Urodynamic biofeedback treatment of urinary incontinence in children with myelomeningocele

Eight children with myelomeningocele and chronic neurogenic urinary incontinence were provided urodynamic biofeedback training. During urodynamic biofeedback, six of the eight children demonstrated improved self-regulation of detrusor and/or sphincter functioning. However, substantial improvements in clinical symptomatology (i.e., urinary incontinence) were clearly shown by only one child. Unexpectedly, chronic neurogenic fecal incontinence was reduced in four children. Several methodological modifications are discussed which may improve clinical symptomatology and which may facilitate further urodynamic biofeedback research for these children with congenital neurogenic urinary incontinence.     

Ethical and practice considerations for biofeedback therapists in the treatment of urinary incontinence

The treatment of incontinence presents many unique issues for biofeedback therapists that are routine for professionals in fields such as nursing or medicine. Although, all professional practice is guided by ethical standards, the unique circumstances encountered during biofeedback treatments for this disorder warrant the development of specific guidelines. This is true whether insertable or surface EMG devices are used. Therefore, the purpose of this article is to propose a set of ethical guidelines for biofeedback therapists. The intended audience includes professionals such as psychologists, clinical psychophysiologists, and other mental health-care providers who use biofeedback techniques. These are not formally endorsed by any professional organizations (e.g., APA, AAPB) at this time. Ethical considerations include proper medical evaluation, informed consent, patient instruction, disrobing, nonerotic physical contact, patient safety, and patient satisfaction.     

A components analysis of biofeedback in the treatment of fecal incontinence

Fecal incontinence is a socially disabling symptom for which rectosphincteric biofeedback has been reported to be dramatically effective. The most commonly employed biofeedback procedure incorporates three separate and potentially effective components: (1) exercise of the external sphincter muscle, (2) training in discrimination of rectal sensations, and (3) training synchrony of the internal and external sphincter responses. This paper reports the results of single case experiments employed with eight incontinent patients to examine the contributions of each of these components. All eight patients improved, but only one required the biofeedback procedure as it was originally described. Three responded to sensory discrimination training, one to exercise training, and one to the training of synchronous sphincteric responses; three recovered independently of the effects of biofeedback. Despite the achievement of continence, the rectosphincteric reflexes following treatment continued to be abnormal in every case. These findings suggest that the character of the external sphincter response to rectal distension is an unreliable index of sphincter function and that exercise and sensory discrimination training procedures are effective for some cases of fecal incontinence.The work described in this paper was supported by Grant No. MA 6241 from the Medical Research Council of Canada.     

Future trends in the treatment of urinary incontinence

Anticholinergic drugs act on efferent nerves to counteract overactive bladder (OAB) after it occurs. To prevent the occurrence of OAB, therapies should be directed at blocking the afferent nerves that control the bladder. Tachykinin-receptor antagonists hold great promise in this regard, since they can be administered orally and do not increase the risk of urinary retention that occurs with anticholinergics. Advanced drug delivery systems, such as controlled-release oral oxybutynin (oxybutynin-XL) can reduce the incidence of anticholinergic side effects. In a similar manner intravesical therapy for OAB is site specific, and thus also reduces the occurrence of adverse events. Moreover, the difficulties of intravesical therapy may now be overcome with advanced delivery techniques such as an implantable, long-acting drug-delivery pump. Another intravesical therapy that has met with great acceptance and success is the administration of chili pepper extracts, especially resiniferitoxin, which may be effective for up to 3 months with one application. Finally, gene therapy holds great promise for OAB, because it is possible to access all of the genitourinary organs via endoscopy and other minimally invasive techniques that are ideally suited for gene therapy.     

Potential targets in the treatment of urinary incontinence

Urgency and involuntary urine loss are distressing problems for both men and women. Attempts to block the primary cholinergic excitatory input to the bladder have led to a number of anticholinergic agents, but treatment with anticholinergics, the current first-line therapy, is not always effective. Metabolic and growth factor receptor targets are being investigated as a way to control the signal transduction process that leads to bladder contraction as well as the release of calcium that triggers this process. Because of the redundancy in mechanisms that promote bladder contraction, it is necessary to investigate multiple targets. Medical research is also focusing on purinergic receptors, the targeting of normally silent C-fibers that become activated due to neuroplasticity in the bladder, nerve-growth-factor blockade, and the blockade of neurotransmitters that control the bladder. Moreover, a strong correlation appears to exist between depression and the occurrence of incontinence, and there is evidence that points to a genetic link. However, the problem, with attacking this multiplicity of sites lies in establishing therapeutic efficacy and a high degree of specificity.     

Biofeedback in treatment of urinary incontinence in stroke patients

Urinary incontinence can occur poststroke owing to weakness or incoordination of sphincter muscles, impaired bladder sensation, or hyperreflexic, neurogenic bladder. Four male subjects who had urinary incontinence associated with a stroke that had occurred 8 months to 10 years earlier, and who averaged 1.6 to 7.5 accidental voidings per week, participated in an outpatient study with a 4-week scheduled-voiding baseline, 2 to 5 sessions of biofeedback-assisted bladder retraining, and 6- to 12-month follow-up. Training sessions included stepwise filling of the bladder and manometric feedback display of bladder pressure, abdominal pressure, and external anal sphincter pressure. Training procedures were designed to teach subjects to attend to bladder sensations, inhibit bladder contractions, and improve voluntary sphincter muscle control. All four subjects achieved and maintained continence regardless of substantial differences in subject characteristics, including laterality of stroke, degree of sensory impairment, and independence in daily activities.     

Bowel function in Danish children with myelomeningocele

Spinal cord lesions affect colorectal motility, anorectal sensation and anal sphincter function. The aim of this study was to describe bowel habits in children with Myelomeningocele (MMC). Questionnaires describing age, gender, neurological deficit, bowel function and the Child Behaviour Checklist were send to all Danish children with MMC aged 2-18 years. Among 208 patients, 125 (60%; 63 girls) responded. Defecation was described as abnormal in 85 (68%). Digital stimulation or evacuation were used by 25 (20%), suppositories by 13 (10%) and enemas 35 by (28%). Time spent at each defecation was > 30 minutes in 29 (24%). Among children aged four years or more (n = 100), daily faecal incontinence was reported by 14 (14%) and weekly incontinence by another 14 (14%). Bowel dysfunction had some or major impact on social activities or quality of life in 48 (40%). Time spent on defecation increased and the impact on quality of life became more severe with advancing age. Information about bowel management had been given to 56% of parents and 9% of children. In conclusion colorectal problems are common in children with MMC and their impact of quality of life becomes more severe as the children grow older. There is an unfullfilled need for information about bowel management.     

Biofeedback in treatment of urinary incontinence in stroke patients

Urinary incontinence can occur poststroke owing to weakness or incoordination of sphincter muscles, impaired bladder sensation, or hyperreflexic, neurogenic bladder. Four male subjects who had urinary incontinence associated with a stroke that had occurred 8 months to 10 years earlier, and who averaged 1.6 to 7.5 accidental voidings per week, participated in an outpatient study with a 4-week scheduled-voiding baseline, 2 to 5 sessions of biofeedback-assisted bladder retraining, and 6- to 12-month follow-up. Training sessions included stepwise filling of the bladder and manometric feedback display of bladder pressure, abdominal pressure, and external anal sphincter pressure. Training procedures were designed to teach subjects to attend to bladder sensations, inhibit bladder contractions, and improve voluntary sphincter muscle control. All four subjects achieved and maintained continence regardless of substantial differences in subject characteristics, including laterality of stroke, degree of sensory impairment, and independence in daily activities.     

Behavioural treatment of urinary incontinence in geriatric patients.

Urinary incontinence and a program to treat it were studied in a geriatric hospital. Of 161 men, 58 (36%) were incontinent. The most common probable causes were cerebrovascular accident and organic brain syndrome. Evaluation by cystometry (after treatment of infections) in 30 patients showed 24 (80%) to have detrusor hyperreflexia. Twenty patients with hyperreflexia completed a timed-voiding routine, which benefited 17 of them (85%).     

Medical and minimally invasive treatment of urinary incontinence

Newer agents and procedures give urologists more options in treating patients who have urinary incontinence related to such etiologies as an ineffective sphincter, detrusor hypersensitivity, obstruction, or a combination of these. Abolition of the involuntary contractions characteristic of detrusor instability can be accomplished pharmacologically or surgically. First-line anticholinergic agents are tolterodine and oxybutynin XL, given orally. Alternatively, intravesical administration provides a high concentration of drug, such as capsaicin or resiniferatoxin, at the detrusor muscle level. However, this commits the patient to intermittent self-catheterization. Surgery is reserved for those who have failed prolonged trials of conservative therapies. For patients with intractable urge incontinence, urologists have the new technique of sacral nerve stimulation.     

Adipose-derived stromal cell transplantation for treatment of stress urinary incontinence

We aimed to investigate the application of adipose-derived stromal cells in the treatment of stress urinary incontinence (SUI). Animal models of stress urinary incontinence were established with Sprague-Dawley female rats by complete cutting of the pudendal nerve. Rat adipose-derived stromal cells were isolated, cultured and successfully transplanted into animal models. Effects of stem cell transplantation were evaluated through urodynamic testing and morphologic changes of the urethra and surrounding tissues before and after transplantation. Main urodynamic outcome measures were measured. Intra-bladder pressure and leak point pressure were measured during filling phase. Morphologic examinations were performed. Transplantation of adipose-derived stem cells significantly strengthened local urethral muscle layers and significantly improved the morphology and function of sphincters. Urodynamic testing showed significant improvements in maximum bladder capacity, abdominal leak point pressure, maximum urethral closure pressure, and functional urethral length. Morphologic changes and significant improvement in urination control were consistent over time. It was concluded that periurethral injection of adipose-derived stromal cells improves function of the striated urethral sphincter, resulting in therapeutic effects on SUI. Reconstruction of the pelvic floor through transplantation of adipose-derived cells is a minimally invasive and effective treatment for SUI.     

Treatment of stress urinary incontinence with duloxetine hydrochloride

Currently, there are no approved medications for the treatment of stress urinary incontinence (SUI) in the United States. The effectiveness of duloxetine in the treatment of SUI is linked to its inhibition of presynaptic neuronal reuptake of serotonin and norepinephrine in the central nervous system, resulting in elevated levels of serotonin and norepinephrine in the synaptic cleft. In animal studies, this agent leads to an increase in nerve stimulation to the urethral striated sphincter muscle. A similar mechanism in women is believed to result in stronger urethral contractions, with improved sphincter tone during urine storage and physical stress. In 3 randomized, placebo-controlled clinical trials, patients receiving duloxetine had a statistically significant and clinically relevant reduction in the number of incontinence episodes and a corresponding improvement in quality of life. If this use of duloxetine is approved by the U.S. Food and Drug Administration, as it has been by the European regulatory agencies, it will be the first drug indicated for the treatment of SUI. This pharmacologic therapy is an additional option for women and is likely to become an integral component of patient management.