Animated Biofeedback: An Ideal Treatment for Children With

Dysfunctional Elimination Syndrome

Abdol-Mohammad Kajbafzadeh,* Lida Sharifi-Rad, Seyyed Mohammad Ghahestani,Hamed Ahmadi, Majid Kajbafzadeh and Amir Hassan MahboubiFrom the Pediatric Urology Research Center and Department of Physical Therapy (LS-R), Children’s Hospital Medical Center, TehranUniversity of Medical Sciences, Tehran, Iran

Purpose: Animated biofeedback is an established treatment for pediatric dys-functional voiding. Bowel dysfunction is closely associated with dysfunctionalvoiding. We evaluated the efficacy of animated biofeedback urotherapy in boweland voiding dysfunction in children with dysfunctional elimination syndrome.Materials and Methods: A total of 80 children with dysfunctional eliminationsyndrome were randomly assigned to undergo animated biofeedback (group A, 40patients) or conservative therapy (group B, 40 patients). Group A underwentanimated biofeedback along with pelvic floor muscle exercises and behavioralmodification (hydration, high fiber diet, scheduled voiding). Group B underwentbehavioral modification only. Dysfunctional voiding symptom score, constipationand fecal soiling episodes per week (according to Paris Consensus on ChildhoodConstipation Terminology criteria), and uroflowmetry parameters were evalu-ated before and 6 and 12 months after treatment in both groups.Results: Subjective and objective voiding problems were significantly improved.Vesicoureteral reflux resolved in 7 of 9 children (78%) and urinary tract infectiondid not recur in 10 of 14 children (71%) within 1 year. Bladder capacity andvoided volume did not significantly improve. Post-void residual and voiding timedecreased considerably, while maximum and average urine flow increased sig-nificantly. All children with fecal soiling and 17 of 25 with constipation (68%) ingroup A were symptom-free within 1 year after treatment. Animated biofeedbacktherapy was more efficient than nonbiofeedback management regarding objectiveand subjective voiding problems and bowel dysfunction (p �0.05).Conclusions: Animated biofeedback effectively treats bowel and voiding dysfunc-tion in children with dysfunctional voiding. Pelvic floor muscle exercises coordi-nate breathing and pelvic floor muscle contractions, and are beneficial in improv-ing bowel dysfunction.

Key Words: biofeedback, psychology, constipation, elimination disorders,

Abbreviations

and Acronyms

BC � bladder capacity

DES � dysfunctional eliminationsyndrome

DV � dysfunctional voiding

DVSS � dysfunctional voidingsymptom score

EMG � electromyogram

KUB � plain x-ray of the kidneys,ureters and bladder

PVR � post-void residual

UTI � urinary tract infection

VCUG � voiding cystourethrogram

VUR � vesicoureteral reflux

Submitted for publication April 9, 2011.Study received institutional review board ap-

proval.* Correspondence: Pediatric Urology Research

Center, Department of Pediatric Urology, Chil-dren’s Hospital Medical Center, Tehran Universityof Medical Sciences, No. 32, 2nd Floor, 7th St.,Saadat-Abad Ave., Tehran 1998714616, Iran(telephone: 98-21-2208-9946; FAX: 98-21-2206-9451; e-mail: kajbafzd@sina.tums.ac.ir).

urination

DYSFUNCTIONAL voiding is a learned be-havior, defined as habitual contractionof the urethral sphincter specificallyduring the voiding phase.1 This entityis closely associated with enuresis, uri-nary incontinence, vesicoureteral re-flux and urinary tract infection and,

therefore, imposes a considerable so-

0022-5347/11/1866-2379/0THE JOURNAL OF UROLOGY®

© 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RES

cial, developmental and physical bur-den on children and their families. An-imated biofeedback, initially describedby McKenna et al 1999,2 is an inter-active modality that has resulted inpromising improvements in urinarycontinence and pelvic floor muscle

tone.3 This therapy has also been ob-

Vol. 186, 2379-2385, December 2011Printed in U.S.A.

EARCH, INC. DOI:10.1016/j.juro.2011.07.118www.jurology.com 2379

ANIMATED BIOFEEDBACK IN PATIENTS WITH DYSFUNCTIONAL ELIMINATION2380

served to attenuate effectively constipation and fecalsoiling in children with dysfunctional voiding.2 Boweldysfunction is reportedly associated with functionalbladder outlet dyscoordination, urinary incontinence,urinary tract infection and vesicoureteral reflux. Koffet al defined the association between constipation, dys-functional voiding, vesicoureteral reflux and urinarytract infection under the inclusive term, dysfunc-tional elimination syndrome.4 Anorectal biofeedbacktreatment has resulted in bowel function improve-ment in the majority of patients with functionalbowel dysfunction.5 We report our experience withthe animated biofeedback modality in combinationwith pelvic floor exercises in the treatment of chil-dren with dysfunctional elimination syndrome inthe realms of bowel and voiding dysfunction.

MATERIALS AND METHODS

A total of 80 children with DES were randomly assigned toundergo animated biofeedback (group A) or conservativetherapy (group B) between June 2008 and February 2010.Group A included 40 children with a mean � SD age of8.5 � 2.7 years with DV and bowel dysfunction. Thesepatients underwent animated biofeedback along with pel-vic floor muscles exercises and behavioral modification.Group B included 40 children with a mean � SD age of 9 �2.3 years with the same diagnosis and similar sex/agedistribution. These patients received education about be-havioral modifications (hydration, high fiber diet, sched-uled voiding) without undergoing biofeedback sessions.Number of diurnal incontinence episodes and wet nightsper week, patients with urgency, patients with constipa-tion according to the Paris Consensus on Childhood Con-stipation Terminology criteria, fecal soiling episodes perweek and urinary tract infections in the last 6 months,and VUR grade, presence of DVSS and uroflowmetry pa-rameters were evaluated before and 6 months and 1 yearafter treatment and compared between the 2 groups.

Inclusion criteria consisted of age older than 5 years,and simultaneous constipation and/or fecal soiling andvoiding dysfunction. Voiding dysfunction was defined ashabitual contraction of the urethral sphincter during thevoiding phase as demonstrated by 2 uroflowmetry EMGsdone in separate sessions showing staccato patterns andincreased EMG activity while voiding or constant EMGactivity with a plateau pattern of void.6 Constipation wasdefined according to the Paris Consensus on ChildhoodConstipation Terminology, consisting of a mean period of8 weeks with at least 2 symptoms that included defecationfrequency less than 3 times weekly, fecal incontinencefrequency greater than once weekly, passage of largestools that clogged the toilet, palpable abdominal or rectalfecal mass, stool withholding behavior and painful defe-cation.7 Children whose physical examination, KUB orhistory was suggestive of an occult neurological defectwere excluded from the study and lumbosacral magneticresonance imaging was requested. Those having a bonyfusion defect on KUB were reentered in the study if mag-netic resonance imaging was normal and no specific neu-

rological condition was attributed.

At study entrance patients underwent 2 separate ses-sions of uroflowmetry EMG with patch electrodes, voidingdiary, KUB, renal and bladder ultrasound denoting blad-der capacity and post-void residual, urinalysis and cul-ture, and precise physical examination by a consultantpediatric urologist. A DVSS questionnaire was also filledout and frequency of stool passage in a week was recordedaccording to parent report. VCUG was performed to ex-clude various urethral or lumbosacral anomalies.

According to a random number chart, patients wereassigned to undergo either animated biofeedback or con-servative therapy (timed voiding, high fiber diet, hydra-tion). Patients in group A were educated about the coor-dinate function of the urinary tract and gastrointestinaltract, scheduled voiding, pelvic floor exercises, hydrationand high fiber diet. Mild bulking agent laxatives wereprescribed when necessary but any medication targetingbladder function was withheld. Antibiotics were continuedif necessary. Patients in group B were recommended tocome for monthly visits for 6 months to reinforce trainingand enhance compliance. At the 6th and 12th monthlyvisits uroflow EMG was done, and DVSS and frequency ofstool passage in a week were reevaluated. Renal bladderultrasound assessing bladder capacity and PVR was alsoperformed. In children who had VUR at the beginning ofthe study VCUG was done at the 6-month visit but wasnot repeated at 12 months unless an episode of UTI oc-curred in the meantime.

Patient guardians in both groups were educated abouturinary and gastrointestinal tract function. Each patientin group A underwent 2 weekly sessions of animated bio-feedback therapy. Uroflow EMG was done at the begin-ning of each session. Sessions stopped at normalization ofuroflow EMG, with a minimum of 6 and a maximum of 12sessions. Evaluations at 6 and 12 months were the sameas for the other group. Details of the project were ex-plained to the children and their caregivers at the begin-ning for both groups, and written informed consent wasobtained. The institutional review board of the TehranUniversity of Medical Sciences approved the study proto-col.

Patient Education and Pelvic Floor ExercisesBefore the start of animated biofeedback a physiothera-pist explained the physiology and function of the bladderand pelvic floor through a short story. For each patient thephysiotherapist assessed pelvic floor muscle activity viapalpation and instructed children how to contract (10 sec-onds) and relax (30 seconds) the pelvic floor muscles. Inaddition to traditional Kegel exercises, our training pro-gram included postural instruction, abdominal wall mus-cle pattern recognition, pelvic floor muscle relaxation, anda combination of breathing and pelvic floor exercises thatcoordinates breathing and the pelvic floor muscles. Chil-dren were instructed to practice exercises at home for atleast 15 minutes twice daily.

Biofeedback/Uroflow EMGUroflowmetry/electromyography was performed in chil-dren in group A with a nearly full bladder before eachanimated biofeedback session. Patch electrodes wereplaced on the perineum at the 3 and 9 o’clock positions to

measure the electrical activity of the pelvic floor muscles,

ANIMATED BIOFEEDBACK IN PATIENTS WITH DYSFUNCTIONAL ELIMINATION 2381

and abdominal electrodes were placed on the rectus ab-dominis to record abdominal muscle activity during void-ing.

Biofeedback therapy was performed twice weekly witha standard biofeedback system (Urostym™). Special ad-aptations to the voiding setting were made for youngerchildren, and foot support was provided.

Several animated computer games, such as Dolphin,Monkey, Fish, Bee and UFO, were used whose movementsrepresented the appropriate muscular responses in thechild. The patient must tighten and relax the pelvic mus-cles in a controlled fashion to complete the game. Duringeach session the results of uroflowmetry/EMG were com-pared to previous sessions, and a physiotherapist dis-cussed different aspects of biofeedback training with thechildren and their parents so that any changes in clinicalprogress, voiding diary, symptoms, and compliance withexercises could be assessed and modified.

FollowupThe treatment outcome was evaluated regarding subjec-tive parameters (presence or absence of daytime wetting,nocturnal enuresis, urgency, constipation, fecal soilingand DVSS) and objective parameters (uroflowmetry re-sults, voiding pattern, pelvic floor activity during void,UTI, BC and PVR) at 6 months and 1 year followingtreatment. VCUG was done at 6 months only in patientswho exhibited VUR in the first study or had a new episodeof UTI. Data were compared between the 2 groups.

Data were analyzed using SPSS®, version 18. Contin-uous variables, expressed as mean � SD, were comparedusing paired sample t tests, and categorical variables,expressed as percentages, were analyzed using chi-squareand McNemar testing. A p value of less than 0.05 wasconsidered statistically significant.

RESULTS

Mean � SD age in group B (10 boys and 30 girls) was9 � 2.3 years (range 6 to 16) and in group A (8 boysand 32 girls) was 8.5 � 2.7 years (5 to 16). Mean �SD number of biofeedback sessions was 9.6 � 1.3(range 6 to 12). All children completed the followupsessions (see figure). All children in group B at-tended their monthly visits.

Of the patients in group A 73% were dry at nightat 6 months and 64% at 1 year. Urgency resolved in35 patients (88%) at 6 months and 1 year of fol-lowup. The magnitude of improvement in these sub-jects is best statistically reflected in DVSS scoreimprovement. At 6 months mean decrease in DVSSin group A was 5.51 vs 2.94 in group B (p �0.0001).Also at 12 months mean decrease in DVSS in groupA was significantly greater (6.45 vs 3.55, p �0.0001).Significant improvement in objective parameterswas also observed, including abnormal voiding pat-tern (92.5% at 6 months and 85% at 1 year werenormalized to a bell-shaped noninterrupted pat-tern). Resolution of fecal soiling and constipation

was also achieved within 6 months and maintained

at 1 year after biofeedback treatment in 100% and68% of patients in group A, respectively.

Of the 14 children with a history of recurrentUTIs in the 6 months preceding the study only 2 hada UTI within 6 months after starting treatment,which increased to 4 children at 1-year followup.Eight patients in group A and 7 in group B had VURat the beginning of the study. In group A the refluxresolved at 6 months after treatment in all affectedchildren except 1, who had grade IV reflux. The rateof improvement in subjective and objective parame-ters at 2 followup sessions was significantly greaterfollowing animated biofeedback compared to conser-vative therapy. At 6 months 68% of patients in groupA and 40% in group B were not constipated(p � 0.01). Fecal soiling resolved in 100% of patientshaving this problem in group A but only 20% ingroup B. At 1 year this therapeutic effect was bestpreserved in group A. Conservative treatment didnot reveal any considerable effect on high gradeVUR and only improved low grade VUR in 3 pa-tients in group B at 6 months (table 1).

Regarding uroflowmetry parameters, BC andvoided volume in both groups improved after treat-ment but the difference was not statistically signif-icant. In group A post-void residual and voiding timedecreased considerably, while maximum and aver-age urine flow increased significantly at 1 year. Al-though voiding time and maximum and averageurine flow demonstrated significant changes at 6months in group B, this beneficial effect disappearedat the second followup evaluation, contrary to thepersistent beneficial effect seen in group A (table 2).

DISCUSSION

According to the report of the International Chil-dren’s Continence Society Standardization Commit-tee, “A child with dysfunctional voiding habituallycontracts the urethral sphincter during voiding . . .the term cannot be applied unless repeat uroflowmeasurements show curves with a staccato patternor else verified by invasive urodynamic study.”6 Al-though in this report the term dysfunctional voidingis preferred, voiding dysfunction is accepted as anequivalent term and both are attributed specificallyto voiding phase.

In recent years biofeedback therapy along withEMG monitoring has become a widespread modalityfor the treatment of DV. The application of animatedcomputer games for treating DV was first intro-duced by McKenna et al.2 Since then, other studieshave been carried out with successful treatment out-comes.1,3,8,9 However, some series have revealed du-rable and effective results with nonbiofeedback be-

havioral therapies.10

fore a

ANIMATED BIOFEEDBACK IN PATIENTS WITH DYSFUNCTIONAL ELIMINATION2382

In this study we randomized patients to 2 groups,nonbiofeedback behavioral treatment and animatedbiofeedback therapy. We describe our experiencewith animated biofeedback in the treatment of DVwith special interest in bowel dysfunction improve-ment. McKenna et al also reported improvement inbowel function with biofeedback treatment of void-ing dysfunction.2 They reported a high compliancerate (95%) with their program, and found 87% to90% subjective and 42% objective uroflow improve-ment in their cohort 6 months after treatment.Herndon et al stated that some factors, includingsmall BC, patient noncompliance and voided volumeplus PVR 70% or less than predicted BC, might

Uroflow/EMG patterns be

predict failure with computer game assisted pelvic

floor muscle retraining.1 Pfister et al,3 and Kaye andPalmer8 also demonstrated that computer game as-sisted biofeedback is comparable to nonanimatedbiofeedback treatment with regard to subjectiveand objective voiding abnormalities, in consider-ably fewer treatment sessions. Our experiencewith animated biofeedback resulted in consider-able improvement in daytime wetting, nocturnalenuresis and urgency, as well as abnormal voidingpattern and EMG activity during voiding in chil-dren with DV.

McKenna et al reported that UTI recurred in 14%of children 6 months following animated biofeedbacktherapy.2 In another study there was only a 7.3%

nd 1 year after treatment

incidence of UTI recurrence after 6 months.8,9 The

ANIMATED BIOFEEDBACK IN PATIENTS WITH DYSFUNCTIONAL ELIMINATION 2383

rate of UTI recurrence in our cohort was 14% at 6months and 28.6% at 1 year after treatment.

There is a close connection between primaryVUR and nonneurogenic bladder dysfunction.Kibar et al reported an overall resolution rate of63% at less than 1 year following biofeedbacktreatment.11 Similar results were reported byPalmer et al, with resolution in 55% and down-

Table 1. Signs and symptoms of dysfunctional elimination befo

Before Treatment

Biofeedback Conservative Therapy Biofe

No. subjective parameters (%):Daytime wetting 10 (25) 11 (27.5) 2Nocturnal enuresis 11 (27.5) 9 (22.5) 3Urgency 17 (42.5) 16 (40) 2Constipation 25 (62.5) 20 (50) 8Fecal soiling 15 (37.5) 20 (50) 0

No. objective parameters (%):Staccato voiding 30 (75) 32 (80) 2Flattened voiding 10 (25) 8 (20) 1Episodic EMG activity during void 33 (82.5) 28 (70) 4UTI 14 (35) 22 (55) 2VUR: 9 (22.5) 8 (20) 1

Grade I 4 (44) 3 (37.5) 0Grade II 2 (22) 2 (25) 0Grade III 1 (11) 1 (12.5) 0Grade IV 1 (11) 2 (25) 1 (Grade V 0 (0) 0 (0) 0

* Compared to before treatment.

Table 2. Bladder, voiding and DVSS parameters before and aft

Before Treatmen

Mean � SD BC (ml):Biofeedback 254 � 113Conservative therapy 237 � 94

p Value 0.017Mean � SD PVR (ml):

Biofeedback 12.5 � 6.2Conservative therapy 13 � 2.5

p Value 0.907Mean � SD voided vol (ml):

Biofeedback 241 � 33.8Conservative therapy 230 � 7.5

Mean � SD voiding time (sec):Biofeedback 34 � 20Conservative therapy 27.4 � 10.4

p Value 0.015Mean � SD max urinary flow rate (ml/sec):

Biofeedback 18.9 � 8.1Conservative therapy 18 � 6.6

p Value 0.062Mean � SD av urinary flow rate (ml/sec):

Biofeedback 9.2 � 4.7Conservative therapy 7.5 � 2.6

p Value 0.407Mean � SD DVSS:

Biofeedback 9.5 � 4.7Conservative therapy 9.6 � 5.4

p Value 0.782

grading in 16% of VUR cases 1 year after biofeed-back treatment for DV.9 Regarding animatedbiofeedback therapy, McKenna et al reported res-olution of VUR in 4 children (28.5%).2 In addition,Pfister et al reported that VUR resolved in 4 chil-dren who had simultaneous pelvic floor activityduring voiding at 6 months after animated bio-feedback therapy.3 In our experience animated

d after treatment

After Treatment

p Value*

12 Mos After Treatment

p Value*Conservative Therapy Biofeedback Conservative Therapy

3 (7.5) 0.04 3 (7.5) 3 (7.5) 0.0035 (12.5) 0.01 4 (10) 6 (15) 0.019 (22.5) 0.03 2 (5) 14 (35) 0.001

12 (30) 0.01 8 (20) 12 (30) 0.00916 (40) 0.04 0 (0) 9 (22.5) 0.005

22 (55) 0.001 3 (7.5) 24 (60) 0.0015 (12.5) 0.001 3 (7.5) 7 (17.5) 0.001

13 (32.5) 0.001 11 (27.5) 18 (45) 0.0015 (12.5) 0.02 4 (10) 10 (25) 0.35 (12.5) 0.001 2 (5) 7 (17.5) 0.0011 (20)1 (20)1 (20)2 (40)0 (0)

tment

6-Mo Followup (p Value) 1-Yr Followup (p Value)

270 � 96 (0.3) 259 � 104 (0.7)240 � 80 (0.6) 238 � 95 (0.9)

0.000 0.000

5.7 � 2.9 (0.002) 7.4 � 4.5 (0.01)11.3 � 1.8 (0.2) 12.6 � 2 (0.8)

0.522 0.545

258 � 15.1 (0.2) 245 � 22.1 (0.8)240 � 10.8 (0.5) 235 � 11.2 (0.7)

22.6 � 12.5 (0.003) 26.5 � 15.5 (0.02)18.5 � 12.3 (0.03) 24.7 � 14.2 (0.3)0.105 0.225

23.7 � 8.2 (0.001) 21.9 � 7.4 (0.04)23.3 � 12.9 (0.002) 19 � 7.1 (0.2)0.085 0.087

11.7 � 4 (0.001) 10.9 � 4 (0.03)10.2 � 6.7 (0.02) 8 � 4 (0.6)0.000 0.009

4.02 � 3.4 (0.001) 3.08 � 3.5 (0.001)6.7 � 4.1 (0.000) 6.1 � 4.1 (0.233)

re an

6 Mos

edback

(5)(7.5)

(5)(20)(0)

(5)(2.5)(10)(5)

(2.5)(0)(0)(0)

100)(0)

er trea

t

0.003 0.000

ANIMATED BIOFEEDBACK IN PATIENTS WITH DYSFUNCTIONAL ELIMINATION2384

biofeedback resulted in a high resolution rate forVUR (89%) at 6 months after treatment.

It has long been recognized that children with DVand recurrent UTIs often have associated bowel dys-function, including constipation and encopresis. Func-tional fecal incontinence in childhood occurs in 0.3% to8% of children, depending on age. Studies of childrenwith functional bowel dysfunction have shown accom-panying UTI and diurnal enuresis in 10% and 30% ofchildren, respectively.12 However, only recently hasthe term DES been used to recognize the existence ofthis relationship. This term recognizes that functionalbowel disorders may fundamentally affect functionallower urinary tract abnormalities such as unstable oroveractive bladder. We found a significant resolutionof constipation and fecal soiling, which is comparableto previous reports.2

The limitations of this study included the smallsample size, especially in those children who hadconcurrent VUR and UTIs. The number of treat-ment sessions with animated biofeedback was rela-tively high compared to previous reports, which

could be due partly to noncompliance of our younger

REFERENCES

EDITORIAL COMMENT

authors are and as correct as their observations may

study population. Another limitation of the study isthat we did not use a validated bowel function ques-tionnaire and instead reported the weekly frequencyof defecation, fecal soiling episodes and loose fecalconsistency as reported by parents.

CONCLUSIONS

Animated biofeedback in combination with pelvicfloor exercises resulted in promising improvementsin subjective and objective manifestations of dys-functional voiding, as well as notable resolution ofbowel dysfunction, vesicoureteral reflux and recur-rent urinary tract infections. Future controlled stud-ies with larger sample sizes are needed to establishthe role of animated biofeedback in the treatment ofdysfunctional elimination syndrome.

ACKNOWLEDGMENTS

Zahra Rahimi and Maryam Alijani, urodynamic sec-tion of the Department of Pediatric Urology, and Dr.Mohammad Javad Mohseni, Pediatric Urology Re-

search Center, assisted with the study.

1. Herndon CD, Decambre M and McKenna PH:Interactive computer games for treatment of pel-vic floor dysfunction. J Urol 2001; 166: 1893.

2. McKenna PH, Herndon CD, Connery S et al: Pelvicfloor muscle retraining for pediatric voiding dys-function using interactive computer games.J Urol 1999; 162: 1056.

3. Pfister C, Dacher JN, Gaucher S et al: The use-fulness of a minimal urodynamic evaluation andpelvic floor biofeedback in children with chronicvoiding dysfunction. BJU Int 1999; 84: 1054.

4. Koff SA, Wagner TT and Jayanthi VR: The rela-tionship among dysfunctional elimination syn-dromes, primary vesicoureteral reflux and urinarytract infections in children. J Urol 1998; 160:

5. Croffie JM, Ammar MS, Pfefferkorn MD et al:Assessment of the effectiveness of biofeedbackin children with dyssynergic defecation and re-calcitrant constipation/encopresis: does homebiofeedback improve long-term outcomes? ClinPediatr (Phila) 2005; 44: 63.

6. Chase J, Austin P, Hoebeke P et al: The manage-ment of dysfunctional voiding in children: a reportfrom the Standardisation Committee of the Inter-national Children’s Continence Society. J Urol2010; 183: 1296.

7. Benninga M, Candy DC, Catto-Smith AG et al:The Paris Consensus on Childhood ConstipationTerminology (PACCT) group. J Pediatr Gastroen-terol Nutr 2005; 40: 273.

8. Kaye JD and Palmer LS: Animated biofeedback

article). In an acco

feedback in the treatment of dysfunctionalvoiding in girls. J Urol 2008; 180: 300.

9. Palmer LS, Franco I, Rotario P et al: Biofeedbacktherapy expedites the resolution of reflux in olderchildren. J Urol 2002; 168: 1699.

10. Wiener JS, Scales MT, Hampton J et al: Long-term efficacy of simple behavioral therapy fordaytime wetting in children. J Urol 2000; 164:786.

11. Kibar Y, Ors O, Demir E et al: Results of biofeed-back treatment on reflux resolution rates in chil-dren with dysfunctional voiding and vesi-coureteral reflux. Urology 2007; 70: 563.

12. Nijman RJ: Diagnosis and management of urinaryincontinence and functional fecal incontinence(encopresis) in children. Gastroenterol Clin North

1019. yields more rapid results than nonanimated bio- Am 2008; 37: 731.

These authors performed a careful and well docu-mented study evaluating the benefit of adding anima-tion biofeedback therapy to the treatment regimen ofchildren with urodynamically proved dysfunctionalvoiding and associated bowel dysfunction. Not surpris-ingly, the cohort undergoing biofeedback therapy,which is generally accepted as the standard of carefor this condition, fared much better than those whowere not so treated. However, as thoughtful as these

be, there are several caveats and shortcomings thatdeserve mention. The characterization by the au-thors of the term DES as being synonymous withcombined DV and bowel dysfunction is not entirelycorrect. Koff et al were quite clear in their reportthat DES referred to a collection of syndromes inwhich bowel dysfunction was associated with a va-riety of bladder/voiding conditions, and that com-bined, focused therapy was critical (reference 4 in

mpanying editorial comment Ca-

ANIMATED BIOFEEDBACK IN PATIENTS WITH DYSFUNCTIONAL ELIMINATION 2385

sale similarly noted the importance of individual-ized evaluation and treatment. This point is not anexercise in semantics.

Although these authors were careful to documentthe specific type of DES assessed in their study, theterm DES has through time become diluted by thosewho use it as a wastebasket term for a host of con-ditions as if it were a single specific entity. Thisoveruse in turn muddies the waters on this subjectand can potentially lead to patients receiving inad-equate therapy, or to treatment being reported asless than effective when in fact it may simply havebeen incorrectly applied.

Multimodal therapy including anticholinergics isoften needed in patients with DV. That anticholin-ergics were not given to either group could certainlyexplain why bladder capacity was not significantlydifferent in either group, and why in the end at leastsome of the wetting and lower urinary tract symp-toms had failed to resolve. Another shortcoming wasin the evaluation of reflux. With the repeat VCUGbeing performed at 6 months instead of at the morestandard 12 to 18 months after initiation of therapy,

REFERENCE

1. Combs AJ, Glassberg AD, Gerdes D et al: Biofeedback therapy for children with dysfu

REPLY BY AUTHORS

REFERENCES

view. J Pediatr Urol 2011; 7: 342.Health Technol Assess 2010

the treated group was durable or if the lack of re-sponse in the controls would have remained.

While it was made clear that the control groupwas garnered from a group of patients for whomanimated biofeedback resources were unavailable, itis less clear why other forms of biofeedback (ie use ofthe uroflow/EMG equipment used in diagnosis, asreported previously) were not used or why, as theequipment became available during the course of 12months, none of the controls was crossed over.1 Nei-ther is it clear why there should ever be a need for ano-treatment control arm when the nature of thecondition and its potential for harm, and the exis-tence of proved, appropriate therapies have alreadybeen established. In this case a far better controlwould have been to compare animated biofeedbacktherapy to equally aggressive nonanimated biofeed-back therapy to determine if there was an addedbenefit of the animation beyond a faster response, asreported previously in the literature.

Andrew J. Combs

Division of Pediatric UrologyColumbia University Medical Center

there is no way of knowing if the initial response in New York, New York

nctional voiding. Urology 1998; 52: 312.

We agree with the comment regarding the definitionof DES by Koff et al, although later DES was used torefer to patients with a main component of dysfunc-tional voiding.1 Many pediatric lower urinary tractdysfunctions have a cause-effect cycle in which pel-vic floor hyperactivity has an important role. Forexample, lower urinary tract dysfunction startingwith infrequent voiding becomes dysfunctional void-ing if left untreated, or the patient may find findtemporary relief of symptoms by voiding infre-quently. We tried to recruit a homogeneous popula-tion of patients to convey a clear message about aspecific question.

VCUG was repeated at 6 months to avoid expos-ing the patient with persistent reflux to additionalrisk during a prolonged period, and those patients

treated endoscopically. However, we did not find astipulation on a 12 to 18-month period between in-terventional treatment of VUR and the first VCUGin the literature as a more standard approach. An-ticholinergics in the spectrum of pediatric lower uri-nary tract dysfunction may be a circumvention ofthe problem rather than a true solution and in ascenario of infrequent voiding leading to urgencyepisodes may ultimately worsen the situation bypushing the patient back into the infrequent voidingphase. Eventually the control group is not a no treat-ment group as a simple behavioral therapy has beeneffective in this and some parallel conditions,2,3 andin many instances the superiority of biofeedbacktreatments are not obviously proven. Therefore, thecontrol group was not under treated according to

with persistent reflux on the 6-month VCUG were available facts.

1. Desantis DJ, Leonard MP, Preston MA et al: Ef-fectiveness of biofeedback for dysfunctional elim-ination syndrome in pediatrics: A systematic re-

2. Imamura M, Abrams P, Bain C et al: Systematicreview and economic modelling of the effective-ness and cost-effectiveness of non-surgical treat-ments for women with stress urinary incontinence.

; 14: 1.

3. Wiener JS, Scales MT, Hampton J et al: Long-termefficacy of simple behavioral therapy for daytimewetting in children. J Urol 2000; 164: 786.