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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.
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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
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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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