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Biofeedback therapy expedites the resolution of reflux in older children
Lane S Palmer1, Israel Franco, Paul Rotario
1Division of Pediatric Urology, Schneider Children's Hospital/Long Island Jewish Medical Center, New Hyde Park, NY, USA.
Insights
Biofeedback therapy effectively treats vesicoureteral reflux (VUR) in children with bladder dysfunction. This approach significantly improves VUR resolution rates and reduces urinary tract infections compared to historical data.
Area of Science:
- Pediatric Urology
- Urodynamics
- Pelvic Floor Rehabilitation
Background:
- Low-grade vesicoureteral reflux (VUR) in older children has a low spontaneous resolution rate.
- Management of VUR remains controversial, with options including surgery, prophylaxis, or observation.
- Bladder dysfunction, including detrusor-sphincter dyssynergia (DSD), plays a role in VUR etiology and persistence.
Purpose of the Study:
- To determine the impact of biofeedback therapy on neurologically intact children with VUR and DSD.
- To assess the efficacy of biofeedback in improving VUR resolution and reducing urinary symptoms.
Main Methods:
- Children with VUR and dysfunctional voiding underwent uroflowmetry with external sphincter electromyography to diagnose DSD.
- Biofeedback therapy was administered, aiming to eliminate DSD and reduce post-void residual urine.
- Voiding cystourethrography was performed after one year to evaluate VUR status.
Main Results:
- 55% of VUR units resolved, and 16% improved after biofeedback therapy in 25 children.
- Post-therapy, post-void residual urine decreased from 40% to 10%.
- Breakthrough infections were eliminated, and symptoms like urgency and wetting improved.
Conclusions:
- Biofeedback therapy offers a higher 1-year resolution rate for low-grade VUR with DSD than historical rates.
- Screening for DSD is recommended in children considered for surgery or chemoprophylaxis discontinuation.
- Biofeedback should be considered as a treatment option for VUR in children with DSD.
Purpose:
In older children the spontaneous resolution rate of low grade vesicoureteral reflux is low and currently its management is controversial in regard to surgery versus prophylaxis versus observation alone. Bladder dysfunction in children with neurogenic bladders and to a less declarative degree in neurologically intact children has a role in the etiology or persistence of reflux. We determine the impact of biofeedback therapy on neurologically intact children with vesicoureteral reflux and detrusor-sphincter dyssynergia.
Materials And Methods:
Vesicoureteral reflux was detected by voiding cystourethrography in children evaluated for urinary tract infections. Children with breakthrough infections or dysfunctional voiding based on history underwent uroflowmetry with concomitant patch electromyography of the external sphincter. Dyssynergia was defined as increased or steady electromyography activity during micturition. Biofeedback was initially performed weekly and the interval increased as indicated. The goals were to eliminate dyssynergia and reduce or eliminate post-void residual urine. Voiding cystourethrography was performed 1 year later to determine the status of the reflux. Ureteral reimplantation was performed during the period of biofeedback when indicated.
Results:
From February 1997 to March 2001, 25 children 6 to 10 years old (mean age 9) with vesicoureteral reflux and detrusor-sphincter dyssynergia were treated with biofeedback therapy. There were 31 units (5 bilateral) with reflux, which was grade I in 10, II in 15, III in 5 and IV in 1. Children underwent an average of 7 sessions of biofeedback (range 2 to 20). On followup voiding cystourethrography, vesicoureteral reflux resolved in 17 units (55%), grade improved in 5 (16%) and reflux remained unchanged in 9 (29%). All cured vesicoureteral reflux was grade I (8 cases) or II (9). Four children (5 renal units) underwent reimplantation. In cured children there were no breakthrough infections during or since therapy and post-void residual urine decreased from an average of 40% before to 10% after therapy. Symptoms of urgency, daytime wetting and hoarding of urine improved or were eliminated in all children with resolved vesicoureteral reflux.
Conclusions:
Treating external detrusor-sphincter dyssynergia in older children with low grade vesicoureteral reflux, with biofeedback results in 1-year resolution rates that are considerably greater than historical resolution rates. External detrusor-sphincter dyssynergia should be screened for in children when surgery or discontinuation of chemoprophylaxis is considered so that biofeedback can be started.