Biofeedback and Incontinence
August 1999; Volume 1: 69-71
By Adriane Fugh-Berman, MD
Pelvic floor muscle (pfm) exercises and biofeedback are underutilized—although effective—treatments for incontinence. Urinary incontinence is common, especially in elders, affecting 38% of community-dwelling women over the age of 60. Among women, stress incontinence (loss of urine during coughing, sneezing, or physical exertion) is more common than urge incontinence (involuntary urine loss associated with a strong urge to void). Mixed symptoms are common. Besides being a major problem in social settings, health care costs related to incontinence are estimated to be $16 billion a year.1
Technique
Biofeedback is "a teaching technique that facilitates learning by providing patients with immediate and observable information about physical performance."2 In the treatment of incontinence, biofeedback may measure pelvic muscle activity through urethral sphincter pressure and electromyography; circumvaginal muscle manometry and electromyography; and anorectal manometry and electromyography. Detrusor pressure feedback can be measured by cystometry. Feedback on intra-abdominal pressure may be utilized to help patients learn to simultaneously contract pelvic muscles while relaxing abdominal muscles (to avoid putting excess pressure on the bladder).2 Theoretically, PFM biofeedback should be more effective for stress incontinence, and detrusor muscle biofeedback should be more effective for urge incontinence, but clinically PFM training or combined biofeedback appears to be helpful in both types.
Kegel reported a high success rate for PFM training for incontinence in 1948.3 Surgery, however, eclipsed Kegel exercises as a treatment, and physical therapies only began to resurface in the 1980s. A number of uncontrolled trials have found a benefit from biofeedback-assisted pelvic muscle exercises for incontinence; only in recent years have better trials been done.
Clinical Trials
Biofeedback may be particularly helpful in urge incontinence. A recent well-designed, double-blind, controlled trial found biofeedback-assisted behavioral treatment superior to conventional drug treatment for urge incontinence.1 One hundred ninety-seven women aged 55 to 92 were randomized to one of three groups: biofeedback-assisted behavioral treatment, oxybutynin, or placebo.
The biofeedback/behavioral training group went through four sessions. During the first session they were taught to identify and contract pelvic muscles through anorectal biofeedback. Participants were taught "urge strategies" at the second visit (sitting down, relaxing, contracting pelvic muscles repeatedly, and proceeding to the toilet at a normal pace once urgency subsided). At the third visit, combined bladder-sphincter biofeedback was used to help patients learn to contract pelvic muscles against increasing volumes of fluid, during detrusor contraction, and under conditions of increasing urgency. The fourth session was used to review and reinforce home practice.
All patients assigned to oxybutynin began with 2.5 mg tid (half of the usual adult dose); if this was ineffective or if side effects were a problem, dosage adjustments were made between a minimum of 2.5 mg/d and a maximum of 5 mg/d. (Similar adjustments were made with the placebo group.) By starting with a low dose and allowing flexible dosing, this design is more similar to clinical practice and also maximizes drug compliance, as individualizing dosage would be expected to minimize adverse effects. Placebo dose adjustments are an interesting aspect of this study and would be expected to maximize the beneficial effects of the placebo.
Patients kept bladder diaries; the main outcomes were reduction in the frequency of incontinence episodes and patients’ perceptions of improvement and satisfaction with the treatments. The attrition rate was 6.2% in the biofeedback group, 17.9% in the drug treatment group, and 18.5% in the placebo group.
Biofeedback/behavioral training was significantly more effective and more satisfactory to the patients than drug treatment or placebo. Biofeedback resulted in an 80.7% reduction of incontinence episodes, compared to a 68.5% reduction with drug treatment and 39.4% reduction with placebo. More than 96% of patients in the biofeedback group were comfortable enough with their treatment to continue indefinitely, while 14% wanted to change to another treatment. Although drug treatment was effective, only 54.7% stated that they could continue indefinitely and 75.5% stated that they wanted to receive another treatment.
PFM training is effective even on homebound elders. A study of adults over the age of 60 randomized 105 subjects to biofeedback-assisted PFM training or to an untreated control group; the treated group achieved a 75% reduction in urinary accidents compared to a 6.4% reduction in the control group.4 Those in the control group then received PFM training. A total of 85 patients completed treatment, achieving a median 73.9% reduction in urinary accidents.
For stress incontinence, PFM exercises are effective, but adding biofeedback to PFM may not result in additional improvement. A systematic review of 11 randomized, controlled trials examining prevention and treatment of stress incontinence with pelvic floor muscle exercises found strong evidence of the efficacy of PFM exercises in reducing the symptoms of stress urinary incontinence.5 However, this review found no evidence that PFM exercises with biofeedback are more effective than PFM exercises alone for stress incontinence.
Besides biofeedback, other "aids" to effective PFM exercising include electrical stimulation and vaginal cones, both of which have been used successfully to treat incontinence. Electrical stimulation requires special equipment and is usually used daily for a 30-minute session of intermittent vaginal electrical stimulation (individually adapted on-off cycles are based on a woman’s ability to hold a voluntary contraction).
Vaginal "cones" are weighted plastic tampon-like devices that are a crude form of biofeedback; rather than the audio or visual feedback that a biofeedback machine provides, vaginal cones simply fall out if one is not contracting pelvic muscles adequately. The weights are graduated (20 g, 40 g, and 70 g), so that after successfully retaining a lighter weight, one moves on to heavier ones. Vaginal cones are now sold directly to consumers in catalogs.
For stress incontinence, however, these cones may be unnecessary. In a single-blind, randomized, controlled trial,6 107 women with stress incontinence were randomized to pelvic floor exercises, electrical stimulation, vaginal cones, or a control group (offered a continence guard). Pelvic floor exercises were done at home (8-12 high-intensity contractions three times daily) and in a group setting once weekly with a physical therapist (exercises were done in different positions and included breathing and relaxation exercises).
Outcome measures—subjective and objective—included pelvic floor muscle strength and a pad test with standardized bladder volume (women’s bladders were emptied by catheter, then refilled by saline, after which women wore a pre-weighed pad and then ran in place and performed jumping jacks, after which the pad was weighed again). Muscle strength was evaluated by vaginal balloon catheter attached to a transducer. Improvement on muscle strength and reduction in leakage was significantly better after pelvic floor exercises than electrical stimulation or vaginal cones.
Recommendation
Addressing a group of ob-gyns recently, I discovered that although most everyone knows about Kegel exercises, few think of it as an effective treatment for incontinence. Clinical trials, however, are quite consistent in finding a benefit from PFM exercises, with or without biofeedback assistance. Why the discrepancy? The answer may have to do with training.
While some women easily learn to effectively isolate and contract pelvic floor muscles, others may find verbal and written instruction inadequate. Kegel exercises can be taught in the office (for home practice, a woman can provide her own feedback by inserting a finger into her vagina). But if this is not successful after a month, don’t jump to the surgical option. Consider referring a patient to a biofeedback therapist (or, alternatively, a physical therapist who specializes in this area).
Biofeedback is clearly an effective tool for teaching proper PFM technique (even Kegel, 50 years ago, utilized a biofeedback device called a perineometer that measured intravaginal pressure). How many women feel confident that they can simultaneously Kegel, decrease intravesical pressure and relax our abdominal muscles? Not me. (The clinical trials that did not utilize biofeedback utilized extensive training sessions, often with a physical therapist).
Some hospitals and health care organizations already offer biofeedback-assisted PFM programs; if it’s not offered in your area, a list of practitioners in your area can be obtained from the Biofeedback Certification Institute of America at (303) 420-2902.
References
1. Burgio KL, et al. Behavioral vs. drug treatment for urge urinary incontinence in older women: A randomized controlled trial. JAMA 1998;280:1995-2000.
2. Burgio KL, Goode PS. Behavioral interventions for incontinence in ambulatory geriatric patients. Am J Med Sci 1997;314:257-261.
3. Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Ob Gyn 1948;56:238-249.
4. McDowell BJ, et al. Effectiveness of behavioral therapy to treat incontinence in homebound older adults. J Am Geriatr Soc 1999;47:309-318.
5. Berghmans LC, et al. Conservative treatment of stress urinary incontinence in women: A systematic review of randomized clinical trials. Br J Urol 1998;82:181-191.
6. Bo K, et al. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 1999;318:487-493.
August 1999; Volume 1: 69-71
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