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Articles    H4'ed 12/5/09

The Use of Electromyographic Biofeedback for Training Pelvic Floor Musculature

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Message Barbara Woolner
Barbara Woolner,
RN, Fellow, BCIA-C, CCCN
Chairperson for SUNA/WOCN Continence Coalition
Jacques Corcos, MD
Associate Professor, McGill University
Chief, Department of Urology
Sir Mortimer B. Davis Jewish General Hospital
Montreal, Quebec
Stephen Drew, Ph.D.
Biofeedback Associates of Northern California
San Rafael, CA


Incontinence is a major healthcare problem costing a conservative estimate of $15 billion, annually, in the USA. This reality is mirrored in countries worldwide. Patients with this problem often lead lives of quiet desperation and social isolation.

Incontinence is among the leading causes of nursing home admission, with approximately 50% of all residents being incontinent. While it is estimated that the number of incontinent geriatric patients can be as high as 80%11, it is more difficult to estimate the incidence in younger populations, though studies by Nygaard show incontinence to be common in young nulliparous women, particularly during physical activities. One Danish study5, conducted with a group of 45-year-old women, found that 22% experienced stress incontinence. It was also noted that only three percent of these women sought medical attention for their problem.

The National Association for Continence (NAFC) states "that while only one out of twelve incontinent patients in the United States actually report their symptoms to their doctors, approximately 80% can be cured or improved. Unfortunately, women wait an average of 3 years before admitting their incontinence to a health care provider. A persistent myth is that incontinence is a natural part of aging. The cause of incontinence is often multi-faceted and many combined factors, other than age, are often responsible. These factors may include childbirth, hormonal status, previous surgery, muscle dysfunction or weakness, physical injury or medication, to name a few.

The main types of urinary incontinence are stress, urge, mixed and overflow. Stress incontinence occurs when the pressure within the abdomen is higher than the urethral resistance. This can happen while coughing, sneezing, bending, lifting a heavy object or participating in athletic activities. Urge incontinence, or overactive bladder, is the inability to prevent urine leakage long enough to reach the toilet when one senses the urge to void. Urge incontinence is the primary type of loss of bladder control in persons over the age of 65. When an individual experiences symptoms of both stress and urge incontinence it is called mixed incontinence and usually one type of symptom is more bothersome to the patient. Only 5-10% of incontinent patients experience overflow incontinence. Overflow incontinence occurs when the bladder cannot empty completely because of obstructions or loss of bladder muscle strength, and, thus, becomes over distended. It leads to frequent, and, sometimes, nearly constant, urine loss. It also usually requires medical management.

Urge incontinence is frequently treated and improved by pharmacologic manipulations. Anticholinergic drugs are usually quite effective in inhibiting the involuntary bladder contractions that cause leakage in patients with this type of incontinence. Many patients will benefit from non-invasive behavioral treatments that can be started along with the medication. Often, these patients will be able to reduce or even stop using medication once they have begun to benefit from the behavioral intervention. Certain pharmaceutical blocker agents can help when overflow incontinence is secondary to a bladder neck obstruction, such as prostate hypertrophy.

Very few controlled studies have shown patient improvement of stress incontinence using medication. Behavioral modification, as a treatment modality for stress urinary incontinence, has been the focus of clinical attention for the past couple of decades in North America, although European doctors have used these techniques for far longer with a very high success rate.

The core behavioral treatment of urinary incontinence is pelvic muscle re-education. The pelvic floor refers to the complex of connective tissues and muscles that close off the pelvic outlet and act as a "floor" to the abdominopelvic cavity. The primary muscular component of the pelvic floor is the Levator Ani group of striated muscle fibers which is comprised of the pubococcygeus, puborectalis and the ileococcygeus muscles. The external sphincter of the urethra and the anal sphincter are in continuity with these muscles. Both receive pudendal innervation. Biofeedback "takes the guesswork out of pelvic muscle training" (reference NIDDK) because it enables the patient to improve pelvic muscle function through muscle awareness, which, when combined with a home exercise program, leads to increased muscle strength and improved coordination.

In a review of several studies using biofeedback to teach pelvic muscle exercises (Kegel's exercises) for the treatment of incontinence14, Tries states that patients benefit from biofeedback by developing a greater sense of control and mastery of bladder and bowel control , thus significantly reducing their fear, anxiety, isolation and hopelessness. A 1998 article in the Journal of the Americal Medical Association (JAMA) by Burgio reports that "patients treated with biofeedback showed a significantly greater reduction in urinary incontinence than a second group who received pharmaceutical intervention.

In 1996, U.S. Department of Health and Human Services, Agency for Health Care Policy and Research (AHCPR), released an updated Clinical Practice Guideline on urinary incontinence, recommending that "behavioral procedures, such as biofeedback, be attempted before consideration of surgical or other invasive techniques.

Assessment of Incontinent Patients

Prior to being admitted to the biofeedback program, patients must be evaluated by a Urologist, Urogynecologist or other physician with expertise in this field. Some forms of incontinence, even genuine stress incontinence, could be secondary to a general disease (multiple sclerosis, diabetes, etc.) or to a local specific disease (carcinoma insitu, interstitial cystitis, tuberculosis, etc.), for which biofeedback treatment may not be appropriate. However, in those cases, although biofeedback does not ameliorate the underlying condition, it may improve the incontinence.

A daily bladder or bowel diary should be kept for one week prior to beginning a behavioral program. This should include the number of incontinent accidents, activity associated with the accidents, times of regular voiding and fluid intake. The evaluation will include a review of the patient's medical history, a vaginal and/or rectal examination, an assessment of bladder and urethral prolapse, rectal prolapse, muscle strength and of the patient's ability to control his or her pelvic muscles. Usually, only urine analysis and culture and post void residuals are necessary. Depending on history and physical examination findings, urodynamic testing, cystometrogram, abdominal leak point pressure, and/or bladder leak point pressure, x-rays and cystoscopy could be useful.

During the pre-treatment visit, the healthcare professional will provide educational information and explain the use of the equipment, including the sensor and its placement. Because of past concerns about sterilization of sensors, "Single-User" sensors, such as shown in Figure 1, have become the standard.

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RN, Fellow, BCIA-C, CCCN Chairperson for SUNA/WOCN Continence Coalition
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