Myomed932 the Role

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The Role of Pelvic-Floor Therapy in the Treatment ofLower Urinary Tract Dysfunctions in ChildrenH. De Paepe,1,2C. Renson,1 P. Hoebeke,1 A. Raes,1 E. Van Laecke1 and J. Vande Walle1

From the1

Paediatric Uro-Nephrologic Centre, and2

Department of Rehabilitation Sciences and Physical Therapy, GhentsUniversity 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 pathophysiology of lower urinary tract (LUT)dysfunctions in children, especially of non-neuropathic bladder sphincter dysfunction. The following therapeutic measurescan be applied to try to inuence 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 acurve on a display (relaxation biofeedback), observation of the ow curve during voiding (uroow biofeedback), learning ofan adequate toilet posture in order to reach an optimal relaxation of the pelvic-oor, an individually adapted voiding anddrinking schedule to teach the child to deal consciously with the bladder and its function and a number of simple rules forapplication at home to increase the involvement and motivation of the child. In children however with persisting idiopathicdetrusor instability additional therapeutic measures may be necessary to improve present urologic symptoms (incontinenceproblems, frequency, urge) and to increase bladder capacity. Intravesical biofeedback has been used to stretch the bladder andseems to be useful in case of sensory urge. Recently a less invasive technique, called transcutaneous electrical nervestimulation (TENS), has been applied on level of S3 with promising results in children with urodynamicaly proven detrusorinstability, 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: [email protected])

The pelvic-oor is under voluntary control and plays an

important role in the pathophysiology of lower urinary

tract (LUT) dysfunctions in children, especially of non-

neuropathic bladder sphincter dysfunction. Although

non-neuropathic detrusor sphincter dysfunction as acause 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 dened 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 dysfunctionof 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 dysfunc-

tion.

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 recur-

rent urinary tract infections (511). Dysfunctional

voiding can be the consequence of overtraining of the

pelvic-oor resulting from excessive squeezing of theurethral 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 reux, bothFig. 1. Pathophysiolog y of dysfunctiona l voiding.

2002 Taylor & Francis. ISSN 00365599 Scand J Urol Nephrol 36

ORIGINAL ARTICLE


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being causative factors for recurrent urine tract infec-tions (UTI) (5). As the pelvic-oor is overtrained,

relaxation during voiding is more difcult which is

dysfunctional voiding. This dysfunctional voiding inturn can maintain bladder instability (14, 12). This

detrusor-sphincter dyscoordination can lead to disrup-

tion 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 incon-

tinence 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 voidingdysfunction 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 thepelvic-oor muscles. This high tone results in dysfunc-

tional voiding and incomplete emptying of the bowel,

leading to obstipation and soiling (17, 18). Recently the

term dysfunctional elimination syndrome was intro-

duced 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 inuence the activity of the pelvic-oor during

voiding: proprioceptive exercises of the pelvic-oor

(manual testing), visualization of the electromyo-

graphic registration of relaxation and contraction of

the pelvic-oor by a curve on a display (relaxation

biofeedback), observation of the ow curve during

voiding (uroow biofeedback), learning of an adequate

toilet posture in order to reach an optimal relaxation of

the pelvic-oor, an individually adapted voiding anddrinking 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 ofdry/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/

Fig. 2. Pathophysiology of dysfunctional voiding associated withurinary tract infections.

Fig. 3. Voiding and drinking chart.

Scand J Urol Nephrol 36

Pelvic-floor therapy for lower urinary tract dysfunctions 261


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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 timethe 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. Thechild is placed in the lateral recumbent position with

the top leg bent forward and the bottom leg stretched

backward. The therapist places two ngers crosswiseon 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, thatis 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 pelvic-

oor strength is evaluated using the standards

described in the Oxford Scale by Zinovieff (25).

The Oxford scale is adapted for children as vaginalexamination 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 displacement3= 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 difculties in children using thisevaluation 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

the strength felt during contraction. Such a child has

rst to learn to release the pelvic-oor muscles in order

to achieve a sufcient 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 cannotreach 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 tiltedslightly 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 avoidedbecause they create a squatting position, which

stimulates straining during voiding. On a normal toilet

a toilet reducer and a small bench or support under thefeet 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 ofthe 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 anumber 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 Nether-

lands) 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


262 H. De Paepe et al.


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bad if the tension remains high throughout the whole

session.

Uroometry and uroow biofeedback

At the end of each biofeedback session, the urine ow

is measured. After the child has urinated, it predicts theform of the curve and the amount of urine. This

prediction is then tested against the real curve, whichagain 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 uroowmetry.

Uroow 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 tomake 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 toremedy 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 arestill dry. If they are wet I have to change them.

At each meal, I drink 2 glasses, and 1 glass inbetween.

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

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 pharmalogica l 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 en-

copresis, based on chronic obstipation, receive desim-

paction 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. Anti-

cholinergics are continued at a lower dose for 3 months

after the end of the therapy.

Therapy is considered successful when the ow-curve 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 (reux,

perineal pain, vaginal irritation, pelvic-oor spasm)

and encopresis is also considered (12, 17, 30).

ROLE OF PELVIC-FLOOR THERAPY IN THETREATMENT OF DETRUSOR INSTABILITY

In children however with persisting idiopatic detrusorinstability additional therapeutic measures may be

necessary to improve present urologic symptoms

(incontinence problems, frequency, urge) and to

increase bladder capacity. Intravesical biofeedbackhas 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 sti-

mulation (TENS), has been applied on level of S3 withpromising 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, thechild is encouraged to suppress the unstable contrac-

tions 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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Intravesical biofeedback is successful if the bladder

capacity is increased during lling and sufcientbladder 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 elec-trical nerve stimulation (TENS) on level of S3 in order

to inuence 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

previous therapies have failed such as medication,

pelvic-oor therapy, wetting alarm, voiding school.

Following exclusion criteria are preset:

anatomical deformity, bladder outow 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 severedetrusor instability the use of transcutaneous electrical

nerve stimulation (TENS) produces changes in pre-

senting urological symptoms, further systematic

evaluation to establish optimal electrical parameters

is required.

Fig. 4. Device for intravesical biofeedback .

Fig. 5. Device for neurostimulation .




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ROLE OF PELVIC-FLOOR THERAPY IN

DISTURBED BLADDER SENSIBILITY

However, theoretically a child is able to maintain

continence, wetting problems may persist caused by

insufcient 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 measure-

ments 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 strainingis 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. Thistraining 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 ofdifculty to ll out a voiding and drinking schedule.

ROLE OF PELVIC-FLOOR THERAPY IN THETREATMENT OF NOCTURNAL ENURESIS

Though wetting problems during day are treated,

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 assoon 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 pelvic-

oor to the exercises before bedtime and during the

rst night in order to improve the manoeuvre ofholding 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 moti-

vators are given to the child if he has accomplishedthe 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 onalarm caused by loss of urine; stage 2 (not

necessary): to weak up before alarm in case of afull 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 weeksusing 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 BIOFEEDBACKTHERAPY

As dyscoordination between detrusor and sphincter

during voiding is an important pathological event in the

development of functional voiding disorders in chil-

dren, 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 weapply pelvic-oor therapy in children with functional

voiding disorders with good results.

Treatment of daytime incontinence

The proposed therapy, with biofeedback as corner-




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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 periodof 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 resolu-tion of low-grade vesico-ureteric reux after this

training suggested the association of voiding dysfunc-

tion and vesico-ureteric reux.

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 groupwithout

biofeedback training a good result was also obtained.The proposed measurements (correction of toilet pos-

ture and keeping a voiding and drinking schedule) were

useful to normalise a dysfunctional voiding and bowel

pattern. These measurements should be considered asessential elements of proper toilet training in the young

child in order to prevent further pathological evolution

of a possible present dysfunction.

THERAPEUTIC RESULTS OFTRANSCUTANEOUS 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 chil-

dren 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

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 anevaluation every 2 months. Forty-one children were

considered to be a responder after 1 month, 10 childrendid 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

signicant volume increase, 23/33 had a decrease ofurge, 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 bladderemptying. To remedy the disturbance in bladder

emptying correction of toilet posture, relaxation

biofeedback and biofeedback uroowmetry are ap-

plied. Useful therapeutic tools in case of disturbance in

bladder lling are intravesical biofeedback (monother-

Fig. 6. Therapeutic measurements in the treatment of lower urinarytract dysfunctions .




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apy or combined with medication) and TENS (mono-

therapy 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 nocturnalenuresis (or isolated nocturnal enuresis) is treated by a

wetting alarm during night.An individual combination of therapeutic measure-

ments has to be selected to solve a particular voiding

problem in children with non-neuropathic bladder

sphincter dysfunction (NNBSD) (Fig. 6).

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