Hypothesis / aims of study
Dysfunctional voiding (DV) is a voiding disorder as functional bladder outlet obstruction caused by inappropriate activities of the pelvic floor muscles and/or the urethral sphincter, while these patients are neurologically intact. Biofeedback pelvic floor muscle training (PFMT) has been widely used as conservative treatment for stress urinary incontinence, paediatric learned dysfunctional voiding, idiopathic detrusor overactivity and chronic pelvic pain, but reported data on this treatment for dysfunctional voiding or poor relaxation of the pelvic floor muscle in women was limited. This study focused on the therapeutic efficacy and identified the predictor of satisfactory outcomes.
Study design, materials and methods
This study is a retrospective survey on 31 women with DV proved by video-urodynamic study, in whom medical treatment had failed. The patients were enrolled in a biofeedback PFMT program with totally 3-month treatment period. At first visit, the patient underwent a brief history review, education of voiding diary recording and the initial pelvic floor muscle assessment with Modified Oxford Grading System to evaluate the strength of the pelvic floor muscles by using vaginal palpation. Six times of office training were conducted by the experienced physiotherapist in a private room. EMG electrodes were applied to gather information of the pelvic floor muscles resting EMG levels. During the practice, the patients were asked to tighten the pelvic muscles in different position (supine, sitting and standing) for 10 seconds followed by relaxation of muscle to baseline EMG level within 2 second as the goal. Real-time EMG monitor and verbal guidance help to make sure that the patient was able to voluntarily contract the correct isolated muscle group without involvement of accessory muscles of the buttocks, legs and abdomen. The uroflowmetry parameters at baseline and follow-up visits at 3 months were analysed. Clinical outcome was assessed by comparing pre-PFMT with post-PFMT satisfaction grade, urodynamic parameters and clinical presentation. Patients with global response assessment (GRA) scale of ≥ 2 were considered to have satisfactory outcomes. Patient characteristics and baseline urodynamic parameters were analysed for factors predictive of outcomes.
The mean age of the patients was 55.6 ± 15.5 years (range 18-77). The most frequent urinary symptom was residual urine sensation (93.5%), followed by frequency (83.9%), urgency (67.7%) and intermittency (64.5%). During follow-up, 25 (80.6 %) patients had satisfactory outcomes and the subjective assessment score had revealed statistically significant improvement after PFMT (Table 1). At 3-month follow-up uroflowmetry data showed significantly improved in the mean maximum flow rate (Qmax), corrected Qmax (cQmax), voided volume (VV),total bladder capacity (TBC), average flow rate (Qave), voiding time (Tvoiding), and time to Qmax (TQmax). Post-training Qmax, voiding efficiency (VE), TBC and TQmax of group with favourable outcome were statistically better. Baseline existence of recurrent urinary tract infection (rUTI), higher voiding and total score of the International Prostate Symptom Score (IPSS) assessment were associated with unsatisfactory outcomes (p= 0.038, 0.036, 0.032, respectively). However, only the existence of rUTI was significantly negative predictor (p=0.007) in the multivariate analysis.
Interpretation of results
Biofeedback PFMT is an effective treatment in women with DV to relieve LUTS, improved Qmax, increased TBC, average flow rate and time to Qmax. About 80 % of patients had satisfactory outcomes in subjective and objective parameters over the short term. Recurrent UTI is a negative predictive factor for the effectiveness of PFMT.