Value of Bladder Neck Descent on Upright VCUG in Predicting Effectiveness of Biofeedback Therapy to Improve Stress Incontinence in Young Nulliparous Females
Stuart B. Bauer, MD1, Evalyn Vasquez, MD-MBA1, Marc Cendron, MD-MBA1, May M. Wakamatsu, MD2, Jeanne S. Chow, MD1.
1Boston Children's Hospital, Boston, MA, USA, 2Massachusetts General Hospital, Boston, MA, USA.
BACKGROUND: Stress urinary incontinence in young, physically active females is becoming an increasingly recognized problem as young women who engage in extracurricular activities are voicing their symptoms more frequently. In some teenagers the degree of incontinence has impacted their quality of life to the point of avoiding physical activities that induce stress related incontinence. To improve accuracy of diagnosis and efficiency of management, we hypothesized that an upright VCUG showing descent of the bladder neck might be helpful in determining the effectiveness of biofeedback therapy in treating girls with stress urinary incontinence. METHODS: Between 2000 and 2015 we performed upright voiding custourethrography (VCUG) in 34 girls with stress urinary incontinence without other lower urinary tract symptoms or detrusor overactivity on urodynamics. Descent of the bladder neck below the pubic symphysis was correlated to an individual's response to biofeedback therapy in achieving urinary continence. BMI was obtained from chart review at time of initial visit and 'Z' scores referring to SDs above or below the mean were calculated. Statistical analysis involved Fisher exact test, two-tailed
RESULTS: 34 girls with stress urinary incontinence resulting from a varying degree of physical activity underwent upright VCUG to determine pelvic floor laxity; an incidence of 0.025% of all females seen with daytime incontinence in our clinic during this time period. Of these, 33 were eligible for inclusion (one was eliminated due to detrusor overactivity on urodynamic testing). Their ages ranged from 5 - 20 years (mean 14.5). The cohort was divided into 2 groups: 20 girls with bladder neck descent > 2 cm on an upright VCUG (Group A) and 13 with < 2 cm descent (Group B). BMI and Z scores were similar for both groups: Group A = 20.3(15.2 - 26.7) and 0.4(-0.9 to 1.6), respectively, versus Group B = 21.3(16.5 - 28.6) and 0.4(-0.9 to 2.4), respectively. 17 of 20 girls in Group A (with descent) were involved in physically active sports, whereas only 1 of 13 in Group B (without descent) engaged in intense athletics. All females were encouraged to follow standard urotherapy practice consisting of timed voiding, an effective bowel regimen and a proper diet. Additionally, biofeedback therapy was recommended to all but only 24 completed a full course of treatment: 16 in Group A (age range 5.4 to 20.6; median 15.2 years) and 8 in Group B (age range 7.3 to 17.3; median 12.5). Only 13 of the 24 (53%) undergoing biofeedback rehabilitation became completely continent. However, the success rates for Group A and for Group B were 42% (6 of 16) and 87% (7 of 8), respectively (p = 0.0335).
CONCLUSIONS: This data suggests that VCUG - used to demonstrate the extent of pelvic floor descent - may be a useful tool to predict whether a patient is likely to respond to intensive biofeedback therapy. It seems reasonable to initiate management with biofeedback training in all girls with debilitating stress urinary incontinence with the likelihood of success dependent on the degree of laxity of their pelvic floor musculature.
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