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Biofeedback Therapy for Urinary Incontinence

What is urinary incontinence, and who experience urinary incontinence?

The International Continence Society defines urinary incontinence (UI) as involuntary leakage of urine which can be objectively shown, causing social and hygienic problems in the person. Its prevalence increases with age, and is 2-3 times more common in women than men.

In which cases do men experience urinary incontinence?

In men, it is most frequently seen after prostate surgery, and radiation therapy and sphincter dysfunction caused by neurological diseases are among the other causes.

Biofeedback Treatment for Urinary Incontinence

In which cases do women experience urinary incontinence?

Important risk factors such as age, number of births, obesity, smoking, chronic cough, constipation, uterine prolapse and menopause play a role in development of female urinary incontinence. It is seen in one out of every 4 women after the age of 30 and more common after menopause and in women who have given birth to several children.

What are the risk factors related to urinary incontinence and are there different types of incontinence?

Continence means the capacity of a person to control urination, and the most important structure in this function is the pelvic floor muscles. The most common type of female urinary incontinence is stress urinary incontinence which occurs during physical activities that increase intraabdominal pressure such as coughing, sneezing or heavy lifting. The most important factor that underlies this situation is the loss of flexibility and strength in muscles due to the damage in the birth process, surgical operations, advanced age and especially menopause.

Another type of incontinence, urge incontinence may be defined as urinary incontinence after a sudden and strong desire to urinate due to involuntary contraction of bladder muscles. Mixed incontinence is a form of incontinence in which symptoms of both stress and urge incontinence are present, and is more common in the elderly population.

Urinary incontinence is an entity that disturbs the patient due to continuous wetting, irritation and smell and that sometimes may lead to emotional problems, including depression. This negatively affects the daily activities of the patients at home, their social and work lives and sexual functions.

Biofeedback Treatment for Urinary Incontinence

How is urinary incontinence treated?

Urinary incontinence treatment is planned taking into account factors like type and severity of incontinence, presence or absence of accompanying pelvic relaxation and its degree if any, history of incontinence surgery, patient’s age, medical background, training and cooperation level, urodynamic evaluation results and measurement of pelvic floor strength.

Urinary incontinence treatment is split into two groups as surgical and non-surgical (conservative) approaches. These options are preferred according to the risks they carry and their potential to relieve the patient’s complaints. Non-surgical (conservative) treatment methods are the first preference in stress incontinence especially due to lack of side effects and long-term recovery of symptoms.

Non-surgical treatment options in urinary incontinence;

  • Bladder training
  • Pelvic floor muscle exercises
  • Biofeedback
  • Electric stimulation
  • Vaginal and urethral tools
  • Medicinal therapy
  • Acupuncture

What kinds of exercises are done in urinary incontinence?

Because pelvic floor muscle exercises (PFME) were first defined by Amold Kegel, they are called “Kegel exercises”. The purpose of these exercises is to strengthen pelvic floor muscles and improve urethral sphincter function. PFME reduce pelvic organ prolapse and stabilize the vagina. Increase in pelvic floor muscle leads to increase in external urethral muscle tone that controls urine flow, and prevents leakage of urine. .

What is the incontinence device – biofeedback used for? How does the method function?

Biofeedback is a method that provides real-time biologic data to the patient about certain unfelt or involuntary physiological events. With electrodes placed, the patient is taught how he/she can control the relevant site of the body, and change and monitor electronic signals. In this method, the monitoring of motor-control is reflected to the patient via audiovisual signals through a screen and a voice mechanism.

As there is no audiovisual feedback during the exercises or electric stimulation, unintended muscles may contract. Biofeedback is more advantageous in this aspect. Significant loss in pelvic floor strength after pelvic surgery, painful sexual intercourse, urge incontinence and pelvic organ prolapse are areas where biofeedback is widely used, including stress incontinence in particular in adults.

EMG biofeedback is the most common type. Electromyographic activity shows electrical activity measured during striated muscle contraction. It is hard to contract or loosen pelvic floor muscles in isolation. In this method, the patient knows how to differentiate pelvic floor muscles and use pelvic floor muscles selectively without the contraction of abdominal muscles. Muscle strength and control increases ability. If the patient has increased pelvic base muscle activity, an effective and selective relaxation may be achieved with this method. The literature describes recovery between 78% and 90% in women with stress urinary incontinence with exercises in combination with biofeedback.

Continuing an individual home exercise program suitable to the patient improves the success of the treatment. Pelvic floor muscle activity is measured at the beginning of every session during the treatment, and effectiveness of the treatment is evaluated in comparison with previous measurements. EMG biofeedback has recently been also a safe and effective treatment option in primary nocturnal enuresis (bedwetting) in children.

How long does biofeedback treatment in urinary incontinence last?

There is no precise standardization in relation to the period and frequency of biofeedback treatment. When we examine the literature, there are treatment protocols varying between 6 weeks to 6 months with 2 or 3 sessions a week. In general, the treatment starts with a 6-8 week treatment program with 2 or 3 sessions a week and the treatment and control process is adjusted according to the underlying problem of the patient and his/her progress.

EMG biofeedback application may be combined with electrical stimulation therapy in which pelvic floor muscles are stimulated with superficial or vaginal electrodes in eligible patients. The purposes of this method include increase in pelvic floor muscle contraction strength, regulation of urethral function and reduction of involuntary excessive and untimely contraction of the bladder. When biofeedback is used in combination with electric stimulation, significant increase in pelvic floor strength and reduction in severity of incontinence have been reported. In urinary incontinence treatment, electric stimulation can be applied for 6-8 weeks in sessions of 20-30 minutes 3 times a week.

Urinary incontinence rehabilitation covers teaching of pelvic floor muscle exercises, biofeedback and electric stimulation applications. Patients diagnosed with urinary incontinence after evaluation by specialties such as urology, gynecology and obstetrics, geriatrics are candidates for the rehabilitation program. Patients who are found by the physical medicine and rehabilitation specialist to be eligible for treatment are included in the program by determining an appropriate treatment protocol. PFME, biofeedback and electric stimulation treatments are applied by a physical therapist or more specifically an urotherapist.

Which specialists are responsible for diagnosing, treating and following up urinary incontinence?

How is preliminary evaluation performed?

Patients diagnosed with urinary incontinence after evaluation by specialties such as urology, gynecology and obstetrics, geriatrics are candidates for the rehabilitation program. Patients who are found by the physical medicine and rehabilitation specialist to be eligible for treatment are included in the program by determining an appropriate treatment protocol. PFME, biofeedback and electric stimulation treatments are applied by a physical therapist or more specifically an urotherapist.

A detailed history review is very important in the evaluation of patients with incontinence. Physical examination, urinalysis, ultrasonographic residual urine test, cognitive function assessment, genital examination in women, laboratory analyses including renal functions and if necessary urine culture, detailed urological, gynecological and urodynamic evaluations of selected patients are performed by relevant specialists. The success of rehabilitation programs are closely related to patient selection in suitable indications in the light of above evaluations. It is of utmost importance that the rehabilitation team informs the patient about incontinence risk factors and causes, applicable treatments and their effects. Especially in studies performed with women, it was observed that urinary incontinency is accompanied by sexual dysfunction at rates from 30% to 46%. Similarly, it is necessary to be sensitive in psychological conditions like depression and anxiety and to provide the patient with the support he/she needs. A rehabilitation program which has been planned in every aspect will increase the success of biofeedback and other physical treatment methods in the treatment of patients with urinary incontinence and improve the patients’ quality of life.

How is acupuncture treatment used in urinary incontinence?

Derived from the words, acus (needle) and punctura (puncture), acupuncture is a completely scientific method involving thin needles inserted into the body at certain points for the treatment of various diseases. Acupuncture is one of the ancient treatment methods, which has been applied in the treatment of diseases for longer than 4000 years in the whole world, including notably China and Far Eastern countries. The main philosophy of this treatment depends on union, balance and harmony between energy flows in both living and non-living things in the whole universe. In this sense, acupuncture is a balance therapy.

In 1979, the World Health Organization (WHO) adopted acupuncture as a scientific method and published a list of medical conditions in which it is effective. Urinary incontinence is a clinical condition in which acupuncture therapy has been demonstrated to be effective in controlled clinical studies and hence been included in the list of the World Health Organization. Where patient selection is meticulously made, we observe that the inclusion of acupuncture therapy in urinary incontinence rehabilitation program described above increases success rates.

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