Biofeedback Treatment for Overactive Bladder

For several decades, biofeedback has been utilized to help patients gain control of urinary problems. First described in the 1950s, pelvic floor muscle training employing biofeedback techniques has re-emerged as many patients seek to improve their urinary symptoms without medications or invasive procedures. Developing evidence and clinical agreement suggest that the pelvic floor musculature plays an important and often overlooked role in the etiology of lower urinary tract symptoms. New techniques involving computerized visual feedback and electrical stimulation or magnetic stimulation seek to improve the efficacy of pelvic floor muscle exercises. However, findings from the literature for increased response to these exercises with intensity of biofeedback programs are conflicting. While they pose few risks or side effects, biofeedback programs are a time-consuming exercise for patients and providers. As we explore the promising role of pelvic floor rehabilitation in treatment of pelvic floor disorders, we must continue to assess the efficacy and cost-effectiveness of biofeedback as an adjunct to pelvic floor muscle exercises.     

Functional and chronic anorectal and pelvic pain disorders

Several organic and functional disorders of the urinary bladder, reproductive tract, anorectum, and the pelvic floor musculature cause pelvic pain. This article describes functional disorders in which chronic pelvic and anorectal pain cannot be explained by a structural or other specified pathology. Currently, these functional disorders are classified into urogynecologic conditions or cystitis and painful bladder syndrome, anorectal disorders, and the levator ani syndrome. Although nomenclature suggests that these conditions are distinct, there is considerable overlap of their symptoms and these disorders have much in common.     

Kombinierte Stuhl- und Harninkontinenz

Background: Double (urinary and fecal) incontinence is relatively common in the elderly. 6% of men and 9.5% of women over 50 years suffer from combined urinary and fecal incontinence. 50% of males and 60% of females with fecal incontinence have concurrent urinary incontinence. The high rate of concurrence of urinary and fecal incontinence is due to an almost identical innervation of the urinary bladder and the rectum and the close vicinity and partial identity of the muscular sphincter mechanisms. Classification: There are two causal entities of double incontinence: 1. neurogenic disorders, 2. pelvic floor dysfunction. Neurogenic disorders can be classified in central and peripheral nervous lesions. Pelvic floor dysfunction can be due to nerve injury or direct muscular lesions. According to the International Continence Society, urinary incontinence is classified into five categories: 1. stress incontinence, 2. urge incontinence, 3. reflex incontinence, 4. overflow incontinence, 5. extraurethral incontinence. With respect to anal incontinence, the first four groups are important. Diagnosis: The diagnostic evaluation comprises meticulous history, physical examination including neuro-urological status, rectal and in females standardized pelvic examination, urinalysis, sonography of the kidneys and bladder after voiding (postvoid residual urine). In women, a transrectal ultrasound of the bladder, urethra and the pelvic floor is important and can replace lateral cystourethrography. In complex cases, dynamic NMR imaging is helpful. Functional investigations include urodynamic studies with uroflowmetry, filling and voiding cystometry and urethral pressure profiles and rectomanometry. Conclusion: For optimal therapy of double incontinence, an interdisciplinary approach is necessary.     

Pathophysiological and Therapeutic Considerations for Non‐Neurogenic Lower Urinary Tract Dysfunction in Children

Non‐neurogenic lower urinary tract dysfunction (LUTD) in children is very common in clinical practice and is important as an underlying cause of lower urinary tract symptoms, urinary tract infection and vesicoureteral reflux in affected children. LUTD in children is caused by multiple factors and might be related with a delay in functional maturation of the lower urinary tract. Behavioral and psychological problems often co‐exist in children with LUTD and bowel dysfunction. Recent findings in functional brain imaging suggest that bladder bowel dysfunction and behavioral and psychiatric disorders in children might share common pathophysiological factors in the brain. Children with suspected LUTD should be evaluated properly by detailed history taking, validated questionnaire on voiding and defecation, voiding and bowel diary, urinalysis, screening ultrasound, uroflowmetry and post‐void residual measurement. Invasive urodynamic study such as videourodynamics should be reserved for children in whom standard treatment fails. Initial treatment of non‐neurogenic LUTD is standard urotherapy comprising education of the child and family, regular optimal voiding regimens and bowel programs. Pelvic floor muscle awareness, biofeedback and neuromodulation can be used as a supplementary purpose. Antimuscarinics and α‐blockers are safely used for overactive bladder and dysfunctional voiding, respectively. For refractory cases, botulinum toxin A injection is a viable treatment option. Prudent use of urotherapy and pharmacotherapy for non‐neurogenic LUTD should have a better chance to cure various problems and improve self‐esteem and quality of life in affected children.     

Abnormal clinical and urodynamic findings in women with severe genitourinary prolapse

In order to investigate the effects of urogenital prolapse on lower urinary tract function, we studied 61 women with stage III to IV pelvic organ prolapse (prolapse group) and 40 volunteers without prolapse (control group). Each woman underwent urinalysis, urinary questionnaire, pelvic examination, and urodynamic study. The incidence of urinary symptoms, including urinary frequency and urgency, stress/urge incontinence, incomplete emptying, difficult voiding and nocturia, were significantly higher in the prolapse group compared to the control group (p < 0.05). Urodynamic parameters, including residual urine, total bladder capacity, and bladder volume at strong desire to void, were not significantly different between the two groups (p > 0.05). Maximal flow rate, bladder compliance at urgency, functional urethral length, and maximal urethral closure pressure, however, were significantly higher in the control group compared to the prolapse group (p < 0.05). In addition, there was a higher incidence of poor pressure transmission ratio in the prolapse group (p < 0.01). The results indicated that severe urogenital prolapse could produce abnormal clinical and urodynamic results.     

Non-invasive Testing and Its Role in Diagnosis and Management of Children With Voiding Dysfunction

Purpose of Review

The symptoms of non-neurogenic lower urinary tract dysfunction (LUTD) including urinary incontinence, frequency, and urgency are among the most common reasons for which children are referred to pediatric urologists. The workup for LUTD is often time consuming and a source of frustration for patients, parents, and clinicians alike. In this review, we describe the non-invasive tests that are available and discuss their utility in the evaluation and management of children with LUTD.

Recent Findings

The available non-invasive tests that can aid in the diagnosis and management of children with LUTD include urine studies, uroflowmetry ± simultaneous electromyography, assessment of post-void residual, renal/bladder ultrasound, and pelvic ultrasound. These tests can often help obviate the need for more invasive tests such as urodynamic studies and can be particularly helpful in complex or difficult cases that do not respond to standard urotherapy.

Summary

Non-invasive tests can help us in our goal of improving diagnostic ability to better classify the child’s LUTD into an actual condition which allows targeted treatment in the hope of better outcomes and more satisfied patients and families.

     

Clinical neurophysiology and electrodiagnostic testing of the pelvic floor

This article summarizes our current understanding of the neuroanatomy and neurophysiology of the pelvic floor. The electrodiagnostic evaluation of the pelvic floor muscles and external anal sphincter, including pudendal nerve conduction studies, sacral reflexes, and needs EMG is presented. The discussion reviews the test methodology, the strengths and limitations of each test, and their clinical utility. The authors have tried to critically review the objective evidence to support the use of electrodiagnostic tests in the evaluation and management of pelvic floor disorders. The reader will have a better understanding of the rationale, methodology, clinical utility, and potential pitfalls for each of the commonly used neurophysiological tests of the pelvic floor.     

Female pelvic floor dysfunction--an imaging perspective

Female pelvic floor dysfunction encompasses a range of morbidities, including urinary incontinence, female pelvic organ prolapse, anal incontinence and obstructed defecation. Patients often present with symptoms covered by several specialties including gastroenterology, colorectal surgery, urology and gynecology. Imaging can therefore bring clinicians from multiple specialties together by revealing that we frequently deal with different aspects of one underlying problem or pathophysiological process. This article provides an interdisciplinary imaging perspective on the pelvic floor. Modern pelvic floor imaging comprises defecation proctography, translabial and endorectal ultrasound, and static and dynamic MRI. This Perspectives focuses on the potential use of translabial ultrasound, including 3D and 4D applications, for diagnosis of pelvic floor disorders. Over the next decade, pelvic floor imaging will most likely be integrated into mainstream diagnostics in obstetrics and gynecology and colorectal surgery. Using imaging to facilitate communication between different specialties has the potential to greatly improve the multidisciplinary management of complex pelvic floor disorders.     

Urodynamics for Spinal Cord Injury – How,When, Why

Patients with spinal cord injury (SCI) often have lower urinary tract dysfunction. Their urological dysfunction should be managed as part of their overall holistic care in a specialist SCI unit. Whilst level of disease can cause broad categories of urological problems, lower urinary tract symptoms may be complex and difficult. Urodynamic studies investigate the urinary tract by measurement of flow and pressure. Urodynamic studies perform an important role in the urological management of patients with SCI. Invasive video urodynamic studies are the gold standard urodynamics of choice in these patients due to the extra information that can be gleaned from fluoroscopy. The major complication of neurogenic lower urinary tract dysfunction is of a risk to the upper tracts. Baseline urodynamic studies are performed in patients with SCI to assess symptoms and risk to the upper tracts, so that management can be planned accordingly. The optimum follow-up schedule for urodynamics remains controversial.     

High incidence of lower urinary tract dysfunction in women with recurrent urinary tract infections

The aim of this study was to evaluate lower urinary tract dysfunction (LUTD) in women with recurrent urinary tract infections (UTIs). One hundred consecutive female patients with recurrent UTIs who underwent videourodynamic study (VUDS) were included. Another 25 women free from recurrent UTIs served as controls. All the underlying diseases, urine analysis and culture results, VUDS findings, and treatment outcomes of voiding dysfunction were carefully reviewed and analyzed. The mean age of the recurrent UTIs patients was 64.0 ± 16.0 years. Storage and voiding dysfunctions were found in 90 (90%) patients, including bladder neck dysfunction in 19 (19%), detrusor hyperactivity with impaired contractility in 6 (6%), detrusor overactivity in 5 (5%), detrusor underactivity in 10 (10%), dysfunctional voiding in 25 (25%), hypersensitive bladder in 6 (6%), and poor relaxation of the pelvic floor muscle in 20 (20%). Only 10 (10%) patients had normal urodynamic tracings. Compared with the controls, the recurrent UTI patients had significantly smaller cystometric bladder capacity, lower maximum flow rate, smaller voided volume, higher detrusor pressure, and larger PVR volume. However, only 6 (11.3%) patients with recurrent UTIs were free from subsequent UTIs following individualized treatment for their voiding dysfunction. A high incidence of vide urodynamic LUTD was identified in women with recurrent UTIs. Despite receiving individualized treatments based on their VUDS findings, only a small portion of these patients were subsequently free from UTIs.     

Evaluation and Management of Urinary Retention Following Colorectal and Gynecologic Oncologic Surgery

Urinary retention after radical pelvic surgery is a relatively common, well-recognized complication. The primary problem is neural disruption to or from the bladder during curative surgery. Resulting symptoms may include urinary retention presenting post operatively early or late. Other symptoms include overflow incontinence, to controlled stress incontinence, or urinary tract infections. Management is predicated on the clinical history, examination, physical findings and urodynamic evaluations. The principles of neurogenic bladder management are based on management of urinary incontinence or retention, prevention of urinary tract infections, prevention of stone disease and preservation of renal function. While not all patients who undergo radical pelvic surgery for oncological disease, develop neurogenic bladder, it must be considered in patient??s with urinary retention. In men, retention after pelvic surgery may not be caused by BPH, but neurogenic bladder, thus a transurethral resection of prostate may not be the appropriate management. Management of urological complications of pelvic surgery depends on a full neurourological assessment of the patient, and a treatment plan based on objective findings of the complete examination.     

Acupoint injection combined with pelvic floor rehabilitation in the treatment of postpartum pelvic floor disorders: A protocol of randomized controlled trial

Background:Female pelvic floor dysfunction is one of the common chronic diseases affecting women''s physical and mental health. Pregnancy and delivery are one of the main causes. Pelvic floor rehabilitation is a common method for the treatment of postpartum pelvic floor dysfunction, but it has some defects. Acupoint injection has advantages in the treatment of postpartum pelvic floor dysfunction, but there is a lack of standard clinical research to verify it. Therefore, the purpose of this randomized controlled trial is to evaluate the efficacy and safety of acupoint injection combined with pelvic floor rehabilitation in the treatment of postpartum pelvic floor disorders.Methods:This is a prospective randomized controlled trial to study the efficacy and safety of acupoints injection combined with pelvic floor rehabilitation. And it is approved by the Ethics Committee of Clinical Research of our hospital. Patients were randomly divided into observation group (acupoint injection combined with pelvic floor rehabilitation group) or control group (pelvic floor rehabilitation group alone). The patients were followed up for 8 weeks after 12 weeks of treatment. The observation indexes included: pelvic organ prolapse degree, pelvic floor muscle strength, urinary incontinence score, adverse reactions, among others. Data were analyzed using the statistical software package SPSS version 18.0.Conclusions:This study will evaluate the efficacy and safety of acupoint injection combined with pelvic floor rehabilitation in the treatment of postpartum pelvic floor dysfunction, and provide reliable reference for the clinical application of this project.Trial registration:OSF Registration number: DOI 10.17605/OSF.IO/VC65Z     

Voiding dysfunction in women with systemic lupus erythematosus

OBJECTIVE: We sought to explore bladder dysfunction in a cohort of women with systemic lupus erythematosus (SLE). METHODS: We conducted a prospective study of 152 female patients with SLE during a 15-month period. The clinical status of SLE was determined according to the SLE Disease Activity Index (SLEDAI), and bladder function was evaluated by lower urinary tract symptoms and urodynamic studies. We adapted the American Urological Association (AUA) index questionnaire to assess lower urinary tract symptoms in patients, which were compared with those in 227 age-matched healthy women. RESULTS: The proportion of individuals reporting urinary frequency, urgency, weak urinary stream, and incomplete emptying, as well as severe lower urinary tract symptoms (AUA index score >/=20), was significantly higher in the SLE group when compared with the control group. The AUA index score showed a modest correlation with the SLEDAI score (r = 0.35, P < 0.001) but not with patient age or disease duration. There was a significant relationship between central nervous system involvement and the AUA index score. The most common urodynamic finding was a small cystometric bladder capacity (<150 ml; n = 7 patients), followed by a subnormal urinary flow rate (<12 ml/second; n = 6 patients). In 3 of 7 patients with small cystometric bladder capacities, imaging studies documented a contracted bladder with marked hydroureteronephrosis. CONCLUSION: Patients with SLE experience an increased prevalence of voiding dysfunction compared with healthy individuals. Voiding dysfunction can be attributable to either direct bladder involvement or other disease-related factors.     

Ketamine‐Induced Uropathy: A New Clinical Entity Causing Lower Urinary Tract Symptoms

Objectives: Ketamine abuse can damage the urinary tract and cause lower urinary tract symptoms (LUTS). This report presents our observations and management on urinary tract damage caused by ketamine abuse. Methods: From November 2006 to February 2009, 20 patients visited Taipei Veterans General Hospital due to ketamine‐related lower urinary tract symptoms. We analyzed the clinical presentations, daily ketamine dose, interval between ketamine usage to develop LUTS, urodynamic studies, radiological image findings, cystoscopic and ureterorenoscopic findings, histological findings, urinary ketamine levels and treatment responses. Results: Of these 20 patients, all had moderate to severe LUTS, including frequency, urgency, dysuria and hematuria. The mean daily consumption of ketamine was 3.2 ± 2.0 g. The mean interval from consumption to the development of LUTS was 12.7 months (range, 2–36 months). Eight patients underwent video urodynamic studies, with a mean cystometric capacity of 70.8 mL. Eight patients had hydronephrosis and six of them underwent ureterorenoscopy. All patients underwent cystoscopy with hydrodistention. Mean bladder capacity under anesthesia was 289.9 mL, and 14 (70%) patients showed significant symptomatic improvement after hydrodistention. Ten patients quit ketamine and nine (90%) experienced symptomatic relief. The response rates of symptomatic improvement to each treatment were 75% (12/16) for oral pentosan polysulfate sodium with prednisolone, 40% (2/5) intravesical instillation of xylocaine and heparin, and 0% (0/2) for intravesical instillation of hyaluronic acid. Conclusions: Ketamine abuse causes damage to the upper and lower urinary tracts. While ketamine abuse is an illicit drug problem, it is also associated with serious urological damage.     

Urodynamics to guide surgical therapy in LUTS/BPH

Our understanding of the disease process of lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH) has improved over the past few years. Furthermore, medical and surgical (including minimally invasive surgery) therapeutic options for treating LUTS/BPH are now available. With these advances we are faced with choosing the most appropriate therapy/therapies for individual patients. Ideally, we could accurately predict outcomes of the therapeutic options to maximize the chance for success, minimize the potential side effects and cost of failed therapies, and improve patient/doctor satisfaction. Noninvasive tests, symptom scores, and invasive urodynamics all have been used to diagnose and manage LUTS/BPH. Although they are somewhat invasive, in some settings, pressure-flow urodynamic studies may provide more useful information in selecting patients best suited for specific treatment modalities. This article reviews the literature with the goal of better defining the role of urodynamics in the nonmedical treatment of LUTS/BPH.     

Clinical Guideline for Female Lower Urinary Tract Symptoms

The “Japanese Clinical Guideline for Female Lower Urinary Tract Symptoms,” published in Japan in November 2013, contains two algorithms (a primary and a specialized treatment algorithm) that are novel worldwide as they cover female lower urinary tract symptoms other than urinary incontinence. For primary treatment, necessary types of evaluation include querying the patient regarding symptoms and medical history, examining physical findings, and performing urinalysis. The types of evaluations that should be performed for select cases include evaluation with symptom/quality of life (QOL) questionnaires, urination records, residual urine measurement, urine cytology, urine culture, serum creatinine measurement, and ultrasonography. If the main symptoms are voiding/post‐voiding, specialized treatment should be considered because multiple conditions may be involved. When storage difficulties are the main symptoms, the patient should be assessed using the primary algorithm. When conditions such as overactive bladder or stress incontinence are diagnosed and treatment is administered, but sufficient improvement is not achieved, the specialized algorithm should be considered. In case of specialized treatment, physiological re‐evaluation, urinary tract/pelvic imaging evaluation, and urodynamic testing are conducted for conditions such as refractory overactive bladder and stress incontinence. There are two causes of voiding/post‐voiding symptoms: lower urinary tract obstruction and detrusor underactivity. Lower urinary tract obstruction caused by pelvic organ prolapse may be improved by surgery.     

Recent Advances in Functional Anorectal Disorders

Defecatory disorders are a common cause of chronic constipation and should be managed by biofeedback-guided pelvic floor retraining. While anorectal tests are necessary to diagnose defecatory disorders, recent studies highlight the utility of a careful digital rectal examination. While obstetric anal injury can cause fecal incontinence (FI), diarrhea is a more important risk factor for FI among women in the community, who typically develop FI after age 40. Initial management of fecal incontinence should focus on bowel disturbances. Pelvic floor retraining with biofeedback therapy is beneficial for patients who do not respond to bowel management. Sacral nerve stimulation should be considered in patients who do not respond to conservative therapy.     

Overlap of voiding symptoms among common urologic conditions

In urologic practice, it is common to assign a specific diagnosis based on the presence of a set of characteristic symptoms. Examples of such symptom-based conditions include overactive bladder, lower urinary tract symptoms, chronic prostatitis/chronic pelvic pain syndrome, and interstitial cystitis/painful bladder syndrome. No objective diagnostic tests clearly differentiate between these conditions, and all are diagnoses of exclusion that are assigned after ruling out other identifiable etiologies for the symptoms (eg, urinary tract infection, bladder cancer). This article reviews the characteristic symptoms that define each condition and highlights the significant degree of overlap that exists between them.     

Neurophysiological testing in anorectal disorders

Neurophysiological tests of anorectal function can provide useful information regarding the integrity of neuronal innervation, as well as neuromuscular function. This information can give insights regarding the pathophysiological mechanisms that lead to several disorders of anorectal function, particularly fecal incontinence, pelvic floor disorders and dyssynergic defecation. Currently, several tests are available for the neurophysiological evaluation of anorectal function. These tests are mostly performed on patients referred to tertiary care centers, either following negative evaluations or when there is lack of response to conventional therapy. Judicious use of these tests can reveal significant and new understanding of the underlying mechanism(s) that could pave the way for better management of these disorders. In addition, these techniques are complementary to other modalities of investigation, such as pelvic floor imaging. The most commonly performed neurophysiological tests, along with their indications and clinical utility are discussed. Several novel techniques are evolving that may reveal new information on brain–gut interactions.     

Is there an association between fecal incontinence and lower urinary dysfunction?

BACKGROUND: Urinary and fecal incontinence in females are both common and distressing conditions. Because common pathophysiologic mechanisms have been described, an association between the two would be expected. The aim of this study was to determine whether patients with lower urinary tract dysfunction have concomitant fecal incontinence when compared with age and gender matched community controls and, second, to determine whether they have predisposing factors that have led to lower urinary tract symptoms and concomitant fecal incontinence. METHODS: A case-control study was performed by means of detailed questionnaire and review of investigation results. One thousand consecutive females presenting for urodynamic investigation of lower urinary tract dysfunction, were compared with 148 age and gender matched community controls. RESULTS: Frequent fecal incontinence was significantly more prevalent among all cases than among community controls (5vs. 0.72 percent,P=0.023). Occasional fecal incontinence was also more prevalent (24.6vs. 8.4 percent,P<0.001). Fecal incontinence was not significantly more prevalent among females with genuine stress incontinence (5.1 percent) when compared with females with detrusor instability (3.8 percent) or any other urodynamic diagnosis. Symptoms of fecal urgency and fecal urge incontinence were significantly more prevalent among those with a urodynamic diagnosis of detrusor instability or sensory urgency than among females with other urodynamic diagnoses or community controls. Multivariate analysis comparing cases with fecal incontinence with other cases and also with community controls did not indicate that individual obstetric factors contributed significantly to the occurrence of fecal incontinence in these patients. CONCLUSIONS: There is an association between genuine stress incontinence, lower urinary tract dysfunction, and symptoms of fecal incontinence, but the exact mechanism of injury related to childbirth trauma is questioned.Supported by a research grant from the ANZAC Health and Medical Research Foundation.Presented in part at the Annual Meeting of the Royal Australian College of Surgeons, Sydney, May, 8 to 10, 1997, and the International Urogynaecology Association Meeting, Buenos Aires, September 20 to 24, 1998.