Current Role of Biofeedback for Pediatric Lower Urinary Tract Symptoms BIOFEEDBACK remains an important treatment option in the management of lower urinary tract symptoms (LUTS) in children. It is provided in many forms from simple instruction without any monitoring of muscle activity to sophisticated multiple muscle group monitoring with advanced interactive computer games that work only with coordinated pelvic and abdominal muscle control.1,2 Some programs focus on improving flow pattern while others focus on pelvic floor and abdominal muscle retraining.3,4 Centers with advanced continence programs understand the multiple and often complicated combinations of problems these children have that require an individualized treatment program. Behavioral and psychological issues further complicate management. Eliminating patients with neurological disorders and anatomical problems is important before initiating medical therapy. Elimination education focusing on increasing fluids, timed voiding, managing constipation and improving hygiene issues may be all that is required. Biofeedback represents one available modality that is used as part of a combination of treatments for these disorders. Accurate assessment of the underlying cause of lower urinary tract dysfunction is important when applying treatment. The evaluation should include voiding diaries, noninvasive urodynamics and ultrasound. Various treatment combinations are used based on the cause of the lower urinary tract dysfunction. Rarely anatomical abnormalities are treated surgically, but most often children receive some combination of urotherapy with or without medication.5 In this issue of The Journal Fazeli et al (page 274) evaluate the available randomized data on the effectiveness of biofeedback for LUTS in children.6 Of 1,195 citations returned by their literature search, the authors found 5 eligible studies. Of these studies only 4 were pooled in the metaanalysis based on available data.7e10 Results indicated the overall proportion of cases with resolved incontinence was similar in the biofeedback and control groups (OR 1.37; 95% CI 0.64, 2.93 and risk






difference 0.07; 0.09, 0.23). There was also no significant difference in mean maximum urinary flow rate (mean difference 0.50 ml; 95% CI 0.56, 1.55) and in the likelihood of urinary tract infection (OR 1.30; 95% CI 0.65, 2.58). The authors concluded that “current evidence does not support the effectiveness of biofeedback in the management of children with nonneuropathic voiding disorders,” but their conclusion is not supported by the data.6 Interestingly, when not pooled, all of the studies but that of Vasconcelos et al9 had odds ratios favoring biofeedback. It would be correct to say there were insufficient randomized study data to support biofeedback. It is apparent from the review that there are few randomized controlled trials and those that exist are only single institution studies. The methodology of the study by Fazeli et al is sound but the available data are insufficient to make any conclusions.6 The fact that the authors identified more than 1,100 studies but only included 4 in the metaanalysis confirms a problem with the accuracy of the review. The review is particularly weak due to the heterogeneity of the 4 studies included, which were widely different in patient population, evaluation and management. The authors acknowledge the difference in patient diagnosis by developing their own term, nonneuropathic voiding disorders, because they could not identify the underlying cause of lower urinary tract dysfunction among the reviewed studies. This term is not used by the International Children’s Continence Society. The studies included in the review involve a mixed group of children with different combinations of causes of voiding dysfunction, all evaluated and treated with different methods. Kajbafzadeh et al used uroflowmetry and electromyography (EMG), with the inclusion criteria of a staccato pattern and increased EMG activity or constant EMG activity with a plateau pattern of voiding.7 Constipation was accurately evaluated, children with neurological abnormalities were excluded from analysis, and behavioral and physiological issues were not addressed. Vol. 193, 14-15, January 2015 Printed in U.S.A.


Klijn et al evaluated patients with a standardized questionnaire on symptoms of bladder and sphincter dysfunction, continence, infections and defecation habits, as well as a medical history, physical examination, ultrasound screening of the urinary tract, degree of rectal distention, urinalysis and urine culture.8 No EMG was included in the evaluation. Patients had to have a high residual and only those with a staccato pattern were included in the study. Patients were started on laxatives, and behavioral and psychological assessment was not obtained. Vasconcelos et al included refractory cases that had previously been treated at their clinic.9 An extensive evaluation of behavioral and psychological issues was accomplished in this study. A dynamic ultrasound was obtained before and after the treatment provided. Lastly, Kibar et al evaluated patients with physical examination, including a neurological examination, urinalysis, urine culture, serum urea and creatinine, lumbosacral spine radiography, urinary ultrasonography, uroflowmetry and EMG, and postvoid residual urine.10 Only patients with a staccato pattern of voiding were included and those with psychosocial issues were excluded from the study. It is unclear what the authors meant by psychosocial disorders. Including cases with different causes of LUTS even if from individual randomized studies will not result in an accurate assessment. The 4 studies included in this review also approach biofeedback differently. Kajbafzadeh et al used animated biofeedback (UrostymÔ) and measured pelvic floor activity along with abdominal muscle activity.7 Six to 12 sessions were required. In the study by Klijn et al biofeedback was done in the patients’ home and based on voiding.8 The treatment was recommended 4 times daily and was provided for 24 weeks. A special personalized videotape was to be watched daily as part of their program.


Vasconcelos et al used a commercially available biofeedback system that generated EMG tracing during the contraction and relaxation phases of pelvic floor muscles but did not monitor abdominal muscle activity.9 A total of 16 sessions were held during a 2-month period. Lastly, in the study by Kibar et al biofeedback was performed with a UDS120 urodynamics system, which enables simultaneous recording of urine flow and EMG, and visual display of flow EMG activity.10 Pelvic floor and abdominal muscle activity were monitored, and the focus was on correction to a normal flow pattern. The treatment was completed during a 6-month period with sessions every 3 to 4 weeks. It is inappropriate to combine these as biofeedback since the techniques vary significantly among the studies and it is inappropriate to lump them together for any analysis. In summary, it is wrong to conclude that the available data do not support the use of biofeedback. It is correct to say the data reviewed are insufficient to determine the efficacy of biofeedback. Due to the heterogeneity of patients and urotherapy programs, this area of study does not lend itself to easy randomization. Using biofeedback in an organized continence program has been beneficial at multiple centers around the world and should remain an option despite the difficulty in obtaining randomized study confirmation of its efficacy. The issue is not about biofeedback. It is about accurately diagnosing the underlying cause of the LUTS and working with a group of physicians and other professionals who can manage behavioral problems, psychological problems and neurological issues, and applying treatment options that address the underlying cause. Patrick H. McKenna Division of Pediatric Urology Department of Urology University of Wisconsin School of Medicine and Public Health Madison, Wisconsin

REFERENCES 1. Paepe H, Renson C, van Laecke E et al: Pelvicfloor therapy and toilet training in young children with dysfunction voiding obstipation. BJU Int 2000; 85: 889. 2. Herndon CD, Decambre M and McKenna PH: Interactive computer games for treatment of pelvic floor dysfunction. J Urol 2001; 166: 1893. 3. Palmer LS, Franco I, Rotario P et al: Biofeedback therapy expedites the resolution of reflux in older children. J Urol 2002; 168: 1699. 4. McKenna PH, Herndon CD, Connery S et al: Pelvic floor muscle retraining for pediatric voiding dysfunction using interactive computer games. J Urol 1999; 162: 1056.

5. Ballek NK and McKenna PH: Lower urinary tract dysfunction in childhood. Urol Clin North Am 2010; 37: 215. 6. Fazeli MS, Lin Y, Nikoo N et al: Biofeedback for nonneuropathic daytime voiding disorders in children: a systematic review and meta-analysis of randomized controlled trials. J Urol 2014; 193: 274. 7. Kajbafzadeh A, Sharifi-Rad L, Ghahestani SM et al: Animated biofeedback: an ideal treatment for children with dysfunctional elimination syndrome. J Urol 2011; 186: 2379. 8. Klijn AJ, Uiterwaal C, Vijverberg M et al: Home uroflowmetry biofeedback in behavioral

training for dysfunctional voiding in school-age children: a randomized controlled study. J Urol 2006; 175: 2263.

9. Vasconcelos M, Lima E and Caiafa L: Voiding dysfunction in children. Pelvic-floor exercises or biofeedback therapy: a randomized study. Pediatr Nephrol 2006; 21: 1858.

10. Kibar Y, Piskin M, Irkilata H et al: Management of abnormal postvoid residual urine in children with dysfunctional voiding. Urology 2010; 75: 1472.

Current role of biofeedback for pediatric lower urinary tract symptoms.

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