ORIGINAL ARTICLE

The Role of Pelvic-Floor Therapy in the Treatment of Lower Urinary Tract Dysfunctions in Children
H. De Paepe,1,2 C. Renson,1 P. Hoebeke,1 A. Raes,1 E. Van Laecke1 and J. Vande Walle1
From the 1Paediatric Uro-Nephrologic Centre, and 2Department of Rehabilitation Sciences and Physical Therapy, Ghents University Hospital, De Pintelaan 185, B-9000 Gent, Belgium (Submitted March 7, 2001. Accepted for publication January 23, 2002)

Scand J Urol Nephrol 36: 260267, 2002 The pelvic- oor is under voluntary control and plays an important role in the pathophysiolog y of lower urinary tract (LUT) dysfunctions in children, especially of non-neuropathic bladder sphincter dysfunction. The following therapeutic measures can be applied to try to in uence the activity of the pelvic- oor during voiding: proprioceptive exercises of the pelvic- oor (manual testing), visualization of the electromyographic registration of relaxation and contraction of the pelvic- oor by a curve on a display (relaxation biofeedback), observation of the ow curve during voiding (uro ow biofeedback), learning of an adequate toilet posture in order to reach an optimal relaxation of the pelvic- oor, an individually adapted voiding and drinking schedule to teach the child to deal consciously with the bladder and its function and a number of simple rules for application at home to increase the involvement and motivation of the child. In children however with persisting idiopathic detrusor instability additional therapeutic measures may be necessary to improve present urologic symptoms (incontinence problems, frequency, urge) and to increase bladder capacity. Intravesical biofeedback has been used to stretch the bladder and seems to be useful in case of sensory urge. Recently a less invasive technique, called transcutaneous electrical nerve stimulation (TENS), has been applied on level of S3 with promising results in children with urodynamicaly proven detrusor instability, in which previous therapies have failed. Key words: biofeedback, dysfunctional voiding, pelvic-floor, urinary tract infection, urotherapy. Mrs H. De Paepe, Department of Rehabilitation Sciences and Physical Therapy, De Pintelaan 185/6K3, B-9000 Gent, Belgium. (Tel: 32 9 240 50 11/32 9 240 26 32. Fax: 32 9 240 38 11. E-mail: hilde.depaepe@rug.ac.be )

The pelvic- oor is under voluntary control and plays an important role in the pathophysiolog y of lower urinary tract (LUT) dysfunctions in children, especially of nonneuropathic bladder sphincter dysfunction. Although non-neuropathic detrusor sphincter dysfunction as a cause of incontinence problems has already been demonstrated in detail in children, little has been published about pelvic- oor therapy for this patient group. Pathophysiology of dysfunctional voiding (Fig. 1) Dysfunctional voiding is de ned as sphincter activity

during voiding or detrusor-sphincter dyscoordination during voiding. Etiologically, dysfunctional voiding seems to be the consequence of overtraining of the pelvic- oor, which itself is the result of a defence against loss of urine due to a lling phase dysfunction of the detrusor. The dysfunctional voiding would, in turn, then maintain the lling phase dysfunction of the detrusor (14). Thus, it seems reasonable to treat the emptying dysfunction along with the lling dysfunction. Pathophysiology of dysfunctional voiding associated with urinary tract infections and obstipation (Fig. 2) A lot of evidence exists in literature about the association between dysfunctional voiding and recurrent urinary tract infections (511). Dysfunctional voiding can be the consequence of overtraining of the pelvic- oor resulting from excessive squeezing of the urethral sphincter and the pelvic- oor in defence against loss of urine whenever unstable contractions occur. These resisted unstable contractions cause high pressure in the bladder which can be responsible for mucosal ischemia and vesico-ureteral re ux, both
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Fig. 1. Pathophysiolog y of dysfunctiona l voiding.

2002 Taylor & Francis. ISSN 00365599

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Fig. 2. Pathophysiolog y of dysfunctiona l voiding associate d with urinary tract infections .

being causative factors for recurrent urine tract infections (UTI) (5). As the pelvic- oor is overtrained, relaxation during voiding is more dif cult which is dysfunctional voiding. This dysfunctional voiding in turn can maintain bladder instability (14, 12). This detrusor-sphincter dyscoordination can lead to disruption of the laminar urinary ow through the urethra. This can lead to UTI as bacteria can be carried back up from the meatus to the bladder as result of the milk back phenomenon (1315). In these children incontinence is a frequent associated problem. Infections can increase bladder instability and bladder sensibility leading to incontinence. Incontinence in turn can lead to a higher susceptibility for infections (16). A training programme aiming at correction of the voiding dysfunction seems reasonable to prevent UTI and treat incontinence. Although the association between bladder and bowel dysfunction is well known, the exact mechanism remains unexplained (9). Efforts to maintain urinary continence may lead to urethral and simultaneous anal sphincter contractions resulting in a high tone of the pelvic- oor muscles. This high tone results in dysfunctional voiding and incomplete emptying of the bowel, leading to obstipation and soiling (17, 18). Recently the term dysfunctional elimination syndrome was introduced by Koff and Jayanathi, to cover both pathologic entities (19). Furthermore obstipation as a cause for urinary symptoms has been mentioned by several authors (1824). PELVIC-FLOOR THERAPY: THERAPEUTIC MEASURES The following therapeutic measures can be applied to try to in uence the activity of the pelvic- oor during voiding: proprioceptive exercises of the pelvic- oor (manual testing), visualization of the electromyographic registration of relaxation and contraction of

Fig. 3. Voiding and drinking chart.

the pelvic- oor by a curve on a display (relaxation biofeedback), observation of the ow curve during voiding (uro ow biofeedback), learning of an adequate toilet posture in order to reach an optimal relaxation of the pelvic- oor, an individually adapted voiding and drinking schedule to teach the child to deal consciously with the bladder and its function and a number of simple rules for application at home to increase the involvement and motivation of the child. The voiding and drinking schedule (Fig. 3) The voiding and drinking schedule is used to teach the child to deal consciously with the bladder and its function. In the diagnostic phase, the child is asked to record the following information accurately for 2 weeks: voiding frequency, urine volume, liquid intake, the number of wet and/or dirty underpants, number of dry/wet nights. In the therapeutic phase, the completed lists are evaluated and structured. In view of the set objectives (including increasing the bladder capacity, recognition of the feeling of a full bladder, and remedying wet and/
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H. De Paepe et al. the strength felt during contraction. Such a child has rst to learn to release the pelvic- oor muscles in order to achieve a suf cient displacement during contraction to evaluate (26). Posture on the toilet Children with dysfunctional voiding are advised to void, sitting down on the toilet. In children who cannot reach the oor by their feet a small bench or support is placed under the feet. In sitting on the toilet, the thighs have to be spread to obtain a good relaxation of the pelvic- oor. The back has to be held straight and tilted slightly forward. Optimal relaxation of the pelvic- oor with this posture has been described before (27). In this position the children have to apply the relaxation they learned during the biofeedback sessions. After voiding children are advised to stay a few seconds and continue to relax not running away from the toilet in a hurry. In young children too low potties must be avoided because they create a squatting position, which stimulates straining during voiding. On a normal toilet a toilet reducer and a small bench or support under the feet can be used. In this proper position the child is learned to count during voiding and up to 5 after voiding. The child may also whistle or sing a song in order to avoid straining with the abdominal muscles, which increases the tension of the pelvic- oor (27). Biofeedback training Before starting biofeedback the child must be aware of the localization and function of the pelvic- oor muscles. Biofeedback is started in those children that show good cooperation and motivation and who are not anxious. We applied relaxation biofeedback in a number of children jounger than 5 years old. The most important factor is maturity. Certainly in this group of younger children extra motivation and explanation to the child is needed (28). An anal plug, registering muscle activity by EMG is used. The muscle activity is displayed on a device (Myomed 932, Enraf Nonius B.V., Delft, The Netherlands) and a curve appears as a visual signal to the child. In this way the child is aware of the grade of relaxation and toning of the pelvic- oor muscles as the curve goes up with contraction and falls down with relaxation. This training is an active form of exercise which needs a conscious collaboration of the child, who learns to perform a short submaximal contraction (3 seconds) followed by a prolonged relaxation (about 30 seconds). One session takes 30 of these exercises. The relaxation is evaluated as good when the exercises are done with low tension (the curve comes down easily) from the start on. Results are medium if at the start of the session the exercises are done with high tension which reduces during the session. Results are

or dirty underpants during the day and/or night), the voiding frequency and liquid intake is adjusted and further supervised. During therapy, the voiding and drinking chart has to be lled out by the child. For this purpose a child friendly chart is developed. For example: every time the child has sit properly on the toilet, it may stick a sticker on the chart. We advise a voiding frequency of 56 times a day with a regular uid intake: 2 glasses at each meal and 1 glass in between. Soft drinks like coke and ice tea, coffee and tea, ice-cooled drinks have to be avoided, because they can induce detrusor instability. Manual testing Pelvic- oor contractions are rst taught manually. The child is placed in the lateral recumbent position with the top leg bent forward and the bottom leg stretched backward. The therapist places two ngers crosswise on the perineum and asks the child to do as though it wants to hold urine. The pelvic- oor muscles have to be able to be contracted as selectively as possible, that is without the involvement of the gluteus. With this, the proprioception of the pelvic- oor is stimulated so that the child learns to localize and control the pelvic- oor. By manual testing the pelvic- oor can be evaluated for strength, exhaustability and endurance. The pelvicoor strength is evaluated using the standards described in the Oxford Scale by Zinovieff (25). The Oxford scale is adapted for children as vaginal examination is impossible. So pelvic- oor strength is measured perineal and graded as follows: 0 = no contraction 1 = vibration 2 = weak contraction 2 = contraction without displacement 3 = contraction with displacement 3 = strong contraction The values 4 and 5 (Oxford Scale) can not be used while this evaluation needs a vaginal measure. The exhaustability is estimated by repeating the same contraction at least 5 times. In order to test endurance the patient is asked to hold the contraction for 5 seconds with the same force. If a patient can repeat the same contraction 5 times and can hold the contraction for 5 seconds, exhaustability and endurance are evaluated good. If not, it is evaluated medium or bad depending on the results. There are some dif culties in children using this evaluation scale. First a selective contraction is needed, which is sometimes only obtained after a few sessions. Further, a child with an overtrained pelvic- oor has a raised basic tone of the pelvic- oor which causes a minimal difference between the strength felt at rest and
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Pelvic-floor therapy for lower urinary tract dysfunctions bad if the tension remains high throughout the whole session. Uro ometry and uro ow biofeedback At the end of each biofeedback session, the urine ow is measured. After the child has urinated, it predicts the form of the curve and the amount of urine. This prediction is then tested against the real curve, which again is a form of biofeedback. In order to void with a bell-shaped curve like a mountain the micturition may not be interrupted. The children of whom we know they have residual urine we regularly check with the ultrasound after the uro owmetry. Uro ow biofeedback means that the child is able to visualize the owcurve on a screen during micturition. So the child directly gets information and is able to make corrections during micturition. Rules for application at home The involvement and motivation of the child is very important to succeed. On the base of simple rules, the children are explained how to contribute every day to remedy their bladder problems. The child learns what is wrong with the bladder and the pelvic- oor in words it can understand by using drawings, illustrated books, a story or balloons imitating the bladder (29). Some simple rules for application at home can be used: Every time I feel that my bladder wants to pee, I go immediately to the toilet and sit properly on my potty (adapted toilet). When I get up, I go to the toilet, before I go to bed, I go to the toilet and between in I also go regularly, even when I am busy playing. I always pay attention to my posture while I am voiding and never void in a hurry. During voiding I keep my stomach asleep, keeping my hand on it; I do not strain but count or sing. After voiding I do not run away from the toilet immediately but I count quietly up to 5 before wiping off properly. Every time I go to the toilet, I look if my pants are still dry. If they are wet I have to change them. At each meal, I drink 2 glasses, and 1 glass in between. I pay attention to my diet: a lot of bres, vegetables and fruit make defecation easy. I do not use soap or bubble baths for intimate hygiene. Duration and frequency of the therapeutic sessions Each session lasts about 1 hour and sessions are held once a week. In the group of younger children, who do not receive biofeedback training, the ambulatory sessions are held once every 2 weeks. Every 68

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sessions the children are evaluated by their doctor. The maximal training consists of 2024 sessions (6 months) and the children are followed for at least 6 months after training (12, 17, 30). Adjuvant pharmalogical therapy During treatment the children with urodynamically proven detrusor instability receive anticholinergics (oxybutinin 0.3 mg/kg). The children with a history of recurrent UTI are put on prophylactic antibiotics (trimethoprim 2 mg/kg). The children suffering encopresis, based on chronic obstipation, receive desimpaction drugs. A low dose of diazepam may reduce pelvic- oor spasms. After successful therapy, when the child is free of infection, prophylactic antibiotics are stopped. Anticholinergics are continued at a lower dose for 3 months after the end of the therapy. Therapy is considered successful when the owcurve normalises, when there is a regular toilet visit without wet pants, when the children stay free of infection during follow-up of at least 6 months. Treatment of other urological symptoms (re ux, perineal pain, vaginal irritation, pelvic- oor spasm) and encopresis is also considered (12, 17, 30). ROLE OF PELVIC-FLOOR THERAPY IN THE TREATMENT OF DETRUSOR INSTABILITY In children however with persisting idiopatic detrusor instability additional therapeutic measures may be necessary to improve present urologic symptoms (incontinence problems, frequency, urge) and to increase bladder capacity. Intravesical biofeedback has been used to stretch the bladder and seems to be useful in case of sensory urge. Recently a less invasive technique, called transcutaneous electrical nerve stimulation (TENS), has been applied on level of S3 with promising results in children with urodynamicaly proven detrusor instability, in which previous therapies have failed (31). Intravesical biofeedback (Fig. 4) Intravesical biofeedback is applied in order to reach a normal bladder capacity by stretching the bladder in children with persisting low bladder volume. Therefore a catheter is used, connected to a hollow tube and an infusion (32). The bladder is lled gradually and unstable bladder contractions may occur increasing the uid volume in the hollow tube. In a rst step, the child is encouraged to suppress the unstable contractions by squeezing the pelvic- oor. Secondly the unstable contractions are controlled by the mechanism of central inhibition. The bladder is lled once a week. After 6 sessions the child is evaluated by the doctor.
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Fig. 5. Device for neurostimulation .

previous therapies have failed such as medication, pelvic- oor therapy, wetting alarm, voiding school. Following exclusion criteria are preset: anatomical deformity, bladder out ow obstruction neurological disease. Therefore a portable electrostimulation equipment (ENS 911, Enraf Nonius B.V., Delft, The Netherlands) is used with following parameters: Low-frequency TENS (2 Hz/burst frequency) 2 hours daily is preset. An asymmetrical biphasic pulse with pulse width of 150 msec is generated. Frequency modulation (spectrum) is used to prevent adaptation. Maximum tolerable intensity, just below the pain treshold is preset. The electrodes are placed bilaterally on level of S3 (one channel treatment). In a number of children anticholinergics are continued. An individually voiding and drinking chart is given to be lled out monthly. Every month the children are evaluated. Evaluation forms are to be lled out asking for diurnal and nocturnal incontinence, frequency, bladder capacity and medication. If there is no result after 1 month, therapy is discontinued, if there is result therapy is continued for 2 months. Though in children with severe detrusor instability the use of transcutaneous electrical nerve stimulation (TENS) produces changes in presenting urological symptoms, further systematic evaluation to establish optimal electrical parameters is required.

Fig. 4. Device for intravesica l biofeedback .

Intravesical biofeedback is successful if the bladder capacity is increased during lling and suf cient bladder volume also can be reached at home. Adjuvant urological symptoms such as incontinence problems during day and/or night, frequency and the feeling of urge are considered. Good results are obtained in case of low capacity based on sensory urge. Transcutaneous electrical neurostimulation (TENS) (Fig. 5) Neurostimulation is applied by transcutaneous electrical nerve stimulation (TENS) on level of S3 in order to in uence the unstable bladder contractions in children with persisting idiopathic detrusor instability (31). Following inclusion criteria are preset: non-neuropathic bladder sphincter dysfunction (NNBSD) urodynamicaly proven bladder instability, motoric urge frequency: micturition of more than 8 times a day persisting urologic symptoms: urinary incontinence, urge, frequency, low capacity
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Pelvic-floor therapy for lower urinary tract dysfunctions ROLE OF PELVIC-FLOOR THERAPY IN DISTURBED BLADDER SENSIBILITY However, theoretically a child is able to maintain continence, wetting problems may persist caused by insuf cient control of bladder feeling. If a child continuously holds up urine, denying the feeling of full bladder because it is playing, or it detests toilet visit, incontinence may occur. If incontinence occurs on regular intervals, the child becomes used to the feeling of being wet. A child who avoids visiting school toilets, risks developing a lazy bladder. To remedy this problem of ignorance following measurements can be used: some rules for toilet visit, a wetting alarm or bladder manager during day. Some rules for toilet visit A child has to learn to visit any toilet and to sit completely down on the toilet seat. In order to get used to any toilet, the toilet at home may not be too hygienic and any pronouncements upon avoiding strange toilets are unacceptable. A busy child has to be urged to discontinue any activity when there is a feeling of urge. A child may not be pushed to hurry up during voiding because straining is then stimulated. Wetting alarm during day A wetting alarm may be useful for paying attention to a full bladder (33). It can be used to determine the amount and frequency of incontinence and the situation in which wetting problems occur. Therefore a sensor is put in the underwear giving alarm with minimal urine loss. The goal is to enter a competition against the wetting alarm: when the child is able to void without alarm, he has gained one point, when there is alarm before voiding, the child has lost. The points are collected on a diary. This training is a short-time one. Once the child is able to stay 3 days without alarm, the wetting alarm is put off and he has to stay dry for 1 week more. If there are no longer alarms, the wetting alarm is stopped. Bladder manager This is a special type of wetting alarm by which a buzzer is used to encourage voiding on regular times. The child has to put off the buzzer and visit the toilet. Following data can be registered: number of wet pants, number of toilet visits with or without urine loss, time to answer the given signal. It is a useful tool in case of dif culty to ll out a voiding and drinking schedule. ROLE OF PELVIC-FLOOR THERAPY IN THE TREATMENT OF NOCTURNAL ENURESIS Though wetting problems during day are treated,

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bladder capacity has gained normal volume and owcurve is normalized, nocturnal enuresis may persist. In this case, behaviour therapy is needed to stop wetting during the night. A wetting alarm at night is used to weak up the child if minimal loss of urine occurs. At that moment the child has to hold urine as soon as possible and visit the toilet. The sensor and wet sheets have to be changed. In order to improve the respons to the alarm a dry bed training is used based on the method of Azrin et al. (34). The dry bed training makes use of 3 elements: The positive exercises including the pelvic- oor exercises: We also add contractions of the pelvicoor to the exercises before bedtime and during the rst night in order to improve the manoeuvre of holding up as soon as the alarm sounds. The wetting alarm: The wetting alarm informs the child of a full bladder. Motivators (social, material, activities): These motivators are given to the child if he has accomplished the given tasks. The dry bed training is composed of three phases: The intensive night. The follow-up training is characterized by three stages of learning: stage 1: adequate reaction on alarm caused by loss of urine; stage 2 (not necessary): to weak up before alarm in case of a full bladder; stage 3: to stay dry without weaking up; the bladder control occurs unconsciously. What to do if the child is dry: The alarm may be stopped if the child is able to stay dry during 2 weeks using the wetting alarm, afterwards he has to stay dry 2 weeks more without alarm. The given rules concerning uid intake and voiding frequency have to be continued in order to prevent relapse.

THERAPEUTIC RESULTS OF BIOFEEDBACK THERAPY As dyscoordination between detrusor and sphincter during voiding is an important pathological event in the development of functional voiding disorders in children, correction of the sphincter dysfunction seems reasonable. The urethral sphincter, which is part of the pelvic- oor, is under voluntary control and accessible to treatment with biofeedback. Over the past 5 years we apply pelvic- oor therapy in children with functional voiding disorders with good results. Treatment of daytime incontinence The proposed therapy, with biofeedback as cornerScand J Urol Nephrol 36

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stone, was applied in a group of 50 girls with daytime incontinence and detrusor-sphincter dyscoordination on urodynamics (12). In this population biofeedback therapy seems to be effective in curing daytime incontinence in 92% within maximal 18 sessions. Relapse occurred in 5 girls during a follow-up period of 6 months. Treatment of urinary tract infections Biofeedback therapy was effective in curing recurrent urinary tract infections in a group of 42 girls. Success rate was 83% within 24 sessions (17). With the results presented in this paper, we indirectly proved the correlation between functional voiding disorders and urinary tract infections. Infections recurred less in children who were able to correct their voiding dysfunction. Persistence of incontinence (= persistence of voiding dysfunction) was a poor prognostic factor in this perspective. Furthermore the high rate of resolution of low-grade vesico-ureteric re ux after this training suggested the association of voiding dysfunction and vesico-ureteric re ux. Toilet training in the young child The proposed pelvic- oor therapy was applicable in the young child (30). The given measurements were useful to attain bladder (success rate of 81.2%) and bowel control (success rate of 62.5%) within 20 sessions. Mean duration of therapy was 10 sessions. In the group without biofeedback training a good result was also obtained. The proposed measurements (correction of toilet posture and keeping a voiding and drinking schedule) were useful to normalise a dysfunctional voiding and bowel pattern. These measurements should be considered as essential elements of proper toilet training in the young child in order to prevent further pathological evolution of a possible present dysfunction. THERAPEUTIC RESULTS OF TRANSCUTANEOUS NEUROSTIMULATION In a prospective study we evaluated the clinical effects of transcutaneous neurostimulation (TENS) in detrusor overactivity in children with non-neuropathic bladder sphincter dysfunction (31). Between May 1998 and July 1999, 55 children (33 boys and 22 girls) between 6 and 12 years old, with proven detrusor instability on urodynamics, underwent neurostimulation. Most children have been under anticholinergics for 3 months. In those children in whom anticholinergics had no effect, neurostimulation was given as a single therapy, in the others a combined therapy was given. Stimulation of 2 Hertz was applied during 2 hours daily. Surface electrodes were put on both sides at the level of the sacral root S3. In children not responding to
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Fig. 6. Therapeuti c measurement s in the treatment of lower urinary tract dysfunctions .

2 Hertz, 80 Hertz was applied during the whole night. After 1 month of trial stimulation, those children who responded continued treatment for 6 months with an evaluation every 2 months. Forty-one children were considered to be a responder after 1 month, 10 children did not respond because lack of motivation and 4 because of no effect. The results were evaluated in 33 children who underwent therapy for at least 2 months. All developed a better bladder sensibility, 12/18 had a normalization of voiding frequency, 23/33 showed a signi cant volume increase, 23/33 had a decrease of urge, 17/30 children with daytime incontinence and 7/21 children who were bedwetting became dry. Eleven children stopped therapy after 6 months and were considered healed, 2 relapsed during the follow-up period of 3 months. CONCLUSION The role of pelvic- oor training in the treatment of LUT in children consists of different therapeutic measurements. The disturbance in bladder lling has to be treated together with the disturbance in bladder emptying. To remedy the disturbance in bladder emptying correction of toilet posture, relaxation biofeedback and biofeedback uro owmetry are applied. Useful therapeutic tools in case of disturbance in bladder lling are intravesical biofeedback (monother-

Pelvic-floor therapy for lower urinary tract dysfunctions apy or combined with medication) and TENS (monotherapy or combined with medication). Recognition of a full bladder may be stimulated using a wetting alarm as a supplement to a voiding and drinking schedule. A bladder manager is useful to encourage a regular toilet visit. Persisting nocturnal enuresis (or isolated nocturnal enuresis) is treated by a wetting alarm during night. An individual combination of therapeutic measurements has to be selected to solve a particular voiding problem in children with non-neuropathic bladder sphincter dysfunction (NNBSD) (Fig. 6). REFERENCES
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