Journal of BehavioralMedicine, Vol. 15, No. 3, 1992

A Psyehophysiological Evaluation of Female Urethral Syndrome: Evidence for a Muscular Abnormality A. M. B e r n s t e i n , 1 H. C. P h i l i p s , 2 W. L i n d e n , 3 and H. F e n s t e r 4

Accepted for publication: May 18, 1991

This is a preliminary investigation into a recently defined urological disorder occurring in a subgroup of women with "urethral syndrome" suggestive of pel-. vic floor muscular (PFM) dysfunction. Symptoms include straining to void, urgency, frequency, hesitation, incontinence and~or retention, and subpubic pain. Finding neither bladder nor urological abnormalities, urologists may consider these women emotionally unstable without organic cause for their symptoms. However, their distress may be a consequence rather than a cause of their voiding problems. Sixteen female urological patients were matched with 16 asymptomatic controls to investigate PFM functioning, psychological status, and symptomatology. Results showed heterogeneity of symptomatology and little elevation of depression or anxiety when comparing patients with controls. Hypotheses of muscular abnormality were confirmed. Patients evidenced poor control over tensing and relaxing PFM, elevations of PFM activity under various conditions, and chronic pain as a prominent symptom. Treatment approaches specifically designed to address PFM dysfunction are discussed. KEY WORDS: female urethral syndrome; biofeedback; learning and urological disorders;

detrusor-sphincter dyssynergia.

1Division of Psychology, Department of Mental Health Sciences, Hahnemann University, Philadelphia, Pennsylvania. 2Clinical Psychology Department, University of British Columbia - Shaughnessy Hospital, Vancouver, British Columbia, Canada. 3Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada. 4Division of Uruology, University of British Columbia - Shaughnessy Hospital, Vancouver, British Columbia, Canada. 299 0160-7715/92/0600-0299506.50/0 9 1992 Plenum Publishing Corporation

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Bernstein, Philips, Linden, and Fenster

~ ~ " ~ ! ~ ~

~ /Detrusor ~ _ ~l~,)~J~~Trig~

moo,...oo,o . /1 'ntramura'~/#~/ , ~ ~Y//

-- I-

Intramural MuscIe-Strial

i

t J~~L-Vagina )

Sn

/

~--

Fig. 1. The structural relationships in the lower urinary tract of the female. [Drawing taken from Abrams et al. (1979). Urodynamics, Springer-Verlag, New York, as modified by Gosling (1979).]

INTRODUCTION With increasing sophistication in urodynamic techniques (Abrams et al., 1983; Blavais, 1984), urologists can now differentiate a subgroup of patients with a set of urological symptoms but no evident bladder or neurological abnormalities. These patients report symptoms such as frequency, urgency, straining to void, hesitation, incontinence and/or retention, and subpubic pain. Until recently, women with such symptoms have been grouped together as having "urethral syndromes" (Schmidt, 1985). Although often receiving the diagnosis of urethral syndrome, it is likely that these patients form a heterogeneous group with respect to etiology and maintaining factors. One proposed subgroup includes those who suffer from a dysfunction of the pelvic floor musculature (PFM). Such a dysfunction has variously been called detrusor-sphincter dyssynergia (DSD) (Norgaard and Djurhuus, 1982), functional dyssynergia (Libo et al., 1983), and pseudodyssynergia (Evans, 1971). Micturition is a complicated act, involving the coordinated activity of many centers and the integration of bladder, urethra, and sphincter mechanisms (see Fig. 1). It is, therefore, understandable if such a complex system should breakdown and lead to various voiding dysfunctions. During normal micturition, the detrusor tenses and the PFM relaxes, allowing emptying of the bladder. One dysfunction that may develop would be for the detrusor muscle and the PFM to begin to act in a dyssynergic, or incoordinated, manner - as the detrusor tenses to empty the bladder, the PFM also tenses, leading to weak/erratic flow, straining to void, and

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incomplete emptying of the bladder. Due to residual urine which provides excellent grounds for bacterial growth, there is an increased risk of recurrent bladder infections (Seddon and Bruce, 1978). Such a dysfunction can be described as "functional urinary incoordination" (FUI), differentiating this functional disorder from DSD, a disorder occurring in the wake of neurological damage caused by trauma (e.g., spinal cord lesions) or disease (e.g., multiple sclerosis). The term "functional urinary incoordination" (FUI) is used throughout this paper to avoid these neurological connotations and provide a simple description of possible muscular dysfunction, or incoordination between bladder and PFM activity. Little is known about the specific incidence of FUI. However, it is likely that it forms a subgroup of those diagnosed with female urethral syndrome (FUS) and prostatitis (Blavais, 1984). Estimates of FUS range from 335 to 70% (Evans, 1971; Seddon and Bruce, 1978) of female urological outpatients, while prostatitis effects 5% 5 of male urological outpatients. Due to the higher incidence of this disorder among women, this study focuses on a female population diagnosed with FUS. Until recently, these individuals have been treated with dilation, drugs, and surgery. Unfortunately, FUS (including FUI), in general, has proven resistant to these traditional urological techniques (Elder and Stephenson, 1980; Libo et al., 1983; Schmidt and Tanagho, 1981). Such techniques may actually exacerbate rather than alleviate many of these symptoms (Firlit and Cook, 1977). Recently, the feasibility of specifically treating the presumed PFM abnormality has been considered in reestablishing normal PFM functioning. It has been hypothesized that those with FUI have a learned muscular dysfunction which could be reversed by retraining. Urologists and psychologists have begun collaboration using electromyographic (EMG) biofeedback techniques to normalize PFM activity. The patient is provided with continuous information regarding PFM functioning and taught to use this information to regain adequate muscular control. Results obtained thus far suggest that this painless, noninvasive biofeedback method may be clinically effective (Libo et al., 1983; Maizels et al., 1979; Norgaard and Djurhuus, 1982; Sugar, 1983; Philips et al., 1988). Enthusiasm for a new t h e r a p e u t i c m e t h o d , h o w e v e r , s h o u l d not curtail i m p o r t a n t psychophysiological investigation of FUI. Such studies will lead to a better understanding of the nature of these urethral syndromes. Perhaps due in part to an inability to help these patients with traditional approaches, some urologists have viewed those with FUI as having 5Estimates provided by Dr. Howard Fenster, Head of Division of Urology, Shaughnessy Hospital, Vancouver, British Columbia, Spring 1985.

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predominantly psychological or psychiatric rather than physical problems. As Abrams et al. (1983) state, "Psychogenic voiding patterns are often diagnoses of exclusion following persistently negative urological studies" (p. 19). This point of view has been encouraged by the growing distress many patients express to their general practitioners and urologists when there appears to be no medical solution to ongoing problems. Their symptoms can have an extreme impact upon almost all aspects of their lives (social, leisure, work, sexual, and emotional adjustment). To date, no controlled studies have been undertaken to assess the extent to which these women have classifiable psychiatric and/or psychiatric problems. In addition, no attempt has been made to consider the impact of their prolonged urinary problems. The aim of the current study was to undertake a controlled evaluation of the symptomatology and psychophysiological characteristics of a group of women with FUS, in order to assess the extent of PFM abnormality and psychological disturbance. Based upon what is known about FUI, the following hypotheses were formulated. 1. Psychophysiological differences between patients and controls would be observed in PFM functioning under various conditions. (a) While at rest, patients, in order to prevent incontinence and possibly bracing muscles in response to pain from bladder fullness, were predicted to have higher EMG readings reflecting greater PFM activity pre- versus postvoiding than controls, who would demonstrate greater consistency in PFM activity regardless of the state of the bladder. (b) While voluntarily attempting to relax or tense, controls, compared to patients, should have greater voluntary control over the PFM, evidenced by lower EMG levels while relaxing and higher levels while tensing. (c) While voiding, patients should experience greater difficulty relaxing the PFM during voiding, thus demonstrating higher EMG levels than controls during voiding. Psychophysiological differences would further be observed in awareness of PFM functioning and bladder fullness - controls demonstrating higher correlations between subjective ratings and objective measures (i.e., EMGs and amount of urine voided) than patients. 2. Pain experienced by the patient group (not an issue for the asymptomatic controls) was predicted to be greater prevoiding, due to pressure from bladder fullness and, possibly, to increased tension in the PFM to prevent incontinence, compared to postvoiding.

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3. Although patients would differ from controls on symptomatology, given the criteria used to group subjects, how and to what degree these groups differed in voiding behavior (i.e., frequency, duration, hesitancy, flow characteristics, nocturia, dysuria, and incontinence) were to be examined to gain a better understanding of this dysfunction. 4. Investigating possible psychogenic causes of FUI, the two groups may show differences on measures of depression and/or anxiety. 5. Finally, looking at possible genetic and/or iatrogenic causes for FUI, historical data (i.e., previous bladder and gynecological infections, number of urological operations, family history of urological problems) were examined, with an expectation for differences between patients and controls~

METHOD Subjects Thirty-two adult females were evaluated. Sixteen of these were urological patients who had been assessed in the Urodynamics Lab of a general hospital. Testing was performed on a four-channel Lifetech urodynamic apparatus with video capability. All subjects met the following four criteria: (a) negative neurological evidence; (b) normal or elevated bladder pressure; (c) pelvic floor muscular spasms while voiding during urodynamic assessment - raw EMG spasms (visual inspection) and staccato flow pattern; and (d) report of one or more of the following symptoms - weak flow, straining to void, frequent voiding, urgency, incomplete voiding, and pain while voiding. Sixteen controls without urological problems were recruited by project researchers and included graduate students, co-workers, and personal acquaintances. Criteria for inclusion in the study consisted of the absence of any urological problems requiring treatment over the past year. The two groups of women (urological and controls) were matched by age (mean ages: patients, 33 years; controls, 32 years) and number of natural childbirths (means of 1 for both groups), both factors presumed possibly to affect PFM functioning (i.e., specifically, muscles typically growing weaker as we get older, and the PFM affected by the trauma of natural childbirth).

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Superfi( F

Gluteus M

MUSCm f3roups of Pelvic Floor (PFM)

Electrode Site

Fig. 2. Electrode placement for recording PFM activity. [Drawing taken from Hollinshead, W. H. (1974). Textbook of Anatomy, 3rd ed., Harper & Row, Philadelphia.

Measures

Psychophysiological Indices (i) PFM activity was evaluated using silver/silver chloride surface electrodes in a standardized placement (Fig. 2). The integrated microvolt levels were assessed during a number of 45-see epochs using a Cyborg Biolab: pre- and postvoiding, while resting, relaxing, and tensing to instruction; and prior to and during voiding (assessing the first 15 sec of voiding). [For more details see Bernstein (1986).] (ii) Subjective estimates of tension in the PFM during the sampling periods were obtained from subjects using an analog scale from 0-5 (0 representing no felt tension and 5 representing maximum tension in the PFM). (iii) Subjective reports of bladder fullness were also obtained using a scale from 0 to 5 (where 0 represented no urine in the bladder

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and 5 represented maximum fullness). The actual amounts voided were measured.

Pain Experience Subjective levels of pain were obtained from subjects during the eight sampling periods, asking participants to use an analogue scale from 0 to 5 (where 0 represented no pain and 5 represented maximum, excruciating pain). In addition to this, pain was assessed on a number of psychological inventories (Bernstein, 1986).

Symptomatology Given the reported heterogeneity of symptoms, in order to discern what these symptoms entailed and how disparent they were from what might be considered normal, each subject monitored her voiding behavior for 1 week prior to the experimental session. From this monitoring, the following measures were obtained: average daily voiding frequency, average duration, average hesitation prior to voiding, flow characteristics, discomfort while voiding, daily incidence of incontinence, and nocturia. (Monitoring forms are available from the authors.)

Psychological Indices Standardized questionnaires were used to evaluate depression and state-trait anxiety (Beck et al., 1961; Spielberger et al., 1970).

History Historical information was also obtained, which included reports of previous bladder and gynecological infection, number of urological operations, and family history of urological problems.

RESULTS

Psychophysiological Evaluation Table I shows the PFM activity levels of the two groups during the eight sampling periods. Factorial analyses of variance (ANOVAs) with

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Table I. Group Mean EMGs for PFM Activity Levels (Resting, Relaxing, and Tensing) Across Conditions (Pre-, During, and Postvoiding) Prevoid

Patients Mean SD Controls Mean SD

Void

Postvoid

Rest

Relax

Tense

Rest

Void

Rest

Relax

Tense

2.30 1.76

1.65 1.26

5.62 2.76

1.64 1.09

3.46 2.76

.97 .58

.96 .70

4.84 2.96

1.24 .63

1.05 .44

8.98 3.56

1.45 1.39

2.46 1.87

.92 .42

.91 .45

7.41 2.65

2.40 2.20

2.00

1.80

=. r

1.60

1.40

1.20 1.00

A w D

.80 .60 r Pre-Vold

Resting

Legend

9 9

i Pre-Vo|d

Resting

i

Post-Void Resting

i

Post-Void Relaxing

Patients Controls

Fig. 3. Group mean EMGs for PFM activity levels (resting and relaxing) across conditions (pre- and postvoiding).

repeated measures were performed examining group differences (as the factor) by conditions (repeated measure). Both groups demonstrated the ability to relax their PFM after voiding [main effect - conditions: F(1,30) =

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9 Patients [ ] Controls

REST RELAX TENSE REST VOID REST RELAX TENSE

Pre-Volding

Voiding

Post-Voiding

PFM Activity Levels

Fig. 4. Group mean EMGs across eight sampling periods.

12.65, p < .002] (see Fig. 3). The change in the PFM level from pre- to postvoiding was, however, greater for patients than for controls [Group x Condition interaction, F(1,30) = 5.61, p < .025]. This finding supports the prediction that the state of the bladder had a significantly greater effect on the ability to relax the PFM for patients than for controls. When asked to demonstrate their capacity to tense their PFM on instruction, controls showed significantly higher activity levels than did the patients [main effect - Group: F(1,30) = 9.43, p < .005]. Although both groups showed higher EMG levels prior to voiding, the patients had significantly higher E M G levels while resting and relaxing in the prevoiding period than the controls [Group x Conditions interaction: F(1,30) = 7.58, p < .001] (see Fig. 4). Finally, there were no significant differences between groups in the mean levels of tension while voiding. This failure to show significant differences, despite the higher levels of tension in the patient group, may be due either to the large variability of the patient response or to artifacts in measurement (elaborated under Discussion). It appears that women are not accurate at estimating the amount of activity in the PFM or bladder fullness whether they have urological problems or not (see Table II). Independent Pearson product-moment correlations relating the five subjective ratings of PFM activity to corresponding E M G readings as well as to ratings of bladder fullness to amount voided were low, demonstrating no significant relationships. Between group comparisons were computed using one-tailed Fisher Z's on the obtained cor-

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Table II. Correlations Relating Subjective Ratings with Objective Measures Prevoiding

Patients Controls

Relaxing

Tensing

Resting just prior to voiding

-.33 .06

-.43 -.11

-.05 .02

Postvoiding Relaxing

Tensing

Urge/cc

.15 .63

.17 .09

.56a .30b

an = 13. bn = 14.

relation coefficients. Univariate t tests, performed using a Bonferroni correction factor of .002, revealed nonsignificant findings, reflecting difficulty experienced by both groups in judging PFM activity. In addition, there was no difference between groups in the correlation of subjective reports of bladder fullness and actual amounts voided. Thus, it would appear that women with these urological problems are no worse or better than normal in estimating the amount of urine in the bladder. However, as the subjects were not catheterized to check on residuals, this result needs to be interpreted cautiously.

Pain A high proportion of patients reported substantial, often chronic pain problems (67% of the patient group). A 2 • 2 A N O V A with two repeated measures, PFM Activity Level (resting versus tensing) and Conditions (preversus postvoiding) on pain ratings, supported the prediction that pain intensity would be significantly greater in these individuals pre- as opposed to postvoiding [F(1,15) = 5.21,p < .04] and tended to increase with tension in the PFM [F(1,15) = 3.39, not significant but a trend indicated]. Standardized self-report questionnaires further revealed that these patients have obtained scores similar to those obtained by chronic pain sufferers (as compared to information recently compiled on 134 chronic pain patients seen in the Back Pain Clinic at Shaughnessy Hospital, Vancouver, B.C., available from the authors).

Symptomatology Detailed examination of the patient group revealed them to be far from homogeneous with respect to symptomatology (see Table III). Subgroups could be differentiated. They consisted of those whose primary complaint was pain (subpubic and/or lower back), those reporting incontinence

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Table III. Comparison of Patients and Controls on Symptomatology Patients (n = 16)

Voiding frequency Voiding duration Flow (% erratic) Discomfort Nocturia Incontinence

Controls (n = 16)

M

SD

M

SD

t

p

10.60 12.50 47.50 1.06 1.05 2.79

4.13 6.69 26.90 1.24 1.31 5.57

6,56 12,87 9,31 ,00 .17 .09

1.77 5.18 10.50 .00 .28 .26

3.62 -.18 5.29 3.44 2.62 1.94

.001 ns ,0001 .002 ns ns

Table IV. Comparison of Groups on M e a n Scores for Psychological Self-Report Measures Groups Patients

BDI a STAI ~ - State STAI --Trait

Controls

M

SD

M

SD

t

p

10 43 42

10 t6 18

3 34 35

4 10 9

2.50 2.70 1.26

ns ns ns

aBeck Depression Inventory (BDI). ~ Anxiety Inventory (STAI).

(with and without pain), and those with frequency problems (with and without pain). Due to the small number of subjects in this study, separate analysis of these specific subgroups was not possible. However, subsequent research into this disorder should consider the heterogeneity of this population and use specific criteria based on these various subgroups. Psychological Evaluation Standardized self-report questionnaires reflected no significant group differences in the level of anxiety (trait or state) or depression, between urological and asymptomatic controls (see Table IV). Patients did, however, obtain slightly elevated scores, suggesting that psychological factors may be relevant to the development, maintenance, or sequelae of their urological problems. However, it should be emphasized that there was no evidence of pathological levels of anxiety or depression in the patient group. The average depression score falls at the cutoff between normal and borderline depression (see norms given by Beck et al., 1961). The anxiety score

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Bernstein, Philips, Linden, and Fenster

averages fall at approximately the fiftieth percentile for general medical

patients. History In interviews, the patients reported experiencing significantly more bladder infections (t = 4.7, p < .0001) than the control group and had undergone more frequent urological procedures (dilations, cystoscopies, and surgical procedures) (t = 5.01, p < .0001). No intergroup differences were observed in history of family urological problems or incidence of gynecological infections.

DISCUSSION A comparison was made between 16 women with apparent functional urinary incoordination and 16 age-matched asymptomatic controls. The investigation was undertaken in order to examine the characteristics of this recently defined subgroup of women with urethral syndrome. This subgroup was hypothesized to have malfunction of pelvic floor musculature (PFM), associated with their urological symptomatology. In fact, the results suggest the criteria for "functional incoordination" needs to be modified. No significant intergroup differences were found between patients and controls with respect to the activity of the PFM while voiding. The EMG activity was evaluated during the first 15 sec of the voiding period (e.g., assessed from when the subject signaled onset of flow, thus excluding the hesitation period). This short epoch proved necessary to ensure flow in all subjects during the entire assessment period. However, it is clear that the hypothesized spasming which limits flow was not unique to this pathological group. The normal asymptomatic women also demonstrated an elevation of EMG activity while voiding. This finding may well reveal a potentially important artifact of measurement (i.e., all subjects may have experienced increased tension due to being measured while voiding - normally a private act). The importance of this finding should be particularly noted when assessing patients for functional impairment, since elevations in PFM activity while voiding could be expected from both those with and those without functional impairment. Use of this as a diagnostic criteria thus becomes highly questionable. Future methods will hopefully be developed to eliminate this possible difficulty in measurement. Other PFM abnormalities were, however, detected, which may prove useful in diagnostic assessment.

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PFM activity remained elevated while the urological patients were resting and relaxing, when the bladder was full. In other words, these individuals appear unable to relax the PFM and show tonic elevations or spasming of these muscles. In addition, they demonstrated a poor ability (compared to "normals") to tense the PFM when instructed. The latter suggestion of muscular weakness may be an important finding with respect to those patients who experience incontinence. All three muscular abnormalities detected [i.e., high tonic levels (prevoid), poor ability to relax (prevoid), and poor ability to tense (pre-/postvoid)] suggest inadequate voluntary control of the PFM. There was no suggestion that women with incoordination are abnormally poor at recognizing either the level of tension in their PFM or bladder fullness. In fact, both normal and abnormal groups were equally poor at discerning bodily functions in terms of PFM activity and state of bladder fullness. Contrary to urologists' impressions, these patients do not show abnormal levels of depression or anxiety. The slight elevations found are likely to be a consequence of unresolved urological problems and, thus, would be expected to reduce with successful treatment. The extent to which pain is reported as an associated and often primary concern is important. Its relationship to PFM activity suggests that elevated muscular activity may be not only a cause, but also a consequence of pain and discomfort. That is, there is some evidence that pain may increase with tension. Due to increased tension shown to exist in the PFM of patients, some understanding is obtained for the high prevalence of pain in these patients. Management of the chronic pain problem, which needs to be considered carefully in planning the treatment method for these women, may focus on relaxation to break the apparent cycle of tension and pain. In conclusion, a subgroup of women - formerly grouped together as having "urethral syndrome" - can now be identified. Associated with their obstructive symptomatology, they have demonstrable abnormalities of PFM control. The importance of normalizing the physiological component of their disorder is currently being studied (Philips et al., 1988). Future research will need to differentiate the extent that the muscular component plays an active role in this type of voiding dysfunction. It seems likely that clarifying the relative role of PFM in the treatment of these women will lead to advances in the understanding of this urological dysfunction.

ACKNOWLEDGMENTS The authors wish to express thanks to the urodynamic technicians at Shaughnessy Hospital, Vancouver, British Columbia, as well as to the

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W o o d w a r d F o u n d a t i o n , w h o s u p p l i e d t h e C y b o r g B i o l a b . A p p r e c i a t i o n is also e x p r e s s e d to R a l p h H a k s t i a n , P h . D . , U n i v e r s i t y o f B r i t i s h C o l u m b i a , f o r a s s i s t a n c e with statistical analyses.

REFERENCES Abrams, P., Feneley, R., and Torrens, M. (1983). Urodynamics, Springer-Verlag, New York. Beck, A. T., Ward, C. H., Mendelsohn, M., Mock, J., and Erbaugh, J. (1961). An inventory for measuring depression. Arch. Gen. Psychiat. 4: 561. Bernstein, A. M. (1986). A Psychophysiological Investigation of Functional Urinary Incoordination, M.A. thesis, University of British Columbia, Vancouver. Blavais, J. (1984). Multi-channel urodynamic studies. Urology 23(5): 421-438. Elder, D. D., and Stephenson, T. P. (1980). An assessment of the Frewen regime in the treatment of detrusor dysfunction in females. Br. J. Urol. 52: 467-471. Evans, A. T. (1971). Etiology of urethral syndrome: Preliminary report. Z UroL 105: 245-250. Firlit, C. F., and Cook, W. A. (1977). Voiding pattern abnormalities in children. Urology 10(1): 25-29. Gosling, J. A. (1979). The structure of the bladder and urethra in relation to function. Urological Clinics ofN. A. 6: 31-38. Libo, L. M., Arnold, G. E., Woodside, J. R., Borden, T. A., and Hardy, T. L. (1983). EMG biofeedback for functional bladder-sphincter dyssynergia: A case study. Biofeed. SelfRegul. 8(2): 243-253. Maizels, M., King, L. R., and Firlit, C. F. (1979). Urodynamic biofeedback: A new approach to treat vesical sphincter dyssynergia. J. Urol. 122: 205-209. Norgaard, J. D., and Djurhuus, J. C. (1982). Treatment of detrusor-sphincter dyssynergia by biofeedback. Urol. Int. 37: 236-239. Philips, H. C., Fenster, H., and Samson, D. (1988). An effective treatment for voiding dysfunction: A control treatment trial. J. Behav. Med. 15: 45-63. Schmidt, R. A., and Tanagho, E. M. (1981). Urethral syndrome or urinary tract infection? Urology 28(4): 424-427. Seddon, J. M., and Bruce, A. W. (1978). Cystourethritis. Urology 11(1): 1-10. Spielberger, C. D., Gorsuch, R. L., and Lushene, R. E. (1970). State-Trait Anxiety Inventory: Test Manual for Form X, Consulting Psychologists Press, Palo Alto, CA. Sugar, E. (1983). Bladder control through biofeedback. Am. J. Nurs. 1152-1154.