Half-Day Urotherapy Improves Voiding Parameters in Children with Dysfunctional Emptying

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european urology 49 (2006) 570 574 available at www.sciencedirect.com journal homepage: www.europeanurology.

1 european urology 49 (2006) available at journal homepage: Pediatric Urology Half-Day Urotherapy Improves Voiding Parameters in Children with Dysfunctional Emptying Wendy F. Bower *, S.Y. Yew, K.Y.F. Sit, C.K. Yeung Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR China Article info Article history: Accepted December 5, 2005 Published online ahead of print on January 4, 2006 Keywords: Dysfunctional voiding Pelvic floor muscle relaxation training Urotherapy Abstract Objectives: Children with voiding dysfunction benefit from intensive bladder emptying re-education; however, hospitalization for such training is not always financially viable or realistic. The aim of this study was to evaluate whether half-day voiding re-education in pairs improved immediate and mid-term voiding parameters. Methods: 48 children (mean age, 8.9 years; 54% male) identified in the urotherapy clinic as having either (1) abnormal uroflow curves, (2) a postvoid residual urine (PVRU) > 10% of voided volume, or (3) proven dysfunctional voiding, were recruited and age- and gender-matched. Training over a half day included postural instruction, abdominal wall muscle pattern recognition, pelvic floor muscle relaxation training, and supervised voiding. Data from the initial clinic visit was compared to that after training, and at 1 and 3 mo follow-up. Families completed a questionnaire after the session. Results: Urine flow curves were abnormal in 76.2% of initial clinic visit voids, 14% of patients after the half-day training session, and 11.7% of children at the 3-mo follow-up. Initial emptying efficiency (voided volume as a percentage of total bladder volume for that void) and mean PVR significantly improved following half-day training with gains maintained at both follow-up visits. Conclusion: Training children in pairs over a half day resulted in significantly improved bladder emptying that was sustained at the 3-mo follow-up. # 2005 Elsevier B.V. All rights reserved. * Corresponding author. Tel address: wendyb@surgery.cuhk.edu.hk (W.F. Bower) /$ see front matter # 2005 Elsevier B.V. All rights reserved. doi: /j.eururo

2 european urology 49 (2006) Introduction Bladder rehabilitation is effective in the management of abnormal micturition that cannot be attributed to structural causes [1 3]. Children who present with poor emptying parameters often also display bladder overactivity, pelvic floor muscle nonrelaxation, incontinence of urine, bowel dysfunction, and urinary tract infections [4]. Evaluating and managing each of these symptoms thoroughly requires repeated clinic visits and large investments of time. Some services offer in-patient or residential programs to allow adequate instruction in aspects of bladder and bowel training and supervised practice of pelvic floor recruitment and relaxation. Children can then be evaluated while applying the new skills to voiding and learning thus reinforced or corrected. Where this intensive approach to training is not financially viable or compatible with educational requirements, and single clinic visits preclude adequate rehearsal of strategies, a different treatment approach is needed. The aim of this study, therefore, was to make a preliminary evaluation of the efficacy of half-day voiding re-education in changing micturition parameters. A secondary aim was to train children in pairs and to appraise their response to this method. 2. Methods Subjects were recruited from consecutive children between the ages of 4 and 13 yr who had been screened in the pediatric urology clinic, undergone urodynamic investigation with simultaneous perineal electromyography (EMG), and subsequently were referred for urotherapy. Inclusion criteria were abnormal uroflow curve shapes, a postvoid residual urine (PVRU) > 10% of voided volume, or urodynamically proven dysfunctional voiding (ie, either positive EMG activity from perineal electrodes during micturition or recruitment of the abdominal muscles before or during voiding attempts). Neurogenic or structural origin of symptoms excluded participation. A clinical diagnosis of daytime problems only, nocturnal enuresis, or day and night symptoms was present in 13%, 45.7%, and 32.6% of patients, respectively. Urodynamic findings confirmed an overactive bladder (OAB) in 43 of 48 children, terminal only in 24% and phasic in the remaining children, as per the definitions of de Grier and Feitz [5]. Thirty-nine percent of the children were not taking any medication at the time of half-day voiding re-education. Twenty-four subjects were taking antimuscarinic medication in combination with another drug, most commonly antidiuretic hormone. All children were free of urinary tract infection at the time of therapy. After an initial individual clinic visit subjects were age- and gender-matched and scheduled to attend a half-day voiding re-education session in pairs. On this occasion bladder function was reviewed, the aims of the session discussed, and toileting strategies and optimal posture introduced. A mirror was used to instruct the children in abdominal muscle relaxation (rectus and transverse abdominus) and recognition of end expiration. While in pairs an EMG machine reading from the forearm muscles was demonstrated. Each child was then privately instructed in pelvic floor proprioception and practiced recruitment and relaxation with feedback from either perineal surface or anal plug EMG electrodes. Subjects voided at urge over the real-time uroflowmeter with simultaneous pelvic EMG, and a bladder ultrasound was taken immediately afterward. Children discussed the flow pattern and voiding EMG activity with each other and the clinician. At least three voiding efforts were obtained from each child. Care was taken to prevent competitiveness between children. Voiding parameters of flow rates (maximum and average), flow duration, flow shape, postvoid residual (PVR) volume and emptying efficiency (volume voided divided by sum of PVRU plus voided volume) were obtained at the initial clinic visit, the completion of the half-day session, and at follow-up 1 and 3 mo later. After the session, families completed a questionnaire about the training process; this was not a symptom evaluation nor an outcome measure. Data were entered into the statistical program SPSS and differences analyzed using two-tailed t tests with a significance level of p < Results Data sets were obtained from 48 children (54% male) who ranged in age from 4 to 13 yr (mean age, 8.7 yr; SD, 2.07). The two diagnostic groups did not differ significantly in initial volume of PVRU, bladder emptying efficiency, or flow rates. Bladder emptying, as evidenced by PVR volume of urine and emptying efficiency, improved significantly following half-day training and was maintained at follow-up (Table 1). Initial PVRU volume correlated significantly with the presence of OAB ( p = 0.037), with children demonstrating no proven OAB having a mean of 19 ml PVRU and those with moderate or severe OAB evidencing a mean of 56 and 50 ml PVRU, respectively. Table 2 summarizes the voiding flow curve shapes at each of the time points. It can be seen that the proportion of bell-shaped curves increased following training and improvement was sustained at both 1 and 3 mo of follow-up. Table 1 Bladder emptying and comparison with initial clinic visit Mean PVR volume (ml) Mean emptying efficiency (%) 1st clinic visit End of 1/2 day 23.2 p < p < mo follow-up 27.5 p < p < mo follow-up 20.7 p < p < 0.001

3 572 european urology 49 (2006) Table 2 Uroflow curve shapes Bell shape (%) Staccato (%) Intermittent (%) Prolonged (%) 1st clinic visit End of 1/2 day mo follow-up /12-mo follow-up A strong significant correlation was found between initial emptying efficiency and voiding curve shape in children with positive pelvic floor EMG activity during urodynamic voiding (r = 0.50, p = 0.002). No such correlation was observed in children with pelvic floor quiescence during voiding ( p = 0.415). Subgroup analysis by presence or absence of abdominal activity preceding or during the void did not reveal any correlation with emptying efficiency or voiding parameters. Overall maximum flow rates increased significantly after the half-day re-education session ( p < 0.001) and remained higher at the 3-mo follow-up ( p < 0.005). When flow rates were analyzed with respect to voiding shapes, only obstructive flow patterns showed no improvement in flow rate. One-way ANOVA for initial emptying efficiency revealed the bell-shaped or staccato voiding shape to be significantly associated with better bladder emptying ( p = 0.049). Logistic regression for emptying efficiency failed to retain any of the tested variables. Analysis of the training process questionnaire showed 60% of children were initially nervous about attending the training session; in half the cases this related to apprehension about the other child who would also be present. However, throughout the free comments section all children stated their pleasure at meeting a new friend with a similar problem and having a partner to train alongside and also to play with during bladder filling. The EMG biofeedback was reported to be helpful in identifying pelvic floor muscle location and proprioception by 94% of subjects and the uroflow trace by 93%. All children stated increased confidence in voiding optimally following the half-day visit. 4. Discussion The learning of a new skill requires practice and correction and repeated performance of the optimal maneuver [6]. Thus, the ability to gather children with a voiding dysfunction into a residential setting and focus on their bladder for several days in succession offers the opportunity to train and supervise voiding mechanics without distraction. Not all health care systems prioritize bladder disorders highly enough to allocate hospital beds to affected children over several days, or alternatively, schools may not permit children to miss consecutive days of learning. Busy clinics preclude spending long periods of time with individual children and often fragment retraining opportunities. Hence, there is a need to identify a cost- and time-efficient approach to voiding re-education that allows intensive training and inspection of micturition techniques over time. The micturition parameters of bladder emptying efficiency and volume of retained PVRU are key indicators of bladder emptying dysfunction [7]. This study has shown conclusively that voiding mechanics in children with functional emptying problems can be significantly improved and maintained for at least 3 mo with a single half-day intensive training approach. These findings agree with those of Nelson et al. [8] who reported changes in maximum flow rate and reduction in PVR following a series of 2-h biofeedback sessions. A finding of 31% abnormal flow curve after serial biofeedback in that study was well matched by the drop to 12% of abnormal voids noted in this study at 3 mo of followup. Therapy was conducted in pairs and may confer a health care cost bonus; it was perceived as a positive experience by affected children. This study was not a one-shot treatment intervention nor an evaluation of the treatment effect on urinary incontinence. It is acknowledged that comprehensive management of the child with voiding dysfunction requires a multimodal multidisciplinary approach and that improvement of voiding parameters per se do not always correlate with resolution of incontinence [8]. Instead this study investigated a concentrated learning and rehearsal opportunity designed to integrate advice given at routine clinic visits. Unbalanced recruitment-relaxation of the pelvic floor muscles, such as may occur during voiding in children with emptying dysfunction, is known to be associated with conversion of specific muscle fiber types and changes in fiber diameter and concentration. Loss of endurance ability has also been observed, along with poor awareness and control difficulties.

4 european urology 49 (2006) Studies using ultrasound have established that neither children [9] nor adults [10] with bladder control problems can correctly identify pelvic floor muscle activity or reliably recruit or relax the muscle group on command. Because inappropriate levator ani and external sphincter activity is observed during functional voiding disorders, any rehabilitation of micturition must first establish pelvic floor awareness, proprioception, and selective increase or decrease of levator activity. Clinicians need to spend time identifying the pelvic floor with children, either by palpation or by visually displaying its activity with technology such as EMG or transabdominal or perineal ultrasound. Learning the skill of pelvic floor muscle relaxation, free from increased intra-abdominal pressure and gluteal and adductor work, requires practice. Specificity of function necessitates that skills then be rehearsed until correct in the voiding position and during micturition. A comprehensive voiding re-education approach requires training during at least three voids. It would also seem likely that reversal of fundamental changes to muscle physiology will not occur with one-shot education, but requires at least 8 wk of corrected practice. The children in this study were reviewed at regular 1-mo intervals and the functional task of voiding re-evaluated after an interval suitable for skeletal muscle remodeling to have occurred. There is a suggestion from the data that performance fell off between the half-day training and 1 mo follow-up but that after review further improvement was common. This accords with principles of motor control training and highlights the need for review of voiding re-education at intervals long enough to allow practice of new skills yet short enough to allow regular corrective feedback. One of the difficulties of using uroflow parameters as outcome measures is the subjective nature of curve classification and the known association with voided volume. In this study the uroflow curves were classified according to the International Children s Continence Society criteria of bell, staccato, intermittent, and prolonged patterns [11]. The voided volumes were at physiologic fullness following fluid loading and no child was asked to defer emptying when an obvious urge was present. In the future it may be interesting to document pelvic floor muscle activity parameters at each visit to understand the timeline of change in pelvic floor motor control and the relative importance of strength, endurance and coordination in rehabilitating children with dysfunctional voiding. An obvious limitation of this study is the cohort design. Because it appears that the half-day bladder rehabilitation approach integrated well into routine clinic reviews and allowed intensive voiding reeducation and regular feedback, a more comprehensive study is warranted. A randomized trial comparing a support group only, a half-day training group, and a standard clinic treatment group would perhaps highlight any advantage from the intensive program. Cost benefit should be evaluated in a future study, so as to establish whether short treatment confers a cost saving or not over routine extended therapy. 5. Conclusion Children in this study reported the experience to be positive. Given the observed significant improvement in posttreatment bladder emptying mechanics, half-day training for dysfunctional voiding has been incorporated into our regular practice. References [1] Hoebeke P, Walle van de J, Theunis M, Paepe de H, Oosterlinck W, Renson C. Outpatient pelvic-floor therapy in girls with daytime incontinence and dysfunctional voiding. Euro Urol 1996;48: [2] McKenna PH, Herndon CD, Cannery S, Ferrer FA. Pelvic floor muscle retraining for paediatric voiding dysfunction using interactive computer games. J Urol 1999;162: [3] Paepe de H, Renson C, Laecke van E, Raes A, Walle van de J, Hoebeke P. Pelvic floor therapy and toilet training in young children with dysfunctional voiding and obstipation. BJU Int 2000;85: [4] Nijman RJM, Butler R, Van Gool J, Yeung CK, Bower WF. Conservative management of urinary incontinence in children. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence: 2nd International Consultation on. Incontinence. Plymouth: Health Publications Ltd; 2002 [5] R De Grier RPE, Feitz WFJ. Urodynamics Proceedings of ESPU 4th course on paediatric urodynamics. Utrecht, The Netherlands; [6] Fox PW, Hershberger SL, Bouchard Jr TJ. Genetic and environmental contributions to the acquisition of a motor skill. Nature 1996;384: [7] Yeung CK. Pathophysiology of bladder dysfunction. In: Gearhart n, Mouriquand, editors. Paediatric Urology. Philadelphia: WB Saunders; 2001,, Chap. 29. [8] Nelson JD, Cooper CS, Boyt MA, Hawtrey CE, Austin JC. Improved uroflow parameters and post-void residual following biofeedback therapy in pediatric patients with dysfunctional voiding does not correspond to outcome. J Urol 2004;172(4 Pt 2):1653 6, discussion 1656.

5 574 european urology 49 (2006) [9] Ab E, Schoenmaker M, van Empelen R, Klijn AJ, de Jong TPVM. Paradoxical movement of the pelvic floor in dysfunctional voiding and the results of biofeedback. BJU Int 2002;89(suppl 2):48. [10] Thompson JA, O Sullivan PB. Levator plate movement during voluntary pelvic floor muscle contraction in subjects with incontinence and prolapse: a cross sectional study and review. Int Urogynae J 2001;12(suppl 3):61. [11] Norgaard JP, van Gool JD, Hjalmas K, Djurhuus JC, Hellstrom AL. Standardization and definitions in lower urinary tract dysfunction in children. International Children s Continence Society. Br J Urol 1998;82(suppl 3):1 16.

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