERIAL AND METHODS

Between 2001 and 2004, 95 children with an average age of 8.1 years (1-13 years), referring with complaints of diurnal incontinence, nocturnal enuresis and recurrent urinary tract infections, were included in the study. Apart from conventional evaluation and ultrasonographic and urodynamic examinations, voiding cysto-urethrography was performed in children with upper tract changes.

RESULTS

Seventy-three children (76.8%) completely responded to medical treatment, in 12 children (12.6%) the clinical status has been significantly improved, and in the remaining 10 children (10.5%) conservative management was unsuccessful. Of the children demonstrating complete response or significant improvement, 18 children (18.9%) continued to be under medication during 3-22 months of follow up with a mean maintenance period of 7.4 months. Average time to resolution in all groups was 2.6 years (0.2-3.8 years).

CONCLUSION

Conservative therapy (especially oral anticholinergic agents) in children with overactive bladder is effective when applied appropriately (especially in patients with evident detrusor instability) with adequate follow up. Taking the effect of behavioural factors into account, biofeedback training programs in addition to medical treatment should solve the problem in the majority of cases.

Overactive bladder

The overactive bladder is a common condition, which has significant effects on quality of life. The aetiology in most cases is unknown, and treatment outcomes have until recently been unsatisfactory. Management includes excluding pathology and implementing behavioural changes such as caffeine reduction, bladder and pelvic floor training, as well as antimuscarinic drug therapy. Compliance is often problematic, and this can be improved with some of the newer antimuscarinics with fewer side-effects, and a good therapist/patient relationship. In the majority of cases this 'treatment package' is successful, but in those where it is not, intravesical therapies have been introduced, e.g. neuromodulation, alternative drug therapies (e.g. vanilloids, botox) and surgery. With a better understanding of the aetiology and identification of risk factors better outcomes from treatment are likely.

Bladder augmentation using PelvicolTM implant for intractable overactive bladder syndrome

The objective of the study was to evaluate the effectiveness of an implant of porcine dermis to augment the bladder in women with refractory overactive bladder syndrome (OAB). Twelve women underwent a Pelvicol bladder augmentation. A visual analogue score for severity of incontinence and a quality of life questionnaire was carried out pre-operatively and at 12 months post-operatively. Follow up cystoscopy was carried out in three women in addition. Three women were dry and cured; five women were significantly improved; two women were slightly improved and the procedure was unsuccessful in the remaining two women. There were no significant complications and voiding was spontaneous in every case. A bladder augmentation using porcine dermis may have a role in the surgical management of non-neuropathic women with OAB that has failed to respond to conservative therapy.

Protocol- and therapist-related variables affecting outcomes of behavioral interventions for urinary and fecal incontinence

Biofeedback techniques used to treat urinary and fecal incontinence lack standardization. Most early protocols used a pressure device placed within the vagina or anal canal, or electromyographic (EMG) sensors in the same locations, to measure the external anal sphincter (EAS) or pelvic floor muscle (PFM) contractile function, and most early studies provided feedback from a single physiological transducer. The goal was to improve bowel and bladder control by improving EAS or PFM contractile function. Protocols that have resulted in the most consistent reductions in urinary incontinent episodes used 2 or more channels of physiological information to reinforce stable abdominal and bladder pressures concurrently with PFM contraction. For fecal incontinence, more significant treatment results were derived when protocols measured (1) patient perception of sensory cues associated with rectal distention and potential loss of stool, (2) short-latency EAS contraction when perceiving rectal distention, (3) inhibition of (extraneous muscle) activity that would increase intra-abdominal pressure during EAS contraction, and (4) reinforcement of sustained (up to 30 seconds) contractions rather than only brief 1- to 2-second contractions. Limited data support the use of surface abdominal EMG measures as indices of extraneous muscle activity associated with increased intra-abdominal pressure and anal or vaginal EMG probes to obtain measures of PFM function. Better results may also be obtained when there are at least 4 training sessions, when daily home exercises are prescribed, and when the therapist is well trained and experienced. These inferences are based for the most part on indirect evidence, and more studies are needed that compare different treatment protocols.

Conservative therapy for overactive bladder: pelvic floor exercises

Overactive bladder affects the lives of millions of people. Anticholinergic medications are traditionally used to treat this condition, but some patients find these agents difficult to tolerate and ineffective. Conservative treatment with pelvic floor exercises, with or without biofeedback, electric stimulation, and behavioral modification, are excellent modalities that can be effective in the motivated patient. This review describes the available literature supporting the efficacy of pelvic floor exercises in the treatment of overactive bladder and guidelines for patient selection.

Influence of behavior modification on overactive bladder

Behavioral interventions have been used for decades to treat urge incontinence and other symptoms of overactive bladder. Perhaps the earliest form of treatment was the bladder drill, an intensive intervention designed to increase the interval between voids to establish a normal frequency of urination and normalization of bladder function. Bladder training is a modification of bladder drill that is conducted more gradually on an outpatient basis and has resulted in significant reduction of incontinence in older, community-dwelling women. Multicomponent behavioral training is another form of behavioral treatment that includes pelvic floor muscle training and exercise. This intervention focuses less on voiding habits and more on altering the physiologic responses of the bladder and pelvic floor muscles. Using biofeedback or other teaching methods, patients learn strategies to inhibit bladder contraction using pelvic floor muscle contraction and other urge suppression strategies. Although behavioral and drug therapies are known to be highly effective for reducing urge incontinence, few patients are cured with either treatment alone. Thus, future research should explore ways to enhance the effectiveness of these conservative therapies. Although the mechanisms by which behavioral treatments work have not been established, there is some evidence that behavioral and drug interventions may operate by different mechanisms, suggesting that they may have additive effects and that combining them may result in better outcomes. Future research needs to examine the mechanisms by which these therapies reduce incontinence and whether combining behavioral and drug treatment will result in better outcomes than either therapy alone.

Comparative analysis of biofeedback and physical therapy for treatment of urinary stress incontinence in women

OBJECTIVE

To compare the effectiveness of an intensive group physical therapy program with individual biofeedback training for female patients with urinary stress incontinence.

DESIGN

Randomized study of two therapeutic interventions consisting of a specific physical therapy program (PT) or biofeedback training (BF) daily for 4 wk, followed by a 2-mo, unsupervised home exercise program in both groups in an outpatient clinic of a large university hospital. Forty women, referred by gynecologists for nonoperative treatment of genuine stress incontinence of mild-to-moderate severity, were included. Measurements of daytime/nocturnal urinary frequency and subjective improvement of incontinence were the main outcome measures at initial presentation, after completion of the therapy program, and at follow-up after 3 mo. Standardized examinations of digital contraction strength, speculum tests, and manometric measurements were documented as secondary outcome measures.

RESULTS

In the PT group, the daytime urination frequency decreased 22% after 4 wk of therapy and 19% after 3 mo (P < 0.05) from baseline. The nocturnal urination frequency was reduced by 66% after 4 wk of therapy and 62% after 3 mo (P < 0.001). In the BF group, the daily urination frequency decreased 10% after 4 wk of therapy and 5% after 3 mo (P > 0.05). The nocturnal urination frequency declined 36% after 4 wk of therapy and 66% after 3 months (P < 0.05). Subjective assessment after 3 mo showed that in the PT group, 28% of patients were free of incontinence episodes, 68% reported improved symptoms (incontinence episodes improved by >50%), and 4% were unchanged. In the BF group, 62% were free of incontinence episodes, and 38% were improved. Results of the digital contraction strength assessments, speculum tests, and manometric measurements showed statistically significant improvement in all variables in both groups after 3 months.

CONCLUSION

Four weeks of both intensive group physical therapy or individual biofeedback training followed by an unsupervised home exercise program for 2 mo are effective therapies for female urinary stress incontinence and result in a significantly reduced nocturnal urinary frequency and improved subjective outcome. Only group physical therapy resulted in reduced daytime urinary frequency. BF therapy resulted in a better subjective outcome and higher contraction pressures of the pelvic floor muscles.

Biofeedback in overactive bladder

Biofeedback is a form of learning or re-education in which the participant is retrained within a closed feedback loop. Information about one or more of the patient's normally unconscious physiologic processes is made available to the patient as a visual, auditory, or tactile signal. Objective responses are recorded on a polygraph trace so that they can be easily observed. Subjective responses are more difficult to monitor and it is often difficult to separate these effects of biofeedback from the placebo effect. Biofeedback has been successfully employed in cases of urinary incontinence due to detrusor instability. Indeed, a recent report has shown that biofeedback-assisted behavioral treatment is more effective than either oxybutynin or placebo in the treatment of urge and mixed urinary incontinence in older, community-dwelling women. Patients embarking on biofeedback need to be well motivated and intelligent enough to understand what is expected of them. The treatment is time consuming for both the patient and the operator, but the benefits of successful treatment include a reduction in morbidity and side effects associated with other therapies. Biofeedback can be employed as an adjunct to other forms of treatment, such as drug therapy, and is particularly useful in children.

Combined behavioral and drug therapy for urge incontinence in older women

OBJECTIVE

The purpose of this study was to examine the effects of combining behavioral treatment and drug treatment for urge incontinence in community-dwelling older women.

DESIGN

Modified crossover design (extension of a randomized clinical trial). Eligible subjects were stratified according to type and severity of incontinence and randomized to behavioral treatment, drug treatment, or a control condition (placebo). Subjects not totally continent or not satisfied after 8 weeks of a single treatment were offered the opportunity to cross over into combined therapy.

SETTING

A university-based outpatient geriatric medicine clinic.

PARTICIPANTS

Subjects in the clinical trial were 197 ambulatory, nondemented, community-dwelling women (age 55 years or older) with persistent urge urinary incontinence. Thirty-five subjects participated in combined treatment.

INTERVENTION

One group of subjects received four sessions (over 8 weeks) of biofeedback-assisted behavioral training followed by 8 weeks of behavioral training combined with drug therapy (oxybutynin chloride individually titrated from 2.5 mg to 15 mg daily). The second group received drug therapy first, followed by 8 weeks of drug therapy combined with behavioral training.

MEASUREMENTS

Bladder diaries completed by subjects before and after each treatment phase were used to calculate change in the frequency of incontinent episodes.

RESULTS

Eight subjects (12.7%) crossed from behavioral treatment alone to combined behavioral and drug therapy. Additional benefit was seen in improvement from a mean 57.5% reduction of incontinence with single therapy to a mean 88.5% reduction of incontinence with combined therapy (P = .034). Twenty-seven subjects (41.5%) crossed from drug therapy alone to combined drug and behavioral treatment. They also showed additional improvement, from a mean 72.7% reduction of incontinence with single therapy to a mean 84.3% reduction of incontinence with combined therapy (P = .001).

CONCLUSIONS

This study shows that combining drug and behavioral therapy in a stepped program can produce added benefit for patients with urge incontinence.

Conservative management for urinary incontinence

Gynaecologists have become increasingly aware of the need to offer conservative therapy for genuine stress incontinence. There is good objective evidence from randomized controlled trials to support the use of supervised pelvic floor exercises. The efficacy of biofeedback therapy, vaginal cone weights and electrostimulation therapy is variable and requires further study to identify those women who will benefit the most. The mainstay of therapy for detrusor instability/sensory urgency remains bladder training, which has proven objective efficacy, but new treatments such as transcutaneous electrical nerve stimulation (TENS) offer promise. Finally, for certain groups of women with mixed stress and urge leak, a new range of vaginal and urethral devices provide useful additional options. The specific requirements for future research are discussed.

The usefulness of a minimal urodynamic evaluation and pelvic floor biofeedback in children with chronic voiding dysfunction

OBJECTIVE

To report our experience of assessing children with chronic voiding dysfunction (>6 months' duration) using a minimal urodynamic evaluation, and the management of detrusor-sphincter dyscoordination (DSdc) using pelvic floor biofeedback.

PATIENTS AND METHODS

From 1994 to 1997, 120 children (mean age 7.5 years) with three predominant and associated symptoms were referred to one urologist; they had nocturnal enuresis (28 children), urge incontinence (42) or urinary tract infection (50). All patients were assessed by urinary culture, renal ultrasonography and a minimal urodynamic evaluation, i.e. urinary flowmetry with sphincter electromyography (EMG) using perineal surface electrodes. If they had urinary tract infection and/or renal dilatation, they underwent voiding cysto-urethrography. In children with DSdc, urinary training with frequent voiding was instituted initially, with subsequent pelvic floor biofeedback exercises if the improvement was deemed unsatisfactory.

RESULTS

DSdc was diagnosed in 33 children (28%), none of whom had isolated nocturnal enuresis. Pelvic floor biofeedback was undertaken by 15 children (12 girls and three boys); it was well accepted because it was administered as a computer game. In all affected patients the DSdc resolved on EMG and there was a significant clinical improvement. Vesico-ureteric reflux was detected in 24 patients, associated with DSdc in 10. The reflux resolved spontaneously on antibiotic prophylaxis in six children and after urinary re-education in four.

CONCLUSION

A minimal urodynamic evaluation seems to be useful in the diagnosis of DSdc which caused urinary tract infection and/or bladder overactivity. The results with pelvic floor biofeedback were excellent in these children.

The role of bladder biofeedback in the treatment of children with refractory nocturnal enuresis associated with idiopathic detrusor instability and small bladder capacity

PURPOSE

Not all children with primary nocturnal enuresis, an unstable detrusor and small bladder capacity can be treated successfully with anticholinergics and bladder drill. We report our use of bladder biofeedback in patients who did not respond to 3 months of such treatment.

MATERIALS AND METHODS

A total of 24 patients (median age 10.4 years) were studied. For bladder biofeedback a transurethral catheter was placed and connected with a 3-way connector. The bladder was slowly filled through this catheter and the intravesical pressure could be seen on a vertical tube, which was also connected to the transurethral catheter. The perineal bulbar detrusor inhibiting reflex was used in cases of involuntary bladder contraction. During the day patients retained urine as long as possible and completed a micturition chart.

RESULTS

Of the 24 patients bed-wetting stopped completely in 17 and decreased in 6, and treatment failed in 1. All patients were followed for at least 6 months after treatment. There were 2 cases of recurrence in the group that was cured.

CONCLUSIONS

Intravesical biofeedback can successfully treat patients with refractory primary enuresis associated with unstable detrusor and small bladder capacity.

The role of bladder biofeedback in the treatment of children with refractory nocturnal enuresis associated with idiopathic detrusor instability and small bladder capacity

PURPOSE

Not all children with primary nocturnal enuresis, an unstable detrusor and small bladder capacity can be treated successfully with anticholinergics and bladder drill. We report our use of bladder biofeedback in patients who did not respond to 3 months of such treatment.

MATERIALS AND METHODS

A total of 24 patients (median age 10.4 years) were studied. For bladder biofeedback a transurethral catheter was placed and connected with a 3-way connector. The bladder was slowly filled through this catheter and the intravesical pressure could be seen on a vertical tube, which was also connected to the transurethral catheter. The perineal bulbar detrusor inhibiting reflex was used in cases of involuntary bladder contraction. During the day patients retained urine as long as possible and completed a micturition chart.

RESULTS

Of the 24 patients bed-wetting stopped completely in 17 and decreased in 6, and treatment failed in 1. All patients were followed for at least 6 months after treatment. There were 2 cases of recurrence in the group that was cured.

CONCLUSIONS

Intravesical biofeedback can successfully treat patients with refractory primary enuresis associated with unstable detrusor and small bladder capacity.

Behavioral interventions for incontinence in ambulatory geriatric patients

Behavioral intervention is a group of therapies used to modify stress, urge, or mixed urinary incontinence by changing patient bladder habits or by teaching new skills. Three broad categories of behavioral treatment are reviewed: pelvic muscle exercise, biofeedback, and bladder training. The literature concerning each of these methods indicates that the treatments are effective for most community-dwelling older adults. More research is needed to identify the best methods for implementing these treatments, to explore the role of various components of treatment packages, to examine issues of durability, and to improve adherence to behavioral protocols necessary for long-term effectiveness.

Sensory urgency: how full is your bladder?

OBJECTIVE

To investigate whether women with sensory urgency have an abnormal perception of bladder fullness.

DESIGN

Prospective observational study.

SETTING

Urodynamic Unit, St George's Hospital, London.

SUBJECTS

15 women with sensory urgency, 15 women with idiopathic detrusor instability and 15 without symptoms of frequency or urgency (control group).

INTERVENTIONS

All the women attended for cystometry. Each was asked to complete a visual analogue score of how full she perceived her bladder to be on a scale from 1 to 10. This was done before filling cystometry and at three times during bladder filling. At each time actual filled volume was noted.

MAIN OUTCOME MEASURES

Maximum bladder capacity and individual perception of bladder fullness.

RESULTS

Women with sensory urgency and detrusor instability had similar maximum bladder capacity although values in both groups were significantly lower than in the control group; thus percentage of maximum bladder capacity was used for analysis. Linear regression was performed for each group of patients and a predicted visual analogue score at 25, 50 and 75% of capacity calculated. These were compared between groups by rank analysis of variance. There was no significant difference between sensory urgency and detrusor instability. However, at 25, 50 and 75% of capacity, both groups had a significantly higher score than the control group.

CONCLUSIONS

This abnormal perception would explain symptoms of frequency and urgency in these two groups. These results also confirm the similarity between detrusor instability and sensory urgency.

Biofeedback therapy technique for treatment of urinary incontinence

Biofeedback treatment of urinary incontinence is a management method that has low risk and therapeutic efficacy for selected patients. Biofeedback therapy techniques vary widely and have not been well described or standardized. A technique for biofeedback therapy is described that allows accurate signal monitoring and assures appropriate biofeedback to the patient. External anal sphincter electromyographic performance is presented to the patient as a color line graph with pitch variable audio feedback. The method has complete flexibility in providing biofeedback training according to patient performance level and is one that can be easily interpreted by patients who have voiding dysfunctions.

Use of biofeedback in treatment of psychogenic voiding dysfunction

A young man with psychologic problems and a long history of social inadequacy presented with voiding dysfunction. Videocystometrography revealed a normal filling phase and normal initiation of voiding interrupted by considerable straining by the patient and marked sphincter electromyographic (EMG) activity. Temporary amelioration was achieved by infiltration of the sphincter with lignocaine hydrochloride and by biofeedback therapy. In such cases optimal results are expected from long-term behavioral therapy.

Is the treatment of urgency incontinence a placebo response? Results of a five-year follow-up

The treatment and symptomatic outcome were reviewed in 50 women who had presented with urgency incontinence as their main symptom 5 years previously. All had idiopathic urgency incontinence and, on the basis of urodynamic investigation, 40 were considered to have detrusor instability and 10 sensory urge incontinence. The results indicate that the natural history of sensory urgency is one of spontaneous resolution; all treatments of detrusor instability (including surgery) produced an unsustained short-term symptomatic response. This pattern of response to therapy may be interpreted as being largely of a placebo nature and this emphasises the need for long-term follow-up in the assessment of new treatment modalities.

Bladder neck electrical conductivity in the treatment of detrusor instability with biofeedback

A new method for controlling the symptoms and objective signs of detrusor instability was investigated in a pilot study. The method uses the activity of the bladder neck, monitored by a conductivity catheter, as a biofeedback signal. Voluntary closure of the bladder neck mechanism abolishes abnormal detrusor activity. Ten severely symptomatic women with detrusor instability were assessed clinically and urodynamically before and after a course of biofeedback. Statistically significant improvements in the symptoms of urgency and urge incontinence were found. Five of the seven women who agreed to have repeat cystometry had stable cystometrograms. There was a statistically significant fall in the mean maximum deflection at rest from 41.5 to 16.5 microA (P less than 0.05) measured during bladder neck electrical conductivity tests before and after treatment.

Behavioral training for post-prostatectomy urinary incontinence

We treated 20 men with persistent post-prostatectomy incontinence by biofeedback-assisted behavioral training procedures. Initially, scheduled 2-hour voiding resulted in a mean 33.1 per cent increase in urge incontinence, a mean 28.5 per cent decrease in stress incontinence and no change in continual leakage. Subsequently, biofeedback was used to teach selective control of the sphincter muscles and/or inhibition of detrusor contractions. Individualized home practice included a voiding schedule, sphincter exercises, active use of the sphincter to prevent urine loss and strategies to manage urgency. After 1 to 5 biofeedback sessions patients with urge incontinence demonstrated an average 80.7 per cent decrease in incontinence, while stress incontinence was decreased an average 78.3 per cent and patients with continual leakage were less successful, with a mean 17.0 per cent improvement. The findings indicate that biofeedback training is an effective intervention for episodic stress or urge incontinence after prostatectomy. However, its usefulness appears to be limited in patients with postoperative incontinence characterized by continual leakage.

Behavioral training for urinary incontinence in elderly ambulatory patients

Research questions addressed by this study were: 1) Is the treatment of chronic urinary incontinence (UI) in elderly, nondemented ambulatory patients using bladder-sphincter biofeedback as effective when performed by an internist/geriatrician and a nurse practitioner as that reported by behavioral scientists?; and 2) how does bladder-sphincter biofeedback compare to a program of behavioral training that does not utilize biofeedback? Twenty-seven patients with UI were assigned based on the number of baseline accidents documented in a self-maintained log, their sex, and the predominant pattern of symptoms (urge or stress) to one of two treatment groups: biofeedback (13 patients) or behavioral training not utilizing biofeedback (14 patients). Patients were given up to six treatments. Patients in both groups achieved a highly significant (P less than .001) reduction in urinary accidents 1 month following treatments compared with their baseline number of accidents. The average reduction of accidents over this time period was 79% for the biofeedback group and 82% for the group receiving behavioral training without biofeedback. All patients showed improvement and no patient experienced any side effect. A internist/geriatrician and a geriatric nurse practitioner may achieve success utilizing behavioral therapy with or without biofeedback for the treatment of chronic urinary incontinence for ambulatory elderly patients.

Treatment of the unstable bladder with propantheline and imipramine

This study shows propantheline and imipramine to be effective in the management of the unstable bladder. It emphasizes the need for urodynamic studies for the accurate diagnosis of urinary incontinence. Comparisons have been made of the efficacy of propantheline and imipramine in various groups of incontinent women and indicates that in appropriately selected groups the 'cure' rate is over 70% but if sphincter weakness is excluded, urodynamics cannot differentiate between those women with unstable bladders who will respond to this medication and those who will not.

Urinary incontinence in the elderly. Ways to relieve it without surgery

Few studies of incontinence have been done on the elderly as a specific population, although epidemiologic reports reveal that incontinence is a debilitating condition that affects 15% to 30% of the elderly population of the United States. In diagnosing the problem, we use the simplest procedure that can supply the required information. However, if the diagnosis is uncertain or the treatment being considered is risky, urodynamic testing is necessary. Several nonsurgical treatments are available and have varying degrees of success in reestablishing continence. Some, such as pharmacotherapy and intermittent self-catheterization, are effective for some patients and are replacing bladder drill and bladder distention in popularity. Less conventional techniques (electrotherapy, biofeedback, and periurethral injection) are useful only in select cases and have had fewer clinical trials. Clamps and external devices for men and pessaries for women are prone to complications and generally are avoided in our practice. Long-term use of indwelling catheters is a last resort, to be considered only when all other alternatives have been exhausted. Further clinical research that considers the particular problems of the elderly is needed so that practical, humane, and effective treatment becomes possible.

A device for treatment of destrusor hyperreflexia by bio-feedback

Treatment of detrusor hyperreflexia is still a difficult field. Recently bio-feedback has been described as a successful treatment of voiding dysfunction. In this paper we describe a device, which makes it possible for the patients to register any pressure changes in the bladder.

Urodynamic biofeedback treatment of urinary incontinence in children with myelomeningocele

Eight children with myelomeningocele and chronic neurogenic urinary incontinence were provided urodynamic biofeedback training. During urodynamic biofeedback, six of the eight children demonstrated improved self-regulation of detrusor and/or sphincter functioning. However, substantial improvements in clinical symptomatology (i.e., urinary incontinence) were clearly shown by only one child. Unexpectedly, chronic neurogenic fecal incontinence was reduced in four children. Several methodological modifications are discussed which may improve clinical symptomatology and which may facilitate further urodynamic biofeedback research for these children with congenital neurogenic urinary incontinence.

Bladder distension in the management of detrusor instability

In a 10-year period, 15 patients were treated with bladder distension because of urinary symptoms associated with detrusor instability. All patients had failed to respond to previous drug therapy. Ten patients had previously undergone surgical procedures for urinary incontinence, also without success. Five patients had repeated bladder distensions performed because of lack of improvement after the first procedure. Follow-up cystometry was performed in 14 cases. In all cases the instability was unchanged. Only one patient reported improvement in voiding symptoms. No complications were seen. With a success-rate of 6% (1 out of 15 patients) we do not recommend bladder distension with the present procedure as therapy for detrusor instability.

Repeated bladder distension by the Cystomat in the treatment of detrusor instability

Treatment of idiopathic detrusor instability with drugs and prolonged distension of the bladder is often unsatisfactory. Some amelioration of symptoms has previously been described by using the Cystomat. The present study showed that 1 week's treatment with the Cystomat produced convincing subjective improvement as well as an increase in bladder capacity. The improvements were statistically significant and persisted for 3 months. Although the mechanism by which bladder distension exerts its effect is poorly understood, the technique of repeated distension offers an alternative in the treatment of patients with idiopathic detrusor instability.