Urinary biofeedback therapy in children with dysfunctional voiding

Urinary Dysfunction and Urinary Biofeedback Treatment RESEARCH Journal of Medical Research; 2014: 12(3):108-112 108 Success of Biofeedback Results in Children with Dysfunctional Voiding Mehmet Hanifi Okur, Mehmet Şerif Arslan, Bahattin Aydoğdu, Serkan Arslan, Hikmet Zeytun, Erol Basuguy, Abdurrahman Önen, İbrahim Uygun, Murat Kemal Çiğdem, Selçuk Otçu Dicle University Faculty of Medicine, Pediatric Surgery-Pediatric Urology Diyarbakır, Turkey Abstract Introduction: Urinary dysfunction (ID) is a very common problem that accounts for approximately 40% of patients in pediatric urology outpatient clinics. Uroflometry is a non-invasive test that can be used for diagnosis and follow-up. In this study, we aimed to demonstrate the effectiveness of biofeedback and Kegel exercises combination therapy aimed at relaxing active pelvic floor muscles (PTC) in the treatment of IR. Materials and Methods: In this retrospective study, patients diagnosed with ID with active PTC in electromyography (EMG) uroflometry and EMG during voiding were included in the study. The voiding patterns were classified as stacatto, interrupted, plateau and normal. In the biofeedback treatment, the children were taught to do only sphincter contraction without using the gluteal and abdominal muscles. Each session was applied for 10 minutes as 3 seconds of contraction and 10 seconds of relaxation periods. In addition, active PTC release with Kegel exercises was taught as a combined treatment. Afterwards, exercises at home, 2 times a day for 10 minutes, 3 seconds of tightening and 10 seconds of relaxation sessions were continued for 6 months under parental supervision. Results: Of the 150 patients who applied with complaints of daytime urinary incontinence, sudden need to void, difficulty in pooping, nocturnal urinary incontinence, recurrent UTI, and straining during voiding, 78 patients with active PTC detected in their EMG urophlometry were included in the study with the diagnosis of ID. The ages of the cases ranged from 6 to 17 years, and the mean age was 6.5 years. 31 (39.7%) of the cases were male and 47 (60.3%) were female. In uroflometry, 78 patients; Staccato was detected in 37 (47.4%), normal in 24 (30.7%), plateau in 12 (15.3%), and interrupted voiding patterns in 5 (6.4%). After 6 months of treatment, 68.8% of patients with complaints of voiding during sleep, 72.8% of patients with urge incontinence, 81% of patients with recurrent urinary tract infections, 85% of patients with constipation, 77% of patients with vesicoureteral reflux, and residual urine Complete recovery was achieved in 79% of the detected cases. Conclusion: Constipation, urinary incontinence, enuresis nocturna, recurrent urinary tract infections may accompany the IR clinic. With careful planning and regular controls, we can treat most of the patients with the combined treatment of biofeedback and Kegel exercises to be applied to children aged 5 and over. Keywords: Dysfunctional voiding, urinary biofeedback Abstract Aim: Voiding dysfunction (VD) are the most common problem among patients admitted to pediatric urology outpatient clinic which account for 40% of total admissions. Uroflowmeter is a noninvasive tool used for *V. Presented as an Oral Presentation at the National Pediatric Urology Congress (16-19 April 2014, ANTALYA) Correspondence: Asst. Assoc. Dr. Mehmet Şerif ARSLAN Dicle University Faculty of Medicine, Pediatric Surgery-Pediatric Urology Diyarbakır, Turkey Tel: 0 505 626 0047 E-mail: msarslan47@gmail.com diagnosis and follow up. We aimed to demonstrate the effectiveness of biofeedback and Kegel exercises in the treatment of VD by using uroflowmeter. Material-Method: A total of 78 patients diagnosed as VD using uroflowmeteri with electromyography (EMG) were enrolled to this retrospective study. Voiding pattern of the patients was categorized into four; stacatto, interrupted, plateau and normal. Children were asked to make sphincter contraction without gluteal or abdominal muscles according to the feedback treatment. Each session was performed for 10 minutes with cyclic 3 seconds of contraction and 10 seconds of relaxation periods. In addition, TAD Okur et al. Journal of Medical Research; 2014: 12(3):108-112 109 Kegel exercises were taught to children by a physiotherapist in order to relax pelvic base muscles(PBM) actively. Later on parents were encouraged to continue this 10 minutes contractionrelaxation exercise twice a day for 6 months. Results: Ages of 78 patients with VD were in a range between 6 to 17 years, and with a median age of 6.5 years. Thirty-one patients were male, 47 were female. On uroflowmeter, 37 (47%) patients were voiding in staccato pattern, 24 (31%) in normal pattern, 12 (15%) in plateau pattern and 5 (6%) in interrupted pattern. Complete improvement was observed in 69% of patients with enuresis nocturna, 73% of patients with urgency incontinence, 81% of patients with recurrent urinary tract infection, 85% of patients with constipation, 77% of patients with vesicourethral reflux, and 79% of patients with residual urine at 6 months after treatment. Conclusion: Urinary incontinence, enuresis nocturna, recurrent urinary tract infection and constipation may accompany to VD. Significant improvement in VD of the children above 5 years of age can be achieved with planning and combination of biofeedback and Kegel exercises with regular followup. Key Words: Voiding Dysfunction, Urinary Biofeedback schema dysfunction (ID) is a very common problem that accounts for approximately 40% of patients in pediatric urology outpatient clinics (1). ID is a problem that manifests itself in the form of irregular voiding and inability to fully empty the bladder after voiding, which occurs with the deterioration of bladder dynamics as a result of urinating by contracting the sphincter and pelvic floor muscles (PTC) during the bladder emptying phase (2). Its etiology is not known with certainty. Delay in control development, environmental factors, urinary tract infection (UTI), learned misbehavior are blamed in the etiology (3). Urodynamics; It is a neuro-urological diagnostic method that helps to reveal and measure physiological and pathological factors related to the transport, storage and discharge of urine (4). In the urodynamic examination; cystometry, uroflowmetry, urethral pressure profile and combined studies can also be performed. Uroflowmetry with EMG, which is one of the combined studies, is a non-invasive and inexpensive examination compared to urodynamics, which is frequently used in the diagnosis and especially in the follow-up of ID (5). Urotherapy, pharmacotherapy, surgery in severe cases, and botulinum toxini type A injection in some cases have been tried in the treatment of IR (6). In recent years, urinary biofeedback, which can also be defined as retraining the bladder, which is a non-surgical and drug-free treatment in the treatment of lower urinary tract tract, has been used in the treatment of ID (7, 8). The aim of biofeedback treatment is to teach the correct use of PTK, which is an important phase of voiding control. In this study, we aimed to share the effectiveness of biofeedback therapy, which is a non-invasive option, in the treatment of children diagnosed with ID. Material Method This retrospective study performed routine urine microscopy and EMG urophrometry to our patients who applied to our clinic with complaints of daytime urinary incontinence, sudden need to void, difficulty in pooping, nocturnal urinary incontinence, recurrent UTI, straining during voiding. After voiding, the amount of residual urine was measured with bladder scan ultrasound. In uroflometry; The patient group whose PTC was active on EMG during voiding was included in the study. Urinary ultrasonography (UUSG) was requested for all patients diagnosed with ID. After the clean urine cultures of the patients who were found to have recurrent urinary tract infections and pathology on UUSG, voiding cystourethrography was requested. The patients’ age, gender, presentation complaints, accompanying additional problems, uroflowmetry results, and post-void residual urine amounts were recorded. The patients who were treated were recommended to eat regularly and to go to the toilet regularly after meals. Additionally, oral magnesie calcinee and laxatives were started for those with constipation. Appropriate antibiotic therapy was started for those diagnosed with UTI. Trimethoprimsulfamethoxazole was started for prophylaxis in cases with VUR. Biofeedback treatments of the patients with ID were performed using the Medical Measurument System (MMS, Nedherlands) urodynamic device. At the beginning of biofeedback, patients and their parents were interviewed in the urodynamic-urotherapy unit of our clinic. Then, in the lithotomy position, a total of three electrodes were placed in the perianal region between 3 and 9 o’clock, and one in the lower abdomen. Biofeedback program with EMG was started in the appropriate voiding position. In biofeedback treatment, children were taught to mix only with sphincter contraction without using gluteal and abdominal muscles. Urinary biofeedback was continued for a total of 12 times for 3 months. Kegel exercises were taught to all families simultaneously with biofeedback. Strengthening and awareness of PTK was aimed with Kegel exercises. Each session continued PTC for 10 minutes as 3 seconds of contraction and 10 seconds of relaxation periods. The treatment was continued for 6 months under the supervision of the parents, in the appropriate voiding position, for 10 minutes, 3 seconds, squeezing for 10 minutes, 10 seconds, 2 times a day. Findings at the first encounter and 6 Urinary Dysfunction and Urinary Biofeedback Treatment RESEARCH Journal of Medical Research; 2014: 12(3):108-112 Findings after 110 months were compared. The success of the treatment was determined by clinical improvement and control uroflometry with EMG. SPSS version 15.0 was used for statistical analysis. Data were compared using the Yates chi-square test. The statistical significance limit was accepted as p<0.05. Results Of the 150 patients who applied with complaints of daytime urinary incontinence, sudden need to urinate, difficulty in pooping, nocturnal urinary incontinence, recurrent UTI, and straining during voiding, 78 patients with active PTC in their EMG uroflometry were included in the study with the diagnosis of ID. The ages of the cases ranged from 6 to 17 years, with a mean age of 6.5 years. Of the cases, 31 (39.7%) were male and 47 (60.3%) were female. ID was significantly higher in girls. voiding patterns; staccato in 37 (47.4%), normal in 24 (30.7%), plateau in 12 (15.3%) and interrupted in 5 (6.4%) cases. Residual urine after voiding in 48 (61.5%) cases, constipation in 60 (86.9%) cases, wetting the laundry in the form of drops after the sudden need to void in 55 (79.7%) cases, nocturnal urinary incontinence in 32 (41%) cases, and 25 (36.2%) cases. VUR, recurrent UTI was detected in 21 (35%) cases (Table 1). After 6 months of treatment with biofeedback and Kegel exercises, when we look at the symptoms in the success of the treatment, 68.8% of the cases in which we found nocturnal incontinence, 72.8% of those with Urge incontinence, 81% of those with recurrent UTIs, 85% of those with constipation, 77% of VUR, and 79% of the cases in which we found residual urine We found that there was improvement. We found that especially nocturnal incontinence and VUR symptoms were more resistant to treatment than other symptoms. More than 80% clinical improvement was achieved in both genders. There was no significant difference between the genders. The improvement in active PTC detected on EMG was 89.2%. In uroflowmetry, the improvement in the parameters of decrease in voiding time, decrease in the time to start voiding, decrease in the amount of residual urine and increase in the mean amount of voiding were found to be statistically significant (Table 2). Discussion Voiding disorders such as DI, urge syndrome, and underactive bladder are the complaints that we encounter frequently in the pediatric patient group and that occur as a result of lower urinary system dysfunction. There is no neurological pathology in functional DI, the person cannot use the sphincter correctly during voiding. It is contracting its sphincter when it should be relaxing, or relaxing it when it should. Table 1. The voiding patterns, accompanying symptoms, and pre- and post-treatment indicators of 78 patients with ID. (y:years) Patients with voiding dysfunction EMG/Uroflow voiding pattern before treatment Staccato Normal Plato Interrupte d Unresponsive Improvement Gender t Male 31 (39.7%) 14(37.8%) 8(33.3%) 8 (66.7%) 1(20%) 6(19.3%) 25(80.7% ) Female 47(60.3%) 23(62.2% ) 16(66.7% ) 4(% 33.3) 4(80%) 9(19.1%) 38(80.9% ) Total 37(47.4% ) 24(30.7% ) 12(15.3% ) 5(6%, 4) 15(19.2% ) 63(80.7% ) Age 5-17 years 6-11 y 6-17 y 5-14 y 8-11 y 6-10.5 y 6-17y Average age 9, 7 years 9.1 y 10.5 y 10.2 y 9 y 7 y 8.5y Symptoms Nocturnal incontinence 32(41%) 19(59.3% ) 7(21.8%) 4(12.5%) 2(6%) 10(31.2% ) 22(68.8% ) Urge incontinence 55(79.7% ) 22(40%) 18(32.7% ) 11(%20) 4(% 7.2) 15(27.2% ) 40(72.8% ) UTI 21(35%) 10(47.6% ) 5(23.8%) 4(19%) 2(9.5%) 4(19) 17(81%) Constipation n 60(86.9% ) 26(43.3% ) 20(33.3% ) 10(16.6% ) 4(6.6%) 9(% 15) 51(85%) VUR 25(36.2% ) 9(36%) 8(32%) 5(20%) 3(12%) 6(23%) 19(77%) Residual urine 48(%) 61.5 ) 21(56.7) 15(62.5% ) 10(83.3% ) 2(40%) 10(21%) 38(79%) EMG 78(100%) 37(100%) 24(100%) 12(100%) 5(100%) 8(10.2%) 70( 89.2% ) Total 78 (100%) 8 (10.2%) 70(89.2% ) Okur et al. Journal of Medical Research; 2014: 12(3):108-112 111 Table 2. Analysis of pre- and post-treatment urophrometry results of DS children. (Yates chi-square test. p<0.05 significant) Urophlometry Before treatment After treatment p Bladder capacity (cc) 218.7 (±162.3) 232.4 (±135.6) 0.43 Maximum voiding rate (ml/sec) ) 19.8 (±9.7) 22.4 (±7) 0.24 Urination time (s) 25.5 (±19.5) 17.7(±12.2) 0.001 Flow rate (ml/s) 23 .8 (±17.6) 18.8(±11.6) 0.02 Waiting time (s) 14.7 (±11.9) 7.8(±5.2) 0.002 Mean flow rate (ml/s) 10.4 (±5.3) 12.5(±5) 0.008 Residual urine (ml) 30.8(±23.5) 8.9(±6.3) 0.001 Qmax 14.6 (±5) 14 ,1(±4.9) 0.86 Misuse of the sphincter during voiding was defined as a misbehavior disorder that occurs as a result of incorrect learning during toilet training in childhood. However, in studies conducted in recent years, it has been suggested that this is not just a false learning event, but that there is a disorder in the secretion of some mediators from the central nervous system (CNS) that regulate the functions of the PTC (9). Van goal also showed urethral sphincter dysfunction and delayed maturation of the CNS in the etiology of ID (10). In the clinic of DI, there are sudden urge to void, intermittent voiding, weak flow voiding, straining during voiding, and inability to fully empty the bladder. Incomplete emptying of the bladder or residual urine results in frequent voiding throughout the day (10). Kegel; published positive treatment results in women with stress incontinence as a result of PTC exercises (11). Subsequently, the accuracy of the success of this treatment was supported by many other publications. Kegel’s exercise; It is a noninvasive treatment method consisting of periods of tightening the pelvic muscles for a few seconds and then relaxation (8,12). In the treatment of children with incontinence and recurrent UTI and bladder sphincter discoordination, Maizels first defined the idea of ​​biofeedback for relaxation of PTC (13). Subsequently, many studies have shown that it is an effective and noninvasive treatment method in the treatment of DI in children (14, 15). Biofeedback has been used mostly in the failure of conservative treatment. The aim of biofeedback treatment of patients with DI is to teach the functions of the muscles used by the person during the voiding period to himself and their families. Urotherapy treatment also includes regular fluid intake, regular urination, constipation treatment, and genital hygiene (14). Biofeedback training is applied to children over the age of 5 who are considered to be mentally mature (2). In the literature, there are studies in which 96% complete recovery was achieved in the stacatto voiding pattern and 80% in the interrupted pattern after biofeedback treatment (16). In the literature review, there is no consensus about the duration of treatment and frequency of repetition, duration of relaxation and contraction, and the degree of contraction. Shei Dei Yang and Wang applied 10 seconds of relaxation and 10 seconds of contraction in the PTC in their sessions. Control uroflometry was found to be normalized in 90% of cases with abnormal urophlometry (17). De Paep et al. In the biofeedback program with EMG, 3 seconds of contraction and 30 seconds of relaxation were applied once a week for a total of 30 sessions. They had good results in 65% of their cases (18). Vaconcelos et al. In the studies of s, he formed 2 groups and 24 sessions of Kegel exercises were applied to group 1. Biofeedback was started in Group 2 with 16 sessions of Kegel exercises. After the treatment, the status of the symptoms was checked at 1, 6 and 12 months. They found that the success of the treatment was statistically significant as the duration of treatment increased. In addition, group 2 treated with combined treatment achieved a significant decrease in the amount of residual urine (19). Yagci et al. also applied urotherapy sessions as 3 seconds of contraction and 30 seconds of relaxation periods (20). Van Gool et al. treated 50% of the cases with non-neurogenic bladder-sphincter dysfunction with urotherapy (10). Zivkovic et al. urotherapy started with the education of children and their parents, accompanied by a physiotherapist. Afterwards, diaphragmatic breathing exercises and exercises of PTK were taught. Afterwards, 30 seconds of relaxation sessions were applied at home for at least 6 months, followed by 3 seconds of contraction per day. In their prospective study, they managed to achieve statistically significant improvement in the complaints of urinary incontinence, nocturnal enuresis, urinary tract infection and constipation in the results of 43 patients with ID (21). ID’s; Urophrometry, which is a very reliable test in the diagnosis, treatment and follow-up, is technically easy, inexpensive and noninvasive. We can easily apply it to any patient with suspected ID. Our treatment success results were similar to the literature. We think that the treatment of ID is quite easy with Kegel exercises combined with biofeedback. In the control uroflometry performed after 6 months of treatment; voiding time, flow rate, waiting time, residual urine Urinary Dysfunction and Urinary Biofeedback RESEARCH Journal of Medical Research; 2014: 12(3):108-112 We achieved a statistically significant decrease in the amount of 112. We obtained a statistically significant increase in the mean flow rate. Outcome to the ID clinic; Constipation, urinary incontinence, enuresis nocturna, recurrent UTI may accompany. With careful planning and regular controls, Kegel exercises and urinary biofeedback, which will be started in children aged 5 and over, can easily be treated in a significant part of the patients by re-teaching the physiology of voiding, which is often mislearned. We are of the opinion that there is a need for new prospective studies on the frequency of urotherapy sessions and the duration of treatment in order to obtain better treatment results. References 1. Farhat W, Bagli DJ, Capolicchio G, O’Reilly S, Merguerian PA, Khoury A, et al. The dysfunctional voiding scoring system: quantitative standardization of dysfunctional voiding symptoms in children. The Journal of urology. 2000 Sep;164(3 Pt 2):1011-5. PubMed PMID: 10958730. 2. Demet ALAYGUT SK. What is the Clinical Importance of Voiding Physiology During the Growth Period? Turkish Journal of Pediatric Disease. 2013;1:53-6. 3. Bauer SB. Special considerations of the overactive bladder in children. urology. 2002 Nov;60(5 Suppl 1):43-8; discussion 9. PubMed PMID: 12493352. 4. Ewalt DH, Bauer SB. Pediatric neurourology. The Urologic clinics of North America. 1996 Aug;23(3):501-9. PubMed PMID: 8701563. 5. Malyon AD, Boorman JG, Bowley N. Urinary flow rates in hypospadias. British journal of plastic surgery. 1997 Oct;50(7):530-5. PubMed PMID: 9422951. 6. Petronijevic V, Lazovic M, Vlajkovic M, Slavkovic A, Golubovic E, Miljkovic P. Botulinum toxin type A in combination with standard urotherapy for children with dysfunctional voiding. The Journal of urology. 2007 Dec;178(6):2599-602; discussion 602- 3. PubMed PMID: 17945299. 7. Hoebeke P. Twenty years of urotherapy in children: what have we learned? European urology. 2006 Mar;49(3):426-8. PubMed PMID: 16439053. 8. Onen A, editor The effect of age and gender on results of biofeedback in children: Analyzes os 215 cases. 22nd Annual Congress of the ESPU; 2011; Copenhagen, Denmark. April. 9. de Jong TP, Klijn AJ. Urodynamic studies in pediatric urology. Nature reviews Urology. 2009 Nov;6(11):585-94. PubMed PMID: 19890338. 10. van Gool JD, Kuitjen RH, Donckerwolcke RA, Messer AP, Vijverberg M. Bladder-sphincter dysfunction, urinary infection and vesico-ureteral reflux with special reference to cognitive bladder training. Contributions to nephrology. 1984;39:190-210. PubMed PMID: 6744871. 11. Kegel AH. The physiologic treatment of poor tone and function of the genital muscles and of urinary stress incontinence. Western journal of surgery, obstetrics, and gynecology. 1949 Nov;57(11):527-35. PubMed PMID: 15392751. 12. Bo K. Pelvic floor muscle strength and response to pelvic floor muscle training for stress urinary incontinence. Neurourology and urodynamics. 2003;22(7):654-8. PubMed PMID: 14595609. 13. Maizels M, King LR, Firlit CF. Urodynamic biofeedback: a new approach to treat vesical sphincter dyssynergia. The Journal of urology. 1979 Aug;122(2):205-9. PubMed PMID: 459015. 14. Wiener JS, Scales MT, Hampton J, King LR, Surwit R, Edwards CL. Long-term efficacy of simple behavioral therapy for daytime wetting in children. The Journal of urology. 2000 Sep;164(3 Pt 1):786- 90. PubMed PMID: 10953156. 15. Schulman SL, Von Zuben FC, Plachter N, KodmanJones C. Biofeedback methodology: does it matter how we teach children how to relax the pelvic floor during voiding? The Journal of urology. 2001 Dec;166(6):2423-6. PubMed PMID: 11696803. 16. Wenske S, Van Batavia JP, Combs AJ, Glassberg KI. Analysis of uroflow patterns in children with dysfunctional voiding. Journal of pediatric urology. 2013 Nov 7. PubMed PMID: 24290223. 17. Shei Dei Yang S, Wang CC. Outpatient biofeedback relaxation of the pelvic floor in treating pediatric dysfunctional voiding: a short-course program is effective. Urology internationalis. 2005;74(2):118- 22. PubMed PMID: 15756062. 18. De Paepe H, Renson C, Van Laecke E, Raes A, Vande Walle J, Hoebeke P. Pelvic-floor therapy and toilet training in young children with dysfunctional voiding and obstipation. BJU international. 2000 May;85(7):889-93. PubMed PMID: 10792172. 19. Vasconcelos M, Lima E, Caiafa L, Noronha A, Cangussu R, Gomes S, et al. Voiding dysfunction in children. Pelvic-floor exercises or biofeedback therapy: a randomized study. Pediatric nephrology. 2006 Dec;21(12):1858-64. PubMed PMID: 16967285. 20. Yagci S, Kibar Y, Akay O, Kilic S, Erdemir F, Gok F, et al. The effect of biofeedback treatment on voiding and urodynamic parameters in children with voiding dysfunction. The Journal of urology. 2005 Nov;174(5):1994-7; discussion 7-8. PubMed PMID: 16217376. 21. Zivkovic V, Lazovic M, Vlajkovic M, Slavkovic A, Dimitrijevic L, Stankovic I, et al. Diaphragmatic breathing exercises and pelvic floor retraining in children with dysfunctional voiding. European journal of physical and rehabilitation medicine. 2012 Sep;48(3):413-21. PubMed PMID: 22669134.

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