Is Biofeedback Effective In Children With Primary Bladder Neck Dysfunction?
James Ross, MD1, Michael Leonard, MD2, Melise Keays, MD, MSc2, Julie Lemieux, BSc2, Claude Dubois, BSc2, Luis Guerra, MD, MSc2.
1University of Ottawa, Ottawa, ON, Canada, 2The Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
Primary bladder neck dysfunction (PBND) is a recognized cause of voiding dysfunction in children. PBND has traditionally been diagnosed using videourodynamics, however, EMG lag-time using uroflowmetry has been shown to be a less invasive means of identifying PBND. This study seeks to determine the prevalence of PBND in children with bowel bladder dysfunction using EMG lag-time. A secondary objective was to evaluate the efficacy of biofeedback in the treatment of patients with and without PBND.
IRB-approved retrospective chart review of all patients who had uroflow/EMG as part of biofeedback treatment from 2000 to 2016. As per our institution protocol, most patients received both pre and post-biofeedback uroflow/EMG. EMG lag-time of 6 seconds of greater was used to diagnose PBND. Patients who did not receive either a pre or post-biofeedback uroflow/EMG or had a known underlying anatomic or neurologic cause of voiding dysfunction were excluded.
139 patients underwent biofeedback (44 male, 95 female), mean age 12.9 (SD 4.6) yr, and mean follow-up 23 (SD 24.8) months. Reasons for referral included lower urinary tract symptoms (LUTS)(67.6%), recurrent UTIs (57.6%), and elevated post-void residual (PVR)(12.2%). PBND was present in 34 (24.4%) overall. In the cohort with PBND, the mean (SD) measured outcomes pre-post biofeedback were: dysfunctional voiding symptom score (DVSS) 9.4 (SD 3.1) versus 4.4 (SD 2.9) (p<0.001); Qmax 14.3 (7.6) versus 18.4 (11.9) mL/s (p = 0.044); Qavg 5.7 (3.5) versus 7.5 (4.5) mL/s (p = 0.048); PVR 81.9 (106.2) versus 71.5 (80.0) mL (p = 0.30) and EMG lag-time 28.8 (SD 26) versus 15.6 (15.3) s (p = 0.040). Except for DVSS score, there was no statistically significant difference in the measured outcomes in the non-PBND group following biofeedback.
PBND may be seen in 25% of children presenting with bladder and bowel dysfunction. Uroflow / EMG may be used to diagnose PBND, but should not be used to exclude such patients from the potential benefits of biofeedback treatment. Although it may seem counter-intuitive, our study showed significant benefits of biofeedback in the PBND cohort, which exceeded the gains seen in the non-PBND patients. If a patient with PBND fails to improve after biofeedback, then a trial of alpha-blockers may be warranted. A prospective study randomizing patients with PBND to treatment with either biofeedback or alpha blockers may help to determine the most effective primary treatment for these individuals.
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