Nonpharmacological treatment of lower urinary tract
dysfunction using biofeedback and transcutaneous
electrical stimulation: a pilot study

Section of Paediatric Urology, Division of Urology, Federal University of Bahia, Bahiana School of Medicine and Public Health and Federal University
of São Paulo, Brazil

Accepted for publication 14 February 2006 OBJECTIVE
To report a series of children with lower urinary tract infection. Of 21 children with nocturnal enuresis, bed-wetting continued in stimulation, and their voiding dysfunction by biofeedback; none of the children were using electrical stimulation sessions was 13.1 anticholinergic drugs during treatment.
(4–20). Of the 19 children treated, 12 had CONCLUSION
improvement. In group 2, the mean (range) number of biofeedback sessions was 6 (4–14). dysfunction using biofeedback, and of urge symptoms of urinary urgency and/or daily incontinence completed the treatment and effective for treating LUTD in children.
(range) follow-up was 13.8 (4–24) months, improvement in five. Six children who had no resolution of symptoms after biofeedback had KEYWORDS
children were aged <5 years. The children salvage therapy with electrical stimulation, were divided into two groups: group 1, with after which four had complete improvement urinary tract infection, bladder, children, parasacral electrical stimulation, and group 2, improvement, respectively. Taking the two INTRODUCTION
of side-effects is not low [5]; symptoms like dryness of mouth, constipation, flushing and Lower urinary tract dysfunction (LUTD) is hyperthermia, caused complete intolerance stimulation, which are unsuitable for children with no neurological abnormalities. Hoebeke behavioural alterations, and with UTI, VUR considering that the treatment requires daily, et al. [7] reported the only study in children and renal scarring [1–3]. LUTD is classified as oral ingestion of the drug, adherence to using transcutaneous (superficial) electrical urge syndrome or urge urinary incontinence stimulation over S3. At 1 year after treatment (UI) when there is only a disturbance in the there was resolution of symptoms in 51% of bladder-filling phase, and as dysfunctional The treatment of voiding disturbance with the children. However, there are problems drugs has been substituted by biofeedback dyscoordination (VPD) in the voiding phase. stimulation was applied at a low frequency (2 Hz), with long sessions (2 h), and over a biofeedback series associate this pelvic floor long period (6 months), and the results are whether it is related to bladder filling or training with anticholinergic drugs, which difficult to interpret because the children took voiding disturbance. However, according to makes the results difficult to interpret.
anticholinergics during the treatment.
Reinberg et al. [4], the symptoms of urgency and daily UI were resolved in <30% of Considering the possibility of successful included in the biofeedback studies, and symptoms improved. In addition, the rate Electrical stimulation is occasionally proposed stimulation techniques with no medication, J O U R N A L C O M P I L A T I O N 2 0 0 6 B J U I N T E R N A T I O N A L | 9 8 , 1 6 6 – 1 71 | doi:10.1111/j.1464-410X.2006.06264.x T R E A T I N G L U T D Y S F U N C T I O N W I T H B I O F E E D B A C K A N D E L E C T R I C A L S T I M U L A T I O N dilatation, and to estimate bladder wall thickness. The PVR was considered high when urgency. The children were asked to return it was >10% of the bladder capacity expected for a re-evaluation at the pre-scheduled stimulation and their voiding dysfunction for the age. A complete urodynamic study was appointments or at the first sign of UTI or used only if the initial treatment failed.
a change in voiding pattern. The girls were asked to prioritise voiding comfort by We defined a ‘UTI’ as the growth of ≥100 000 avoiding sitting on a toilet seat with an overly PATIENTS AND METHODS
colonies of bacteria/mL, obtained from a mid- large opening, suggesting options of toilet- stream urine sample. Before treatment, all seat adapters and foot supports to adjust for In our institution, all patients with LUTS are treated initially for 1 month by behavioural biochemically and cultured. After the start of suggestions for a comfortable back posture orientation. In all, 37 children who were not treatment, a urine sample was cultured only if and a relaxed abdomen, by singing a song. The the voiding pattern changed or if there were child was asked to count slowly to 10 at the stimulation and/or biofeedback training. One typical symptoms of UTI. All children with a end of voiding to reduce the possibility of a history of UTI within the 3 months before the PVR. A drawing of the desired voiding posture biofeedback training, was unsuitable for the method and was excluded from the present antibiotic prophylaxis (nitrofurantoin 2 mg/ study. Thus 36 children who completed the Group 1 included 19 children (17 girls and treatment were prospectively evaluated. Their mean (range) age was 7 (3–14) years, 17 were treated with superficial parasacral electrical <5 years old, and the mean follow-up was evaluation 1 month after the first treatment stimulation. All 19 had symptoms of urgency session and then at 3-month intervals. Before and 16 had urge UI. The distribution of the each session, the parents were asked for their number of urinary leaks/month is shown in A rigorous voiding history of the children was opinion about the success of the treatment of Table 1. Eleven children also had nocturnal taken by the same clinician. Routinely, speech, their child, choosing one of four responses: enuresis (NE). All the children who did not motor coordination, limb sensitivity, bulbo- complete resolution, or important, mild, or no have daily UI were also continent during the and ischio-cavernosus reflex, and tonicity of improvement of the LUTS. An analogue scale night. In all, 11 children had a history of UTI. was also used (0, no improvement to 10, no Table 1 also shows the distribution of the lumbosacral area was evaluated for signs of spina bifida. All children with a suspected neurological disorder were evaluated by a improvement. In addition, the children were There was a disturbance of fecal elimination neurologist and excluded from the study. in 12 children, with difficulty in fecal Children aged <3 years were also excluded, as proposed earlier [8], before treatment, after elimination in six, constipation (defined as a the last session and then every 3 months 3-day absence of fecal elimination) in five, afterwards. None of the children were in and encopresis in one. VCUG was used in 13 secondary to anatomical anomalies, e.g. PUV, children and VUR was detected in none of ureterocele, ectopic ureter or megaureter, were excluded from the analysis. Children The children were assigned to two groups: group 1, children with urge syndrome who were treated with superficial parasacral unsuccessfully with oxybutynin (0.4 mg/kg electrical stimulation; group 2, children with per day). Uroflowmetry showed a bell-shaped voiding dysfunction who were treated with curve in 13 children and a flat curve in six; noninvasive, urodynamic examination that biofeedback. All the children had LUTS, e.g. voiding electromyography was normal in all comprised: (i) a voiding chart completed uninterrupted flow, no vesical-sphincter The electrical stimulation was administered in bladder ultrasonography with an estimate of dyscoordination at electromyography and no the office, and consisted of two superficial the postvoid residual urine volume (PVR). The high PVR. Dysfunctional voiding was defined electrodes of 3.5 cm, placed on each side of quantity of liquid ingested, the number of as VPD at electromyography during voiding, S3, with electrical energy produced by a voids/day, the quantity of urine eliminated or the presence of a high PVR. Associated with these approaches, we applied the following Piracicaba-São Paulo, Brazil). The frequency intervals were all recorded, based on the behavioural training: voiding every 3 h or at used was 10 Hz with a mean (range) current voiding chart. The functional bladder capacity the onset of the desire to void; avoidance was considered as the mean volume of all of tea, coffee, sodas and chocolate. The increased to the maximum level tolerated by voiding episodes. From uroflowmetry with the child. The same professional applied the booklet containing drawings to illustrate electrical stimulation, 3 days a week, with pattern (bell-shaped, flat or interrupted) and the need to void before sleeping, to increase sessions of 20 min. The number of sessions the voiding coordination were recorded. The the volume of ingested liquid per day, to eat varied according to the outcome, up to a ultrasonograms were inspected for any kidney foods rich in fibre, and to avoid postponing 2 0 0 6 T H E A U T H O R SJ O U R N A L C O M P I L A T I O N 2 0 0 6 B J U I N T E R N A T I O N A L In group 2 (biofeedback training) there were 17 children (16 girls and one boy); all had urgency and 15 had urge UI. The rate of UI per month is listed in Table 1. Ten children had NE, all with associated daily UI. There was a UTI in 14 children, and the total number of UTIs before treatment are listed in Table 1.
There was a disturbance of fecal elimination in 10 children, including encopresis in one, difficulty in three and constipation in six. VUR was diagnosed in four of the 14 children Number of episodes of UTI before treatment pattern in 12 children and an interrupted electromyography, with a high PVR diagnosed For the biofeedback technique, we first teach the child what normal voiding is like, creating an environment in which the child feels that activity during the voiding. We ask the child to he or she is in a ‘school for learning how to put this print on the wall close to the toilet, biofeedback sessions was 6 (4–14). Of the 17 void better’. This is done initially with the where it is visible during voiding. We do not children, there was a complete improvement teaching of the sound of a continuous urinary recommend practising the pelvic floor muscle of symptoms in 10, significant improvement stream. Also, on the computer screen, we in two, and mild improvement in five; as a created a colourful animation showing the process of bladder filling and the ‘healthy’ 90%, one by 70%, one by 50%, two by 40%, elimination of the urine. In this case, the The Wilcoxon signed-ranks test was used for one by 20% and one by 10%. The parents of bladder is compared to a tank full of liquid analysis of the continuous variables and and the external sphincter to a gate that must Fisher’s exact test for differences of satisfied and decided to have no further be closed when the tank is filling up (bladder proportions, with P < 0.05 taken to indicate treatment. Of the other six children who did storage). The child is shown how the ‘gate’ not reach 100% improvement, only one had must be completely open when the tank is no UI before management. After biofeedback, emptying (voiding). This is accompanied by four had persistent daily UI; two of these had sound to accelerate the learning. As proposed fewer leaks and two maintained their previous by Chin-Peuckert and Salle [10], the children symptoms. All six children, despite still sometimes ‘plays tricks’ on them. Then, the electromyography after biofeedback training. child becomes the ‘boss’ of the gate who can electrical stimulation sessions was 13.1 (4– All of these children then had salvage therapy 20). Of the 19 children treated, 12 had a with electrical stimulation, and after a mean of 12.8 (7–20) sessions, four had a complete Biofeedback training of the pelvic floor expressed as percentages, 12 improved by electromyography electrodes on the perineum 100%, five by 90%, one by 80% and one by criterion for complete improvement, four at the 3 and 9 o’clock position, and one on the 30%. This last child had intense urgency, abdomen. Two voids are necessary for the frequency (>19 voids/day) and >10 urinary completely resolved, one had a significant treatment, one at the start and one at the end leaks/week. After electrical stimulation, the of the session. Each voiding is recorded by improvement. This last child is currently on uroflowmetry. Looking at the musculature number of urinary leaks decreased to three medication (α-blocker) and has improved activity on the computer screen, the child is taught how to contract and relax the pelvic floor muscles. After the session the child sporadically had daily UI. In the other three interrupted flow, and in seven of 12 with takes home (‘homework’) a print of the children UI resolved, but eventually they had flat or staccato flow. All children with a high J O U R N A L C O M P I L A T I O N 2 0 0 6 B J U I N T E R N A T I O N A L T R E A T I N G L U T D Y S F U N C T I O N W I T H B I O F E E D B A C K A N D E L E C T R I C A L S T I M U L A T I O N respectively, had successful reflux surgery. The other two children remain under observation. A urodynamic evaluation in seven children DISCUSSION
We propose treating children with LUTD using TABLE 3 Correlation of pretreatment age with before treatment was 13.3 (13, 3–21); this two different approaches and no medication. resolution of symptoms of LUTD after treatment decreased to 3 (3, 0–9) after treatment As children with urge syndrome usually have (P < 0.001). After treatment, a voiding diary bladder-filling abnormalities (inhibited chart was not available for 11 children. Of bladder contractions and hypersensitivity) nine children with >10 voids/day before and no VPD, our intention was to treat this Resolution of symptoms, n
treatment, five had information available change by parasacral electrical stimulation. after treatment, and all of these had fewer For children with VPD, we chose pelvic floor voids/day, becoming ‘normal’. Eight children had ≤4 voids/day, and of these, all had more prospective analysis, the rate of complete daytime voids, becoming ‘normal’. Of the 11 Cure rate of NE, n
children for whom there was no voiding diary information after treatment, 10 were reported having a slight improvement. There was also a by their parents to have a normal number of significant reduction in the symptom score. daytime voids and one, who failed to respond to electrical stimulation, still had intense encouraged to obtain a ‘bell-shaped’ flow frequency, with only a small improvement and this was accomplished by all. There was also a complete improvement in the VPD on Table 2 shows the results after the complete electromyography. Furthermore, all children course of treatment. Of the children with Before treatment, 22 children had a bladder except one had a normal PVR. McKenna et al. LUTD, there was a complete, significant or capacity ≥40% higher than normal for their [9] reported the successful treatment of UI in mild improvement in 26 (72%), eight (22%) age, and in 14 the bladder capacity was <40% 61%, and total or important improvement of and two (6%), respectively. As a percentage, all symptoms in 89% of children treated with biofeedback and no use of anticholinergics. (81%) of the children with a bladder capacity Comparing children aged ≤5 years with those of ≥40% and in eight of those with a capacity >5 years, there was no significant difference of <40%. This difference was not statistically treatment. We think that, despite achieving significant. After treatment, four children symptoms after the procedures (Table 3). Of developed isolated episodes of UTI. Of 21 biofeedback, some children still have bladder- the 31 children with previous daily UI, five children with NE, bedwetting continued in 13 filling problems such as inhibited detrusor (14%) had persistent daily UI after treatment (62%) after treatment; in six of these the NE contractions and sensory urgency. In the and two reduced the UI, with only sporadic present study, symptoms were not resolved in episodes of leaking. Twelve children had not severity in seven. In 16 children aged >7 years, six children (35%) after biofeedback training; previously responded to medication; of these, nine had symptoms resolved after treatment, two had a significant improvement (by 90% results with biofeedback, but anticholinergics One child who was considered cured after associated with the findings confounded the biofeedback training reverted to symptoms of possible to obtain information on 13 children after treatment; of nine with constipation, treatment she had one episode of UTI. After five were cured, one improved and three had McKenna et al. [9] used interactive computer treatment of the UTI she had symptoms of games to improve the children’s learning. In LUTD with a new onset of VPD appearing on chart with no muscle activity was taken home. grade 3 reflux disappeared in one 4-year-old stimulation simultaneously. In the 8-month at 6 months after treatment. One child with a desired electromyographic response at every pelvi-ureteric duplex system of grade 4 and void, as a tool to learn how to completely grade 2 VUR for the lower and upper units, relax the pelvic floor musculature. This 2 0 0 6 T H E A U T H O R SJ O U R N A L C O M P I L A T I O N 2 0 0 6 B J U I N T E R N A T I O N A L frequency used was 2 Hz, daily for 2 h, and There are criticisms of the present study; we voiding pattern. In addition, the use of the the treatment was prolonged for 6 months in considered the pelvic floor activity during auditory tool shows how a continuous urinary those who had a satisfactory initial response voiding as indicative of dysfunctional voiding. flow should sound and helps the child to on daily UI. In all, 13 (31%) children had The validity of current methods for evaluating identify an interrupted flow. On that basis, the no response, by contrast with the present pelvic floor muscle activity in children during child learns to relax the pelvic musculature, study, in which all the children had some voiding has been questioned. In the present normalizing the urinary flow. This approach study no children with a normal urinary flow avoids high treatment costs by obviating the significant improvement. However, that study need for more expensive interactive games.
differs from the present series in several aspects: (i) In the present study the response (voiding dysfunction group), but it is possible Jerkins et al. [13] reported that children aged that some children in group 1 might have <5 years would not be good candidates for methods, providing a comparison in future biofeedback training, because of anxiety and control group, and the few children included lack of cooperation. However, the present evaluated; its presence denotes involuntary series successfully included children aged contractions or bladder hypersensitivity; (iii) a statistical analyses, although the number simpler method was used to apply electrical included was similar to that in most other Hellstrom et al. [14], who were the first to use stimulation, consisting of shorter sessions series. Also, the follow-up was short; studies biofeedback for children aged 4–5 years. (20 min instead of 2 h), a higher frequency with a longer follow-up show that success is Other, earlier series also reported good results reported that 12 of 16 children treated with motivation is a fundamental component in study continued for 6 months); (iv) Hoebeke the adherence to treatment with biofeedback et al. [10] used anticholinergics in all cases, 3–4 years, showing that childrens need which makes any evaluation of the results of relatively many children aged <5 years; this electrical stimulation difficult; (v) in their raises questions because the spontaneous series there were more boys than girls, the improvement of symptoms seems to be high opposite of the present study. Importantly, at this age. However, the young children were daily UI occurs more often in girls [1–3], only with behavioural orientation or with biofeedback and/or electrical stimulation. To between the series; in the present series we realise this objective, a multicentre study Furthermore, as most children were managed with few sessions, the spontaneous resolution In the present study, 10 children were treated The dynamics of electrical stimulation are not previously with anticholinergics and urinary biofeedback, and treatment of urge syndrome well known, but the reflexogenic activation of training. Despite the unsuccessful treatment by electrical stimulation, is in the short-term a hypogastric inhibitor neurones (sympathetic) safe and effective treatment for LUTD. There and the central inhibition of the excitatory was a significant reduction in the symptom neurones of the bladder (parasympathetic) resolved. Importantly, there were fewer UTIs seem to play the main role in the dynamics of after starting treatment; only four (11%) functional vesical capacity after treatment. electrical stimulation for UI [17]. Various sites children had an isolated UTI after treatment, of electrical stimulation have been used, at 3–6 months after physical therapy, when dysfunction improved their vesico-sphincter including the anal sphincter, the intervaginal, no longer under prophylactic antibiotics. This coordination, patterns of urinary flow and the intravesical and the transcutaneous (the PVR. There was a low incidence of UTI.
common peronial and tibial, the dorsal penis nerve, dermatomal S3) nerves [17,18]. Gladh favourably with the study of Snodgrass [20], CONFLICT OF INTEREREST
et al. [18] reported successful treatment in their group of patients with genital and anal UTI in children with daily UI treated with electrodes; although these authors reported anticholinergics and prophylactic antibiotics.
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Abbreviations: LUTD, lower urinary tract
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