Biofeedback and Self-Regulation, Vol. 8, No. 2, 1983
EMG Biofeedback for Functional BladderSphincter Dyssynergia: A Case Study Lester M. Libo,1 Georgie E. Arnold, Jeffrey R. Woodside, and Thomas A. Borden Universityof New Mexico School of Medicine Tyrone L. Hardy Lo velaceMedical Center, AIbuquerque
The present study utilized E M G biofeedback in the treatment o f functional bladder-sphincter dyssynergia, a learned &coordination o f bladder and urethral sphincter activity during voiding. The condition is usually associated with a history o f painful urination due to bladder infections, surgery, or harsh toilet training. The subject was an 8-year-old girl with chronic diurnal urinary frequency, urge incontinence, and nocturnal enuresis. Treatment consisted o f intensive instruction in alternately tensing and relaxing her lower pelvic musculature, as well as relaxing during voiding. These exercises were accompanied by E M G biofeedback f r o m perianal and perivaginal surface electrode sites. Home practice consisted o f the tense-relax exercise, relaxation during voiding, and self-monitoring and record-keeping. There were 17 sessions over a period o f 9 months. No medication was used. Marked reduction (to normal levels) in diurnal urgency and frequency occurred by the 3rd week o f therapy, and complete recovery o f normal function, including nocturnal continence without waking, occurred by the 13th therapy session, 5 months after therapy began. Follow-up I year after therapy revealed that these gains were being maintained. Pre- and posttherapy urodynamic studies corroborated the achievement o f normal urinary function. Descriptor Key Words:bladder-sphincterdyssynergia; EMG biofeedback; muscle relaxation.
~Address all correspondence to Lester M. Libo, Department of Psychiatry, University of New Mexico School of Medicine, Albuquerque, New Mexico 87131. 243 0363-3586/83/0600-0243503.00/0 @ 1983PlenumPublishingCorporation
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Bladder-sphincter dyssynergia, characterized by incoordination of bladder and external urethral sphincter activity, is a fairly frequent, troublesome, and potentially dangerous condition that can eventually lead to renal damage and even death. It is generally first observed in childhood; the most common symptoms are frequent urination, urge incontinence, nocturnal enuresis, and/or incomplete voiding and hence urinary retention. In normal urination, the bladder contracts and the urethral sphincter relaxes; in dyssynergia, both contract during voiding. There are two major types of dyssynergia: One results from a spinal cord lesion, the other (which is the subject of this paper) from a learned abnormality involving habitual contraction of the perineal musculature and external urethral sphincter during urination. The problem is revealed by urodynamic evaluation, consisting of the simultaneous recording of intravesical pressure, urinary flow, and sphincter electromyography (Cook, Firlit, Stephens, & King, 1977; FMit & Cook, 1977). Hinman and Baumann have argued for the recognition of functional dyssynergia or discoordination between contraction of the detrusor urinae (the muscular coat of the bladder) and relaxation of the urethral sphincter in the group of children who exhibit all the features of a severe obstructive uropathy (i.e., heavily trabeculated bladder, elevated residual urine, hydronephrosis), yet in whom neither anatomical nor neurological disease can be documented (Hinman & Baumann, 1973; Hinman, 1974). Allen (1977) has also argued that frequently the "neurogenic bladder" is nonneurogenic, in that the abnormal function is learned and not due to an as yet undiscovered pathology. Inasmuch as contiaction, instead of the normal relaxation of the external urethral sphincter, occurs during voiding, the detrusor urinae must work against a high level of resistance; the eventual effect is an enlarged and heavily trabeculated ("ropey layers") bladder and ultimately decompensation and/or hydronephrosis. As the bladder becomes thickened, it becomes more irritable (i.e., more subject to spasms); this "uninhibited" quality is the basis for the enuresis commonly seen in dyssynergia. There is no universally effective surgical or pharmacologic therapy for this condition. Interventions include urethral dilatation, sphincterotomy, pudendal or sacral nerve blocks, and detrusor/sphincter-directed chemotherapy. In the earlier stages of the disorder, there may be urinary incontinence, a very brief latency between awareness of the need and voiding (and thus a very high degree of urgency), frequent urination, strong pressure of the urine stream, and very brief and "explosive" voiding, but not necessarily any urine retention or bladder enlargement. The patient described in this paper is of this type. Other patients may not exhibit incontinence or urgency, but the effects of dyssynergia will be evident in the trabeculation of the bladder wall, retention of urine after voiding, and enlargement of the bladder. In later stages, the force of the urine stream is likely to be weak, reflecting bladder decompensation.
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The condition is often linked to a history of urinary infections and/or frequent urologic diagnostic and surgical procedures. The discomfort of these experiences provides a conditioned association between urination and pain, and hence the muscle "bracing" to avoid the pain. With a history of painful voiding, the child tenses the perineum, which contracts the urethral sphincter and also inhibits detrusor contraction. The need to void is followed by tensing, which becomes a learned pattern, as it results in the short-term avoidance of pain. Nocturnal enuresis may be a result of lessened cortical control over an irritable bladder during sleep. The association of tension with urination is self-perpetuating inasmuch as chronic incontinence is likely to result in more bladder infections, which, in turn, are likely to lead to more painful urination. Dyssynergia-related elevated residual urine volumes also may predispose to recurrent infections. Another possible factor in the development of functional dyssynergia is a history of emotionally traumatic bladder training, including harsh parental attitudes toward incontinence. Children with functional dyssynergia sometimes take stringent measures to avoid urinating and have been observed to delay urination by using a squatting posture with adductor contractions in the thighs. Psychological disorders and adverse social environments have also been found to be implicated in bladder dyssynergia (Allen, 1977). In these cases, the dyssynergia can be understood as one specific symptom of generalized muscle tension. The association of tension with voiding may also prevent the acquisition of awareness and control of the lower pelvic musculature, control in the sense of passive volition, or the ability to achieve a behavioral goal by adopting a passive attitude rather than an effortful one. The development of learned or functional dyssynergia with incontinence may be understood as a combination of two phenomena: (a) incontinence due to an uninhibited bladder after repeated infections, and (b) dyssynergia due to the habitual tensing of the musculature associated with painful voiding. Allen conducted a program of bladder retraining that yielded promising results. A number of child patients were instructed to observe continuous electromyographic recordings during urination, while being encouraged to relax the perineum and maintain a sustained stream without straining. Psychological guidance, hypnosis, and medication were also used, and home practice was emphasized. Two pioneering uses of EMG biofeedback were reported in 1979 by Maizels, King, and Firlit, and by Wear, Wear, and Cleeland. The former used bipolar EMG surface electrodes applied to the perianal region at the 3 and 9 o'clock positions. The subjects were three children; a highly successful outcome was achieved by one, a partial success by the second, and none by the third. The second group of investigators worked with eight adult
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patients with urinary retention and/or incontinence, using a new intraurethral catheter with five surface-mounted EMG electrodes. Moderate to marked success was reported for four of these patients. Perhaps the earliest use of biofeedback for urinary retention and incontinence was the single case report by Pearne, Zigelbaum, and Peyser in 1977. They used frontal EMG feedback to decrease generalized muscle tension in an adult patient, resulting in a successful resolution of the urinary problem.
METHOD
Subject The present study utilized EMG biofeedback in the treatment of diurnal urinary frequency, urge incontinence, and noctural enuresis, but not urinary retention, in an 8-year-old girl with functional bladdersphincter dyssynergia documented by urodynamic evaluation. She was the fourth of five children of upper-middle-class, college-educated AngloAmerican parents. Her condition became evident at the age of 2½, following several bladder infections. She underwent cystoscopy and dilatation at the age of 4, and again at the age of 6, following which there was significant improvement, including nocturnal continence. This lasted for only 3 months, however. At the age of 7, she relapsed to her earlier pattern of urinary urgency every 15 to 30 minutes, as well as urinary incontinence every night and occasional incontinent episodes during the day. On initial evaluation, impatience, irritability, and general tension were evident; the parents' reports of her behavior at home confirmed these observations. Psychological interview with the parents, followed by observations of them during therapy, revealed a history of nurturant, permissive child care, a warm, affectionate family atmosphere, and no evidence of either harsh toilet training or punitive attitudes toward incontinence.
Procedure Treatment began with 3 days of hospitalization in a private room for intensive EMG biofeedback-assisted instruction in alternately tensing and relaxing her lower pelvic musclature and in relaxing during voiding. (Outpatient office treatment is also feasible, so long as privacy, a dressing room, and use of a bedpan or urinal can be provided.) Fourteen 1-hour outpatient therapy sessions followed at weekly to monthly intervals over a period of 9 months, and more than 1 year has elapsed since the end of treatment.
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Therapy procedures consisted primarily of EMG biofeedback-assisted tense-relax training of her perineal musculature. The patient was instructed to simulate holding and releasing urine; this was monitored via EMG disposable electrodes, placed at 3 and 9 o'clock in the perianal and perivaginal areas (each area separately), and the ground electrode on the wrist or ankle. EMG readings ranged from .6 (relax) to 8 (tense) microvolts RMS, with the frequency band-pass setting at 100-200 Hz. The apparatus was the J & J Enterprises Model M-53 Dual Channel EMG, Model D-200 Digital Integrator, and Model L-200 Dual Analog Light Display. Analogue feedback was both visual and auditory. Biofeedback instruments were used only during the hospital and office sessions, not at home. Urinary retention was not measured, as urodynamic studies had not revealed retention as a problem in this patient. In the initial training session, the patient was oriented to biofeedback and instructed to alternately tense and relax several noninvolved muscle groups, such as in the forearm, forehead, and legs. This approach served to demonstrate biofeedback and reduced concomitant muscle contraction in nonrelevant areas, such as the feet, when the patient was instructed to tenserelax the lower pelvic musculature. EMG biofeedback of muscle activity in the face and head was also done in order to help reduce this patient's general tension and irritability. These supplemental procedures for the noninvolved sites were conducted only on the 1st day of treatment. For the next 2 days of her hospitalization, the patient was given intensive practice in tensing and relaxing her lower pelvic musculature, with the aid of the EMG biofeedback monitor. Each day, there were six to eight practice periods, varying in length from 5 to 10 minutes, as well as instruction to tense and relax while urinating. The major emphasis in the practice regimen, which was continued at home, was the alternate tensing and relaxing of the muscles involved in holding and releasing u r i n e - a Kegel-type isometric exercise of the pubococcygeus and sphincter ani muscles (a standard treatment for urinary stress incontinence after childbirth) (Kegel, 1956). However, the present study did not follow Kegers recommendations: There was neither digital palpation to identify the pubococcygeal muscle nor the use of a perineometer. In addition to the prescribed daily home practice of relaxation during voiding, the Kegel-type exercises, which the patient continued on a more or less regular basis during the 9 months of outpatient therapy, and the weekly office visits, which involved EMG biofeedback of the perianal and perivaginal sites during voiding and while tensing and relaxing, two supplemental procedures were introduced. 1. During the fourth session (the first outpatient session), approximately 1 week after therapy had begun, the patient was asked to
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keep a daily record, in a small notebook, of "urgency" (1 = low, 3 = high), "force" (1 = low, 3 -- high), "relaxed or tense" (R or T), and "holding" (number of times holding and releasing during urination). The patient was enthusiastic about this task and continued to do it with varying success for the next month. It was discontinuted after the ninth session. 2. In the sixth session, approximately 3 weeks after therapy had begun, the patient's mother was asked to check the patient's bed for moisture during the night, beginning at 3:00 a.m., in an attempt to determine when the nocturnal urinating occurred, and to wake the patient before she urinated and take her to the toilet. This was done by the mother for 2 weeks. Because the patient was to visit her grandmother in another state, it was decided that she would set an alarm clock herself every 3 hours during the night. However, she found that without using the alarm clock, she began waking herself every 3 hours! The self-waking lasted for approximately 3 weeks, after which she slept through the night. Other techniques were introduced by the patient's mother after the patient had some dry nights: reinforcing the patient's success with "reward slips" of cartoon characters and promising her new bedding when she would achieve nocturnal continence.
RESULTS Positive results became evident almost immediately after the first few therapy sessions. With the aid of the EMG biofeedback monitor, especially with the analogue light display, she quickly learned to tense and relax her lower pelvic musculature. Relaxation during voiding, however, was not demonstrated until the 16th session, when the patient went from a baseline level of .9/~V and a brief, 1-second rise to 2.5/~V at the start of voiding, to a sustained level of 1.7 to 1.3 #V during the remainder of voiding. This was in sharp contrast to her earlier EMG levels during voiding of 16-20/~V. Initial improvement, noted in the 3rd week, consisted of a sharp decrease (to normal levels) in diurnal urgency and frequency but not in nocturnal enuresis. Over the next 4 to 7 months, there was a virtually complete clinical recovery of normal function, as follows: (a) no diurnal incontinence, abnormal urgency, or abnormal frequency; intervals between daytime voiding increased to 2 to 4 hours; (b) no nocturnal incontinence; sleep uninterrupted through the night; no waking to void as she did during initial improvement phase; (c) subjective feeling of relaxation during urination (documented 8 months after the start of therapy by a low and steady EMG during voiding, without a spike as had been seen during the initial evaluation and earlier phases of treatment); (d) length of time voiding
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increased from 2 seconds to 5-8 seconds; (e) extreme force of stream reduced, though still strong. The first major improvements noted were the increased intervals between voidings, the decreased urgency, and the ability to hold and release the urine stream during voiding. These began to occur only 1 week after the 3 days of intensive instruction and practice in the hospital. At this point, only home practice of tensing and relaxing the perivaginal and perianal musculature, as well as attempted relaxation during urination, had occurred. Record-keeping by the patient, as described under Procedure, was then instituted. The next week the patient had a 2- to 4-hour retention time and reported relaxed voiding, but was wetter than usual at night (a phenomenon we observed in another patient during the early stage of therapy). One week later, after the mother had begun waking the patient during the night (3 weeks after treatment started), the patient was dry 4 nights out of 7. The patient reported that the force of the urine stream was sometimes lower and that relaxing during voiding "really felt g o o d - n o w I know what it feels like." One week later, at the 7th session, the daytime progress was maintained, but there was a relapse in nocturnal enuresis, with 6 wet nights out of 8. Between the 7th and 13th sessions, there was gradual progress in achieving nocturnal continence: from 5 out of 12 dry nights by the 9th session to 11 out of 16 dry nights by the 10th session to 20 out of 22 dry nights by the llth session and only 1 wet night out of 41 by the 12th session. By the 13th session (the 5th month after therapy began), all of the positive results described above, including the achievement of complete nocturnal continence without waking, were well established. There were 4 more sessions, or a total of 17. These last sessions were devoted to maintaining therapeutic gains through a review of the home practice procedures and continued EMG biofeedback. On 12-month follow-up after the 17th session, all gains have been maintained. The effects of these changes in bladder function on this girl's daily activities and on her morale are noteworthy. Her self-esteem has risen markedly. She no longer needs to leave the classroom every 15 to 30 minutes, nor does she worry about urinary urgency or "accidents." Her teacher reports that she is working harder and achieving more, including being promoted to an advanced reading class. She participates in athletic events. She reported with delight that, on family outings, the occurrence of a traffic jam or isolation from toilet facilities do not upset her any more, as she can tolerate as long as 4 hours without needing to urinate and without her former sense of urgency. Her impatience, irritability, and general tension-which had been evident during the initial evaluation and early days of treatment-have decreased markedly. Her mood is cheerful, confident, and relaxed. Recently (1 ½ years after therapy), she sent the
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authors a letter, in which she stated, "It feels so great to be like everybody else. I like to forget my old bladder problem. I am so very happy." The complete clinical recovery was corroborated by a comparison of pre- and posttherapy urodynamic studies, conducted approximately 1 year apart (Figures 1 and 2). The posttherapy EMG is markedly flatter during urination, and there is completely normal coordination of bladder and external sphincter activity during voiding. Her duration of voiding is still extremely brief (5 seconds); this may be due to her long history of dyssynergia, which produced a hypertrophied, trabeculated bladder.
CONCLUSION Although there were a number of other treatment interventions in this case, the only techniques used consistently through the entire course of treatment and the primarY techniques used prior to the first sign of marked improvement 1 week after treatment began were the biofeedback and the home practice of tense-relax exercises. Furthermore, the achievement of awareness by the patient of the difference between tension and relaxation of her perineal musculature during voiding, which accompanied the EMG biofeedback procedure, seemed to be an integral part of her recovery of normal function. The results represent one of the very few reports of complete success, confirmed in the laboratory by urodynamic analysis, in overcoming functional bladder-sphincter dyssynergia with a relatively simple form of biofeedback and relaxation training, without medication or surgery, and with a fairly brief course of largely outpatient therapy. However, because of the number of techniques introduced during this patient's therapy, one can only conclude from this study that the combination of several techniques, and not necessarily only the EMG biofeedback-assisted specific muscle relaxation, was effective. Nevertheless, the combined use of patient recordkeeping, night waking, parental reinforcement, and general relaxation training, along with a primary emphasis on biofeedback-assisted relaxation training of the perineal musculature, represents a conservative, economical, and relatively brief treatment regimen for this troublesome and potentially dangerous urologic condition, which, in this case study, resulted in an effective outcome.
REFERENCES Allen, T. A. The non-neurogenic neurogenic bladder. Journal of Urology, 1977, 117, 232-238. Cook, W. A., Firlit, C. F., Stephens, F. D., & King, L. R. Techniques and results of urodynamic evaluation of children. Journal of Urology, 1977, 117, 346-349.
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Firlit, C. F., & Cook, W. A. Voiding pattern abnormalities in children. Urology, 1977, 10, 2529. Hinman, F. Urinary tract damage in children who wet. Pediatrics, 1974, 54, 142-150. Hinman, F., & Baumann, F. W. Vesical and ureteral damage from voiding dysfunction in boys without neurological or obstructive disease. Journal of Urology, 1973, 109, 727-732. Kegel, A. Stress incontinence of urine in women: Physiologic treatment. Journal of the International College of Surgeons, 1956, 25, 487-499. Maizels, M., King, L. R., & Firlit, C. F. Urodynamic biofeedback: A new approach to treat vesical sphincter dyssynergia. Journal of Urology, 1979,122, 205-209. Pearne, D. H., Zigelbaum, S. D., & Peyser, W. P. Biofeedback-assisted EMG relaxation for urinary retention and incontinence: A case report. Biofeedback and Self-Regulation, 1977, 2, 213-217. Wear, J. B., Wear, R. B., & Cleeland, C. Biofeedback in urology using urodynamics: Preliminary observations. Journal of Urology, 1979, 121, 464-468.