Treatment of Female Urinary Incontinence with EMG-Controlled Biofeedback Home Training

The aim of the study was to evaluate the efficacy of pelvic floor training with EMG-controlled home biofeedback in the treatment of stress and mixed incontinence in women. Subjects were recruited from the urodynamic outpatient clinic and performed pelvic muscle training with an EMG-controlled biofeedback device for 20 minutes daily for 6 months. The number of pads used per day, the number of incontinence and urgency episodes, voiding frequency, maximum urethral closure pressure, functional urethral length and pressure/transmission ratio during stress were assessed before and after treatment. Thirty-three patients (13 with stress and 20 with mixed incontinence) completed the study. There was a significant decrease in the number of pads used per day, the number of incontinence and urgency episodes, and the voiding frequency. Twenty-eight patients (85%) reported that they were cured or improved. Urodynamic parameters did not change significantly. It was concluded that home pelvic floor training with EMG-controlled biofeedback is efficient in 85% of patients in alleviating the symptoms of genuine stress and mixed incontinence without causing side effects.     

Outcome of biofeedback for faecal incontinence.

BACKGROUND: Biofeedback has been reported to improve or eliminate symptoms in approximately 70 per cent of patients with faecal incontinence. However, it is unknown which patients respond in relation to the different symptomatic types of faecal incontinence and the different structural sphincter aetiologies. METHODS: One hundred consecutive patients (84 women; median age 49 years) who completed biofeedback treatment were prospectively characterized by symptoms and by structural integrity of the internal and external anal sphincters as assessed endosonographically (87 patients). Patients underwent a median of 4 biofeedback sessions. RESULTS: Overall, 43 of the 100 patients regarded themselves as symptomatically cured and 24 improved after treatment. Cure or improvement was experienced by 24 of 30 patients with a structurally normal anal sphincter, by 27 of 46 patients with an external anal sphincter structural defect, and by seven of 11 with an isolated internal anal sphincter defect or atrophy. Thirty-three of 60 patients with urge incontinence alone were symptomatically cured, compared with five of 22 of those with only passive incontinence. CONCLUSION: Biofeedback retraining is effective in the short term in treating a majority of patients with faecal incontinence. It is most successful in treating urge incontinence, but also helps some patients with passive leakage. Even in patients with structural anal sphincter damage, some symptom improvement or cure is achieved.     

Clinical versus urodynamic diagnosis in an incontinent geriatric female population

The clinical presentation of incontinence was compared to diagnoses based on urological and urodynamic evaluation in 135 elderly women assessed consecutively in an outpatient clinic. Most patients (64 per cent) presented with mixed symptoms: 16 per cent presented with pure stress and 16 per cent with pure urge incontinence. After evaluation 46 per cent of the patients had stress incontinence with a stable bladder, 27 per cent had detrusor instability or hyperreflexia without sphincter weakness and 19 per cent had mixed urodynamic abnormalities. Presenting symptoms were predictive of urodynamic diagnosis in 64 per cent of the patients with pure stress incontinence and 55 per cent with pure urge incontinence. In general, symptoms in our patient population were less predictive of urodynamic findings than in previously reported series of younger incontinent women but they were more predictive than in other series of elderly women. Predictive values for some urodynamic findings were enhanced by combining a symptom with certain physical findings. Implications of these data for the evaluation and treatment of incontinence in the geriatric population are discussed.     

Modification of urge incontinence by biofeedback mechanisms

Urge incontinence caused by hyperactive urethral closing mechanism can be influenced by relaxation training of the striated sphincter muscle. This is done through a biofeedback mechanism with pelvic floor EMG control. The indications are for urge incontinence with urethral hyperactivity and pelvic floor hyper-reactivity diagnosed through urodynamic examination. Twenty-two female patients with urge incontinence were treated for four weeks by biofeedback training with a portable pelvic floor EMG apparatus. The urge incontinence were improved subjectively and objectively in 73%. The therapy focused on the striated muscle seemed to have better results than therapy of the detrusor.     

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.     

Current trends in the management of post-prostatectomy incontinence

One of the annoying complications of radical prostatectomy is urinary incontinence. Post-prostatectomy incontinence (PPI) causes a significant impact on the patient's health-related quality of life. Although PPI is stress urinary incontinence caused by intrinsic sphincter deficiency in most cases, bladder dysfunction and vesicourethral anastomotic stenosis can induce urine leakage also. Exact clinical assessments, such as a voiding diary, incontinence questionnaire, pad test, urodynamic study, and urethrocystoscopy, are necessary to determine adequate treatment. The initial management of PPI is conservative treatment including lifestyle interventions, pelvic floor muscle training with or without biofeedback, and bladder training. An early start of conservative treatment is recommended during the first year. If the conservative treatment fails, surgical treatment is recommended. Surgical treatment of stress urinary incontinence after radical prostatectomy can be divided into minimally invasive and invasive treatments. Minimally invasive treatment includes injection of urethral bulking agents, male suburethral sling, and adjustable continence balloons. Invasive treatment includes artificial urinary sphincter implantation, which is still the gold standard and the most effective treatment of PPI. However, the demand for minimally invasive treatment is increasing, and many urologists consider male suburethral slings to be an acceptable treatment for PPI. The male sling is usually recommended for patients with persistent mild or moderate incontinence. It is necessary to improve our understanding of the pathophysiologic mechanisms of PPI and to compare different procedures for the development of new and potentially better treatment options.     

A self-directed home biofeedback system for women with symptoms of stress, urge, and mixed incontinence.

PURPOSE: To evaluate a self-directed home biofeedback treatment system in a group of community dwelling, otherwise healthy women with symptoms of stress, urge, and mixed urinary incontinence (UI). SETTING AND SUBJECTS: Fifty-five women, aged 25 to 81 years, participated in the study. METHODS: Initial evaluation included a self-reported continence assessment, a 24-hour bladder and fluid habits diary, severity indices for stress and urge UI, and assessment of pelvic floor strength using a pneumatic biofeedback device. Subjects completed a 16-week self-directed program. Assessment and severity index data were self-reported using a continence assessment form, a 24-hour bladder habit and fluid form, and stress and urge incontinence severity indices. Strength level of the trainer, number of digital bands lit on the screen during contraction, number of sessions, and program (starter, intermediate, advanced, or maintenance) were recorded on data sheets. INSTRUMENTS: The treatment system includes an 8-minute educational and motivational video; a journal for education, instructions, and daily documentation forms; and a home biofeedback trainer with pneumatic vaginal sensors that displays the strength of pelvic muscle contraction. RESULTS: Forty-four women completed the 16-week program. At the end of treatment, 19 (43%) were dry and 16 (36%) reported 50% or more improvement in number of leaks per day, number of voids per day, or both. Women with stress leakage experienced a significant reduction in the number of incontinent episodes per day and the mean severity index of incontinence (P < .001). Participants with urge UI experienced a significant reduction in the mean number of voids per day and mean severity index for UI (P < .001). Younger subjects were more likely to improve when compared with older participants, but no significant differences were found when comparing women who take estrogen with those who do not take estrogen or when comparing those with a history of bladder surgery with those who had no previous surgery. CONCLUSIONS: These data suggest that self-selected healthy women with symptoms of urge, stress, and mixed incontinence can improve their symptoms and lower their severity index with a minimal intervention, comprehensive, self-directed home biofeedback continence system.     

CLAM CYSTOPLASTY FOR THE OVERACTIVE BLADDER: A REVIEW OF 23 CASES

A clam enterocystoplasty was performed for refractory urge incontinence due to either idiopathic instability (13 patients) or neuropathic hyperreflexia (10 patients). Twelve patients became dry and appliance free. Of the remaining 11 wet patients, seven developed low pressure reservoirs, of whom five had stress incontinence and two had overtlow incontinence. The other four patients had persistent symptomatic involuntary phasic contractions and ongoing urge incontinence. The magnitude of the surgery and the voiding dysfunction associated with the relative lack of motivation of elderly patients made the operation less successful and more hazardous in those over the age of 65. Successful outcome could be improved by careful patient selection and by performing an antistress incontinence procedure, such as implantation of an artificial urinary sphincter cuff or a cystourethropexy, where there is associated bladder outlet incompetence.     

Does electrostimulation cure urinary incontinence?

A followup study is presented of a prospective series of women treated with an inflatable intravaginal electrode carrier and an external pulse generator. The devices were individually adjustable with respect to electrode positioning and stimulation parameters. The study included 40 women with detrusor instability and/or genuine stress incontinence. The primary results for urge symptoms were favorable. Of the patients 73 per cent were primarily free of symptoms during treatment and 45 per cent remained free of symptoms after withdrawal of treatment, including two-thirds in whom re-education persisted during the followup of 6 years. Of the patients with genuine stress incontinence 40 per cent exhibited persistent re-education. There were considerable discrepancies between symptomatic cure or improvement, and the urodynamic findings at followup. Intravaginal electrical stimulation may be regarded as the treatment of choice for urge incontinence due to detrusor instability, and in mixed stress and urge incontinence. The method also is an alternative to an operation in some women with genuine stress incontinence.     

Artificial urinary sphincter for recurrent female urinary incontinence: indications and results

A retrospective review of our experience with the artificial urinary sphincter in 32 women is presented. All patients had a history of recurrent urinary incontinence after failed bladder suspension procedures. Of 32 devices 31 were functioning, with an average followup of 2.5 years, and 91 per cent of the patients were dry without pads. Mechanical complications requiring surgical repair occurred in 21 per cent of the patients. Indications for artificial urinary sphincter implantation in the female patient and technical aspects of the procedure are discussed. The artificial urinary sphincter appears to be an acceptable treatment modality for urethral sphincter deficiency resulting in recurrent urinary stress incontinence in female patients.     

Biofeedback training for detrusor overactivity in children

PURPOSE: We evaluated biofeedback training for incontinence due to detrusor overactivity in children. MATERIALS AND METHODS: Included in our study were 22 boys and 17 girls with a mean age of 11.2 years. We noted nighttime incontinence in 3 patients, nighttime incontinence and daytime urinary symptoms in 26, and daytime incontinence in 10. All patients had detrusor overactivity and incontinence refractory to conventional treatment, including bladder training, tricyclic antidepressants, anticholinergics, desmopressin and/or conditioning therapy. Urodynamic study was performed using an 8Fr double lumen transurethral catheter for cystometry, a double balloon transrectal catheter for rectal pressure and external anal sphincter pressure measurement, and surface electrodes for sphincter electromyography. During biofeedback training patients were instructed to contract the anal sphincter without raising abdominal pressure to inhibit overactive bladder contractions. Biofeedback training was repeated monthly until cystometry revealed a stable bladder or lower urinary tract symptoms improved considerably. RESULTS: Four patients were lost to followup. Of the remaining 35 children urinary symptoms were cured in 23 and improved in 4. Urodynamic studies after 6 months of biofeedback training in 33 cases showed that bladder overactivity disappeared in 10 and improved in 18. Bladder capacity at the initial desire to void and maximum cystometric capacity increased significantly (p = 0.0115 and <0.0001, respectively). Detrusor-sphincter dyssynergia in 2 patients before biofeedback training resolved in each after therapy. CONCLUSIONS: Biofeedback training for detrusor overactivity is effective even in pediatric cases refractory to conventional treatment.     

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.     

Biofeedback bei kindlichen Blasenfunktionsstörungen

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

Is it reasonable to treat refractory voiding dysfunction in children with botulinum-A toxin?

PURPOSE: We present our results with botulinum-A toxin transperineal pelvic floor/external sphincter injection combined with behavioral and biofeedback reeducation in children with voiding dysfunction who had been resistant to previously applied therapies. MATERIAL AND METHODS: Eight boys and 12 girls between 7 and 12 years old (mean age 9) with recurrent urinary tract infection, an interrupted or fractional voiding pattern and high post-void residual urine in whom behavioral, short biofeedback and alpha-blocker therapies had failed were included in the study. They were treated with botulinum-A toxin at a dose of 50 to 100 U. Botulinum-A toxin was injected transperineally into the pelvic floor and/or external sphincter in all patients. In boys the sphincter was localized endoscopically before injection (endoscopically assisted transperineal approach). Behavioral and biofeedback reeducation started 15 days after injection. RESULTS: Followup was between 9 and 14 months. All patients were without urinary tract infection and fever, while 5 were still on chemoprophylaxis. Six months after treatment residual urine decreased in 17 of 20 patients by 0 to 130 ml (mean +/- SD 45.75 +/- 32.17 ml, t = 6.360, p <0.001). Nine patients reestablished a normal voiding curve and 8 showed improvement. Three did not manifest any significant improvement. In 1 girl transitory incontinence resolved spontaneously within 48 hours. There were no other complications. CONCLUSIONS: The effect of botulinum is transitory. However, it can break the circle of detrusor-sphincter dyssynergia and the period when it is sustained can be used for retraining the patient in normal voiding. At this moment botulinum-A toxin is one of last options in refractory cases of voiding dysfunction.     

Stress, urge, and mixed types of partial fecal incontinence: pathogenesis, clinical presentation, and treatment

The authors investigated the hypothesis that partial fecal incontinence (PFI) had variable manifestations that can be categorized as different types of PFI with different pathogeneses and treatment. Anal and rectal pressures as well as external and internal anal sphincter electromyographic activity were recorded in 163 patients with PFI and in 25 healthy volunteers. Patients were treated with biofeedback or surgically. Three types of PFI were encountered: stress fecal incontinence (SFI; 55 patients), urge fecal incontinence (UFI; 72 patients), and mixed fecal incontinence (MFI; 36 patients). Anal pressure decreased in three groups in which MFI had the lowest pressure. A significant reduction in external anal sphincter electromyographic activity occurred in SFI, in internal anal sphincter electromyographic activity in UFI, and of both sphincters in MFI. Biofeedback cured 36 of 55 patients and postanal repair cured 10 of 19 patients with SFI. Forty-eight of 72 patients with UFI responded to biofeedback and 16 of 24 responded to internal anal sphincter repair. Biofeedback failed in MFI patients. Twenty-four of 27 patients who consented to operative correction of the sphincteric defect were cured. Three types of PFI could be identified: SFI, UFI, and MFI. Each type has its own etiology and symptoms, and requires individual treatment. Biofeedback succeeded in treating the majority of SFI and UFI patients. Surgical correction of the anal sphincter was performed after biofeedback failure.     

Urethral pressure variations

The pressure in the area of distal urethral sphincter was measured in 30 patients with symptoms of stress, urge, and mixed stress and urge incontinence. Sphincteric pressures were obtained from 3 to 4 urethral pressure profiles and recordings of the pressure measured with the sensor placed at the site of the distal sphincter for periods of up to ten minutes. In 33 per cent of the patients, the latter method revealed significant pressure variations which rarely were seen in a small series of urethral pressure profiles. The diagnostic reliability of the urethral pressure profile with respect to pressure variations is discussed, and the spatial organization of the pressure variations is measured and discussed.     

Effect of biofeedback and electrostimulation on sphincter function in fecal incontinence

The following study reports on the effect of biofeedback and transanal electric stimulation as a conservative method in the therapy of idiopathic fecal incontinence. 22 consecutive patients in whom the diagnosis "idiopathic incontinence" was established after endoscopy, endoanal ultrasound and measurement of pudendal nerve terminal motor latency underwent combined sphincter training for 3 months. The results were evaluated prospectively by clinical classification using a modified Kelly-Holschneider-score and anal manometry before and after treatment. Combined biofeedback led to a significant increase of the continence score in 18 of 22 patients (7.7 +/- 3.8 vs. 9.3 +/- 3.0, p = 0.004). Both squeeze (77 +/- 28 mmHg vs. 92 +/- 32 mmHg, p = 0.047) and resting pressures (40 +/- 19 vs. 52 +/- 23 mmHg, p = 0.015) increased significantly during the training period. There were no significant differences in squeeze and resting asymmetry indexes, sensory and urge thresholds and maximal tolerable volumes. The prolongation of biofeedback training from 3 to 6 months in 9 patients did not change clinical or manometric results significantly. CONCLUSIONS: The combination of biofeedback training with anal electrostimulation increases anal squeeze and resting pressures, thus leading to an improvement of clinical incontinence symptoms. Therefore it should be the first choice in the therapy of idiopathic fecal incontinence. A training period of 3 months seems to be sufficient.     

OUR EXPERIENCE WITH PUBOVAGINAL SLINGS IN PATIENTS WITH STRESS URINARY INCONTINENCE

Purpose

Pubovaginal slings successfully treat stress urinary incontinence in women with intrinsic sphincter deficiency. Because of its durability, it has been attractive procedure in select patients with urethral hypermobility. We examine our experience with pubovaginal sling.

Materials and Methods

A total of 150 patients were evaluated for pelvic prolapse and urinary incontinence. An abdominal leak point pressure was determined in all patients. Of patients with type II stress urinary incontinence, 36 patients (80%) underwent additional gynecological procedures at the time of the pubovaginal sling, compared to 29% with intrinsic sphincter deficiency and 33% with coexisting urethral hypermobility and intrinsic sphincter deficiency.

Results

The overall cure rate was 93% with a mean followup of 22 months. At 1 week postoperatively spontaneous voiding was accomplished by 56% of the patients with urethral hypermobility and 57% with intrinsic sphincter deficiency. Only 2.8% of patients required surgical therapy for prolonged urinary retention. De novo urgency/urge incontinence occurred in 19% of women with a 3% incidence of persistent urge incontinence.

Conclusions

Pubovaginal slings are effective and durable. Voiding dysfunction is uncommon and is temporary in most patients.     

The model AS 800 artificial urinary sphincter: Mayo Clinic experience

The model AS 800 artificial urinary sphincter was implanted in 100 male and 9 female patients between 7 and 89 years old. Postoperative followup was 1 to 32 months. The indication for implantation was total urinary incontinence in 86 patients (78.9 per cent), stress incontinence in 22 (21.2 per cent) and urgency incontinence in 1 (0.9 per cent). Of the patients 97 (89 per cent) underwent implantation for the first time, 7 (6.4 per cent) had a previous artificial urinary sphincter model replaced by the AS 800 device and 5 (4.6 per cent) underwent reimplantation of a previous model. The cuff was placed around the bladder neck in all 9 female patients, whereas in the male patients the cuff was implanted around the bladder neck in 20 and around the bulbous urethra in 80. Thirty-one patients (28.4 per cent), 29 of whom were continent at night, were practicing nocturnal deactivation of the device. Complete post-activation continence was achieved in 91 patients (83.5 per cent), some leakage occurred in 10 (9.2 per cent) and 8 (7.3 per cent) remained incontinent. A total of 23 patients required 1 or more revisions, the most common indications for the first revision being loss of cuff compression (9), tubing kink (3), cuff erosion (3) and infection (2). At the time of this report 89 patients (81.7 per cent) were continent, 9 (8.3 per cent) still had some leakage, 3 (2.8 per cent) were incontinent, 5 (4.6 per cent) were awaiting reimplantation and 3 (2.8 per cent) had died of unrelated causes.     

Experience with the artificial urinary sphincter model AS800 in 148 patients

The latest version of the artificial urinary sphincter, AS800, was used in 148 patients with urinary incontinence of different etiologies. Followup ranged from 3 to 37 months, with an average of 20.8 months. There were 112 (76 per cent) male and 36 (24 per cent) female patients. The cuff was implanted around the bladder neck in 78 patients (53 per cent) and around the bulbar urethra in 70 (47 per cent). Socially acceptable urinary control was achieved in 90 per cent of the 139 patients with active devices in place. It was necessary to remove the sphincter in 11 patients (7.4 per cent). The reasons for removal were infection and erosion in 8 patients (5.4 per cent), infection without erosion in 2 (1.3 per cent), and erosion due to excess pressure and poor tissues in 1 (0.7 per cent). Comparison of success and failure rates associated with incontinence of different etiologies revealed that patients with incontinence after failure of a conventional antistress incontinence operation and those with incontinence after transurethral resection or radical prostactectomy had the highest success rate, and that patients with incontinence secondary to pelvic fracture or exstrophy and epispadias had the highest failure rates. The deactivation feature (the lock) of the new artificial sphincter model was beneficial for primary deactivation, urethral catheterization or cystoscopy, or for elective nocturnal decompression of the bladder neck or urethral tissues.