Electromyographic (EMG) biofeedback and parasacral transcutaneous electrical nerve stimulation (PTENS) are effective non-invasive therapies for pediatric lower urinary tract dysfunction (LUTD) (1,2,3). Given the strong interaction between bladder and bowel function in children, combining these approaches may enhance treatment outcomes. This study aimed to evaluate whether adding biofeedback and PTENS to standard urotherapy improves urinary and bowel outcomes compared to urotherapy alone.

This prospective randomized study included 61 children (48 girls, 13 boys; mean age 8.28 years) with LUTD. Baseline evaluation comprised clinical history, voiding diary, uroflowmetry, ultrasound, urinalysis and Dysfunctional Voiding Symptom Score (DVSS). Constipation was assessed using Rome IV criteria, Bristol stool scale, and visual analog scale. Participants were randomized into: Intervention group (IG): urotherapy + biofeedback + PTENS and  Control group (CG): urotherapy alone. Outcomes included resolution of urinary symptoms, DVSS changes, uroflowmetry parameters, bowel function, and urinary tract infections (UTI). Reassessment was performed after 6 months.

The combined therapy resulted in significantly greater improvements across clinical outcomes, uroflowmetry parameters, and bowel function compared to urotherapy alone. Complete resolution of daytime symptoms was higher in the intervention group (61.3%) than in controls (36.7%) (p = 0.001). Objective uroflowmetry improvements were more pronounced in the intervention group: maximum flow rate increased significantly (20.6 ± 8.9 to 25.9 ± 9.0 ml/s; p = 0.002), and post-void residual decreased markedly (18.7 ± 25.1 to 1.65 ± 4.9 ml; p < 0.001), indicating near-complete bladder emptying. No significant changes were observed in the control group. Symptom reduction was substantial in both groups but greater in the intervention group, with urgency decreasing to near zero, incontinence from 2.74 to 0.09/day, enuresis from 17.8 to 4.1 episodes/month, and DVSS from 11.9 to 1.1 (all p < 0.001). Bowel function improved significantly, with constipation prevalence decreasing from 67.7% to 6.4% in the intervention group (90.5% reduction) compared to 40.0% to 20.0% in controls (50% reduction) (p < 0.001). No recurrence of urinary tract infections was observed in any patient during 6-month follow-up, indicating complete prevention.

The addition of biofeedback and PTENS resulted in clinically improvements in both bladder and bowel function. The marked reduction in post-void residual and the increased in flow rate suggest improved bladder emptying and restoration of bladder-sphincter coordination. The substantial reduction in constipation highlights the importance of bladder-bowel interaction in pediatric LUTD. Furthermore, the complete absence of UTI recurrence underscores the clinical relevance of improving voiding efficiency and bowel function through combined neuromodulatory and behavioral interventions.

Combining EMG biofeedback and parasacral TENS with standard urotherapy provides an effective, non-invasive strategy for pediatric LUTD, with significant benefits in bladder and bowel function and complete reduction of UTI recurrence. This approach should be considered an effective early therapeutic option in children with bladder and bowel dysfunction.

Chang SJ, Van Laecke E, Bauer SB, von Gontard A, Bagli D, Bower WF, Renson C, Kawauchi A, Yang SS. Treatment of daytime urinary incontinence: A standardization document from the International Children's Continence Society. Neurourol Urodyn. 2017 Jan;36(1):43-50. doi: 10.1002/nau.22911. Epub 2015 Oct 16. PMID: 26473630.
Dos Reis JN, Mello MF, Cabral BH, Mello LF, Saiovici S, Rocha FET. EMG biofeedback or parasacral transcutaneous electrical nerve stimulation in children with lower urinary tract dysfunction: A prospective and randomized trial. Neurourol Urodyn. 2019 Aug;38(6):1588-1594.
Barroso U Jr. When Should We Offer Parasacral Transcutaneous Electrical Nerve Stimulation for Pediatric Patients with Lower Urinary Tract Dysfunction? J Urol. 2017 Aug;198(2):263-264. doi: 10.1016/j.juro.2017.05.041. Epub 2017 May 16.

Continence 19S (2026) 102608
DOI: 10.1016/j.cont.2026.102608