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Biofeedback Therapy
In Pediatric Urology
Jacqueline Liberati
B
iofeedback treatment uses
electronic or mechanical
instruments to relay visual and/or auditory evidence to assist a person in gaining
control over a physiologic process
or function. In pediatric urology
patients, biofeedback treatment is
used to promote retraining of
pelvic muscles. Figure 1 depicts
the pathophysiology of dysfunctional voiding. In the figure,
increased pelvic floor tension or
overtraining is part of a vicious
cycle that leads to pelvic floor and
bladder dysfunction. Biofeedback
methods are used to interrupt the
cycle and promote pelvic floor relaxation and improve bladder function.
With the use of biofeedback methods, the child learns about a unconscious physiologic process through
visual, auditory, and/or tactile signals so that the unconscious physiologic process can be recognized
and then changed or influenced
(Hoebeke et al., 1996).
Historical Review
Biofeedback techniques to
manage external sphincter-detrusor dyssynergia were initially
described in the late 1970s.
Interest has recently returned for
biofeedback utilized as a treatment modality for children with
dysfunctional voiding, recurrent
Jacqueline Liberati, MSN, BS, RN,
CRNP, is a Pediatric Nurse Practitioner,
The Children’s Hospital of Philadelphia,
Philadelphia, PA.
Note: CE Objectives and Evaluation
Form appear on page 211.
206
Biofeedback is one of the unique treatment options available in the
management of voiding dysfunction in children.The focus of biofeedback in pediatric urology is on pelvic floor muscle retraining.
Biofeedback uses monitoring devices and strategically placed electrodes to obtain and relay to the child visual and/or auditory cues on
bladder emptying activity. The visual and auditory cues help train the
child to sense, interpret, and respond to the body’s messages related to voiding activity. The overall goal is to improve the child’s ability to store urine and empty the bladder more effectively.
urinary tract infections, or diurnal enuresis. The concept that
pelvic floor musculature affects
bladder function is not new.
DePaepe and colleagues (2002)
assert the pelvic floor is under
voluntary control and plays an
important role in the pathophysiology of lower urinary tract dysfunctions in children, especially
of non-neuropathic bladder
sphincter dysfunction. Allen and
Bright (1975) reported on the
relationship between dysfunctional voiding symptoms and
objective pathology using urodynamics in the pediatric urological population. It was their idea
that dysfunctional voiding represented a transitional stage
between infant reflex voiding and
mature voiding with cognitive
reflex guarding. Cardozo, Stanton,
and Hafner (1978) initially reported the use of biofeedback in a
highly selected population of
women with detrusor instability.
Controversy exists in the literature in regard to the validity of
objective versus subjective
improvement of symptoms of
voiding dysfunction in children
(McKenna, Herndon, Connery, &
Ferrer, 1999). Some believe that
patients with voiding dysfunction should initially be treated
with behavioral therapy for its
long-term efficacy and biofeedback used only if this therapy
fails (Weiner et al., 2000). Others,
however, attest that biofeedback
achieves perineal synergy, cures
symptoms in children with
detrusor-sphincter dyssynergia,
and that it guarantees long-term
clinical and functional recovery
(Porena, Costantini, Rociola, &
Mearini, 2000). Attainment of
daytime dryness is an important
milestone for children and has
been noted to improve selfesteem dramatically (Hagglof,
Andren, & Bergstrom, 1997).
The earliest method of
biofeedback training for detrusor
overactivity focused on patient
attempts to inhibit overactive
detrusor contraction by concentrating, breathing deeply, clenching the fists, and generally relaxing while watching the cystometric curves or listening to the
auditory signal to which the
increase in detrusor pressure is
converted. Maizels, King, and
Firlit (1979) introduced urodynamic biofeedback as a new
approach to treat vesical sphinc-
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Figure 1.
Pathophysiology of Dysfunctional Voiding
Voiding diaries
Pharmacotherapy
Bladder
dysfunction
Overtraining
of pelvic floor
Pelvic floor
dysfunction
Pelvic floor relaxation therapy
ter dyssynergia in the pediatric
population. Since that time,
effective bladder retraining programs for children have been
developed. VanGool, Vijverberg,
Messer, Elzinga-Plomp, & deJong
(1992) described an effective
treatment program involving a 10day inpatient therapy and biofeedback via uroflowmetry and urine
volume diaries. Biofeedback has
previously been used successfully
to treat various pelvic floor dysfunctions, such as urinary incontinence and pediatric detrusorsphincter dyssynergia (Sugar &
Firlit, 1979; Wennergren & Oberg,
1995). Despite the postulated success of biofeedback in pediatric
urology, it is apparent that this
therapeutic approach is not well
studied in the literature.
Often patients have daytime
and/or nighttime enuresis. For
children with urinary incontinence and bladder overactivity,
the goal is dryness. For children
with vesicoureteral reflux and
recurrent urinary tract infections,
the goal of biofeedback is to
establish low pressure cycling of
the bladder. For children with
severe voiding dysfunction, significant improvement of symptoms, rather than elimination of
symptoms, is the targeted outcome goal (management versus
cure). The common goal of
biofeedback is to make children
aware of their pelvic floor musculature and to teach them functional ways of using these muscles with voiding.
Goals of Treatment
To grasp the basis of voiding
dysfunction and the mechanics
of biofeedback, it is important to
understand the relationship
between the nervous system
(brain and spinal cord) and the
urinary system. The brain and
spinal cord coordinate the functions of the body’s organ systems,
including the kidneys and the
bladder. The kidneys filter waste
from the blood and dispose of
this waste in the urine. The
The goals of biofeedback
vary with the etiology of the
problem. Children with bladder
sphincter dysfunction (defined
as contraction of the pelvic floor
muscles during voiding in the
absence of obstruction) may present with urgency, frequency,
and occasional recurrent urinary
tract infections and vesicoureteral reflux (McKenna et al., 1999).
Biofeedback Methods
UROLOGIC NURSING / June 2005 / Volume 25 Number 3
ureters carry the urine down to
the bladder where it is stored
until time for emptying or voiding. The bladder stretches and
relaxes as it fills and then
squeezes or contracts as it empties. When the bladder is full, a
signal is sent to the brain. The
brain makes us aware of the need
to urinate. As the bladder muscle
contracts, a band of muscles at
the bladder opening, called the
external or urethral sphincter,
relaxes to let the urine out. This
muscular band is also responsible for tightening to keep urine in
as the bladder fills. The surrounding muscles (lower pelvic
muscles) hold the pelvic organs
in place. Tightening of the pelvic
muscles also tightens the urinary
sphincter. Voiding dysfunction
occurs when one or several physiological mechanisms do not
work in a coordinated fashion.
These include the inability to
sense when the bladder is full,
relax the sphincter, tighten the
sphincter, and determine when
the bladder is empty.
Teaching children the dynamics of voiding can be challenging.
The success of biofeedback therapy depends greatly on patient
and parent compliance, motivation to learn, and a willingness to
participate. The procedure must
be discussed clearly with the
patient and family. The child’s
session must be individualized
and be developmentally appropriate for that child. Each child is
taught to identify differences in
relaxation, contraction, and straining. Children observe changes in
the electromyography tracing on
the monitor and wait for cues by
the nurse to elicit a contraction or
relaxation. Under guidance the
child is taught to optimize pelvic
floor relaxation with a stool placed
beneath the feet or with knees
spread which helps to relax the
perineum.
Biofeedback involves use of
electromyography and uroflowmetry. Electromyography patches
are placed perianally at the 3 and 9
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Figure 2.
Biofeedback Involves Use of
Electromyography and
Uroflowmetry
Figure 3.
The External Unit Is Attached to a Computer,
Which Relays the Image to a Monitor
Surface EMG electrodes are placed
at the 3- and 9-o’clock positions of
the the child’s perineum. An additional surface electrode is placed on
the rectus abdominus to measure
abdominal muscle activity.
o’clock positions. A sensor patch is
placed on the abdomen to monitor
accessory muscle activity (see
Figure 2). Leads are connected to
an external unit that interprets and
analyzes the electrical impulses
received from the pelvic floor muscles. The external unit is attached
to a computer, which relays the
image to a monitor (see Figure 3).
At the beginning of all sessions, a provider obtains a voiding history and assesses if the
child is a potential candidate for
biofeedback. The provider then
discusses the accomplishments
of the previous treatment session, patient progress at home,
incidence of breakthrough infection, compliance with home
exercises, and addresses any
questions the family has concerning the pelvic floor muscle
retraining program. After all
questions and/or concerns are
addressed, the biofeedback session commences with placement
of perianal leads. Patients are
completely dressed and reclined
in an adjustable chair during the
session.
The session schedule involves the patient first relaxing
and the nurse obtaining a baseline relaxation reading. Patients
208
then perform Kegel exercises and
short bursts of pelvic floor contractions, called quick flicks.
When patients are not able to isolate the pelvic floor muscles,
immediate instruction is given
on how to isolate them (focusing
on squeezing the leads on the
buttocks). The patient is then
instructed to perform four, 5-second repetitions of quick flicks,
that is, short contractions and
relaxations with the nurse and
patient watching electromyography-generated activity patterns on
the television screen. This is followed by a 30-second relaxation
interval. The patient then performs a series of eight, 10-second
alternating contractions and
relaxations. This interval is then
followed by a 30-second rest
period.
Screening uroflowmetry and
bladder scan for post-void residual urine are performed. The
child is asked if there is residual
urine in the bladder. This
sequence is repeated until the
bladder is empty or the child is
unable to void any more. Over
time, the child becomes increasingly aware of the difference
between poor bladder emptying
and an empty bladder.
An initial biofeedback session lasts approximately 90 minutes and a followup session lasts
60 minutes, depending on how
well the child grasps the concept
and practices at home. Three sessions, 4 to 6 weeks apart, is a
usual starting point; however,
timing of sessions is not welldocumented in the literature.
Other treatment plans include
biweekly sessions or biofeedback
until detrusor-sphincter dyssynergia is resolved (Porena et al.,
2000). Timing between sessions
essentially depends on progress
and retention of concepts taught
previously.
It is generally accepted that
biofeedback is the treatment of
choice for children with dysfunctional voiding in the form of staccato (fail to empty or store urine)
or fractionated (further hyperactivity of the pelvic floor which
stops flow with voiding occurring
in
several
portions)
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Pediatric urologic nurses must be aware of the
back, have facilitated the diagnosis and management of
detrusor-sphincter dyssynerincontinence beyond the typical age of toilet training. gia, which has been identified
as a major cause of voiding
(Schulman, Von Zuben,
dysfunction, establishing and
disturbance in children who are
Plachter, & Kodman-Jones, 2001).
maintaining good bladder habits
uro-anatomically and neurologiTo date, however, there has been
takes a lot of work. A lot of
cally normal (Porena et al., 2000).
no agreement as to the optimal
“homework” is given outside of
The etiology of dysfunctional
form of biofeedback. Some
clinic. This includes comprehenvoiding is controversial. The clinibiofeedback programs attempt to
sive voiding and stooling diaries
cal presentation varies and the
funnel the attention of children
to track voiding habits and acciprecipitating event in autonomic
through intensive inpatient prodents. Maintaining the child’s
somatic dyssynergia usually regrams (McKenna et al., 1999). At
motivation to work vigilantly on
mains obscure. Jayanthi, Khoury,
The Children’s Hospital of
developing healthy voiding skills
and McLorie (1997) suggested that
Philadelphia (CHOP), the current
and to adhere to the treatment
there may be a subgroup of chiloutpatient biofeedback program
recommendations over time is a
dren in whom voiding dysfuncfocuses on what is interpreted as
big challenge. For many chiltion is congenital rather than
the underlying pathologic condidren, a reward system is needed
acquired. This hypothesis is diffition.
to help them focus on establishcult to confirm. Some authors
The key to successful
ing bladder routines. Behavior
have suggested that the beneficial
biofeedback is both patient and
therapy interventions such as
results of biofeedback may be due
parent participation and motivamodeling healthy urinary habits
to intensive one-on-one education
tion. Computer games in biofeedare often needed to alter malrather than physiologic changes
back serve as a mechanism to
adaptive child behaviors that
induced by biofeedback (Wein,
engage the child and maintain
interfere with treatment progress.
1982). Hence, further study is
interest in the program. It is a
Success can only be achieved if
needed.
reproducible technique and is
the child is an active participant
Cost Effectiveness
advocated by others (Pfister et al.,
in treatment and if the child
1999). The games provide visual
believes there are benefits to
Urinary incontinence and
biofeedback as well as positive
obtaining proper voiding habits.
voiding dysfunction are common
reinforcement. Game action is
Pediatric urologic nurses
problems, estimated to affect 13
controlled by patient pelvic floor
must be aware of the significant
million adults and children in
muscle activity.
psychosocial impact of urinary
the United States, and to account
incontinence beyond the typical
for costs exceeding $15 billion
Outcomes
age of toilet training. School,
per year (Fantl et al., 1996). It is
peer, and family relationships are
In biofeedback therapy, chilassociated with a high burden of
often affected, and can result in
dren learn during voiding to susillnesses, high costs, and subdamage to the child’s developing
tain concentration and maintain
stantial negative effect on quality
self-esteem. Problems related to
a relaxed pelvic floor and volunof life. Many medical and psyself-esteem may require additary urethral sphincter (Porena et
chological insurance plans now
tional referrals to appropriate
al., 2000). The accurate monitorcover biofeedback for various
health care providers as needed.
ing of this physiological response
conditions. Some require co-payPediatric nurses are in key posiby electromyography and the
ments. Other plans have annual
tions to identify children with
immediate recognition by feedcaps. A prescription for the trainvoiding problems. Once the
back of the changes provide the
ing, along with a diagnosis, may
problem has been acknowledged,
basis for therapeutic retraining.
be required from a provider
nurses can assess the problem
Outcome variables include
under the medical part of the
and its impact on the family;
improved urinary continence,
plan. Intangible benefits from
educate parents, children, and
fewer urinary tract infections,
biofeedback therapy include
others regarding causes; discuss
and less vesicoureteral reflux.
increased patient satisfaction and
management options; and refer
Improvement with continence
better
patient
compliance.
children for medical intervention
may lead to improved selfAlthough not stated in the literawhen necessary.
esteem for the child as an added
ture, one can imagine how
outcome.
biofeedback therapy can provide
Research Implications
a number of benefits that can be
Nursing Implications
Noninvasive
urodynamic
measured and put into dollar
For children with voiding
techniques, including biofeedterms. These include reduced
significant psychosocial impact of urinary
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Table 1.
CPT Codes for
Reimbursement
•
•
•
•
Biofeedback therapy – 90911
Complex uroflow – 51741
Pelvic floor EMG – 51784
Bladder scan residual – 51798
incidence of urinary tract infections and vesicoureteral reflux,
fewer visits to the physician,
fewer hospitalizations, and decreased use of medications. By
treating the underlying cause,
costs are greatly reduced, patients
are less burdened, and families
can enjoy a better quality of life.
Reimbursement for the evaluation and treatment of patients
with voiding dysfunction varies
from practice to practice, but
most often involves a combination of the different codes (see
Table 1). The initial evaluation
involves a consultation code,
usual detail (99253) or comprehensive (99254) level. If screening radiologic studies are performed, this is usually done
through the radiology office and
there is usually not a billable service for the urologist involved in
that evaluation. If the patient proceeds with further noninvasive
urodynamic studies, he or she
would receive a simultaneous
uroflow study, an EMG, and
bladder ultrasound for PVR
(codes 51741, 51784, 51798). The
patient who proceeds with
biofeedback treatment would be
coded as 90911 for each session.
Most patients are re-evaluated at
the end of the biofeedback sessions by repeating the simultaneous urine flow, EMG, and PVR to
be certain the treatment did not
result in increased hyperactivity
of the pelvic floor, and to be certain that the flow pattern and
EMG pattern are in line with the
patient improvement.
Conclusion
Biofeedback can be a suc-
210
cessful modality for dysfunctional voiding in children associated
with recurrent urinary incontinence, urinary tract infections,
and vesicoureteral reflux. Many
treatment programs typically utilize formal urodynamic studies
to develop an inpatient treatment
program. At CHOP, however, the
initial evaluation and treatment
of children with voiding dysfunction is on an outpatient
basis, focusing on correcting
pelvic floor voiding immaturity.
Although this approach is
time consuming and labor intensive for the patient and the nurse
practitioner, the advantages are
that it is noninvasive and makes
the patient more responsible and
less passive regarding the condition. It provides positive results in
most patients in a short duration
of time. Biofeedback can be readily performed using the resources
available in most pediatric urology practices on an outpatient
basis. Given the excellent results
in the CHOP outpatient clinic,
this strategy is recommended as
adjunctive therapy in pediatric
patients recalcitrant to standard
behavior modification. •
References
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Cardozo, L., Stanton, S., & Hafner, J.
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