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Biofeedback Training for Children with Bladder Sphincter Incoordination
0022-534 7/87 /1381-ll 13$02.00/0 THE JOURNAL
m-
Vol. Printed
UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
October U.S. _,4_.__
BIOFEEDBACK TRAINING FOR CHILDREN WITH BLADDER SPHINCTER INCOORDINATION GERALD R JERKINS, H. NORMAN NOE, WILLIAM R. VAUGHN
AND
ED ROBERTS
From the Department of Pediatric Urology, The University of Tennessee, Memphis, Tennessee
ABSTRACT
We studied 35 children with voiding dysfunction and detrusor-sphincter incoordination. More than 90 per cent of these patients had a history of repeat urinary tract infections, and medication and surgical treatment of the voiding dysfunction had failed. Of the patients 22 (63 per cent) experienced significant improvement or resolution of the voiding dysfunction when biofeedback was usPd to teach normal bladder sphincter coordination as part of the over-all treatment regimen. A review of our experience with these patients indicates that with proper patient selection an even higher rate of success may be possible. (J. Ural., part 2, 138: 1113-1115, 1987) One of the most frustrating problems the pediatric urologist deals with is the child with persistent voiding dysfunction and urinary incontinence without significant underlying urological or neurological abnormalities. Usually these children also have a history of recurrent urinary tract infections, and they have been treated with a variety of medical and surgical approaches. Voiding dysfunction in children may have several patterns, and treatment depends on the type of voiding abnormality encountered. 1• 2 Of particular interest to us has been the application of biofeedback techniques to those children with identified detrusor-sphincter incoordination. The application of biofeedback training to children with bladder external sphincter incoordination is based on the hypothesis that inappropriate relaxation and contraction of the urinary external sphincter are learned phenomena. The child attempts to control the irritable or spastic bladder with contraction of the external sphincter usually at the same time a detrusor contraction is occurring. If, indeed, this is a learned phenomenon, then it would seem logical that a normal coordination between the detrusor and the sphincter also could be learned. Biofeedback training is a method by which the child learns to coordinate external sphincter function with detrusor activity rather than having the sphincter act as an antagonist to the bladder during contractions. With improvement of diagnostic urodynamic studies, we are now able to identify abnormalities of detrusor external sphincter coordination, which may be present in more than 30 per cent of the children with abnormal voiding patterns. 3 • 4 Although the etiology of this pattern is unclear, less invasive diagnostic techniques allow for easier documentation. Once identified, specific therapy, including biofeedback, can be used to correct this voiding abnormality. METHODS
Patient population. The study included 33 girls and 2 boys 3 to 15 years old, with a mean age of 7.5 years. All patients had a history of recurrent urinary tract infection and/or urinary incontinence. Of the children 32 (91 per cent) had a history of repeat urinary tract infection. Endoscopic evaluation revealed cystitis cystica in 15 (43 per cent) and vesicoureteral reflux was identified in 12 (34 per cent), 2 of whom did not have a history of urinary tract infection. Duration of symptoms ranged from 1 to 9 years. All children had undergone 1 or more previous endoscopic evaluations before referral. Diurnal and nocturnal urinary incontinence was noted in 24 patients, 5 had only diurnal incontinence and 1 had only nocturnal incontinence. Five children had recurrent urinary infections and persistent abnormal voiding without inconti-
nence patterns, including a slow urinary stream and infrequent voiding. Bowel symptoms were significant in 8 patients, including 4 with bowel incontinence and 4 with constipation. Biofeedback technique. All 35 children treated with biofeedback during the last 5 years were reviewed retrospectively. These 35 patients represented failures of medical and surgical attempts to improve bladder control and to reduce episodes of infection. A history suggesting detrusor-sphincter incoordination usually included urinary incontinence and a poor urinary stream during voiding. Previous medical treatment usually included a combination of suppressive antibiotics and antispasmodic medication. Surgical procedures included cystoscopy with or without urethral dilation. All patients were evaluated with excretory urography, a voiding cystourethrogram, and a complete history and physical examination. Initially, urodynamic studies, including a cystometrogram with measurement of sphincter electromyography and intra-abdominal pressures, were obtained. The cystometrogram patterns obtained were those of hyperactivity with, at times, uninhibited contractions and poor coordination between detrusor contraction and the external sphincter. After these initial studies a complete urodynamic evaluation, including cystometry, was not obtained on each patient unless physical examination or the voiding cystourethrogram suggested a neurogenic etiology of the voiding dysfunction. All patients underwent simultaneous uroflow with measurement of electromyography activity of the external sphincter. Sphincter electromyography was obtained with surface electrode pads placed in the perineal area. Similar results were obtained with measurement of the external sphincter muscle group by surface or needle electrodes. Obviously in children use of surface electrodes facilitated the test. The uroflow electromyography study was repeated until a satisfactory and representative study with an adequate voided volume could be obtained. Histories from all patients and families included information concerning repeat urinary tract infections, diurnal and nocturnal urinary incontinence, bowel symptoms, urinary symptoms and duration of the voiding problem. The procedure of biofeedback training was explained carefully to the child and the family in an individualized session with the physical therapist. The use of the machine (StoeltingCyberg EMG-J33) (see figure) involved placement of surface electrode pads at the perineal area. The electrical activity of the external sphincter was noted by an audio and visual feedback. Outpatient instruction of the children in voluntary contraction and relaxation of the perineal muscle groups was accomplished easily. However, a few patients underwent a combination of diagnostic studies and initial instruction in the hospital.
1113
1114
JERKINS AND ASSOCIATES
Biofeedback machine for home use
The child and family were instructed to use the biofeedback machine 2 to 3 times per day during voiding at home. Followup at monthly intervals included a repeat interview with the family and examination of the child. Repeat urinalysis and uroflow electromyography study also were obtained. Adjunctive measures used during biofeedback training included control of urinary tract infections with suppressive antibiotics and, when the bladder hyperactivity had been identified or suspected, an antispasmodic also was given. After a normal daytime voiding pattern without incontinence was achieved use of the machine was discontinued and the patient was followed at 3-month intervals. RESULTS
A carbon dioxide cystometrogram evaluation in 10 patients demonstrated a hyperactive pattern with episodes of apparent uninhibited contraction. A simultaneous uroflow and electromyography study showed an incoordinated pattern in all 35 patients. Criteria for successful treatment included primarily daytime bladder control without incontinence or persistent urinary infection. Reduction of the incidence of urinary tract infections and episodes of incontinence was considered as an improvement. A successful result with daytime dryness and normal daytime voiding pattern was achieved in 22 patients (63 per cent). Of the remaining patients 6 (17 per cent) demonstrated improvement with fewer episodes of incontinence and better control of infections, and 7 (20 per cent) demonstrated no significant improvement. In those patients in whom no improvement was noted there was a high incidence of resistance by the patient and/or parents. Psychological counseling was recommended to these families. Of the 12 children with reflux 5 underwent successful surgery, 6 showed resolution of the reflux and 1 is still being followed. DISCUSSION
Electromyography biofeedback is not a new technique. It has been used to train patients with a variety of neuromuscular disorders to inhibit motor activity in certain muscle groups. The mechanism of electromyography biofeedback is unclear but it appears to enhance the patient's own feedback of proprioception and observation. Motivational factors also appear to be important, including the individualized nature of the treatment and the interaction of the physical therapist with the patient. 5 The use of electromyography biofeedback to retrain bladder sphincter incoordination has been described with good results. 6 • 7 In light of our own observations and these reports,
we applied this technique in an attempt to normalize voiding in selected patients in whom surgical and medical treatment had failed. Recent reviews of learned voiding dysfunction in children by Koff and Hinman have outlined elegantly some of the significant problems that can be encountered when normal detrusorsphincter coordination goes awry. 8 • 9 These problems may range from persistent voiding abnormalities with incontinence to progressive changes of the bladder and upper urinary tracts related to long-standing obstruction of the bladder outlet. The experience of treating these 35 patients certainly underscores Hinman's observation that treatment is limited infrequently to 1 modality. 9 In addition to biofeedback, all of these children required antispasmodics and/or antibiotics as part of the treatment program to normalize voiding. We are encouraged that the electromyography biofeedback technique is a useful adjunctive modality in treating the child with detrusor-sphincter incoordination. As with any treatment proper selection of the patients is the key to ultimate success, and many factors appear to be important in selecting the child who can benefit from biofeedback. Urinary tract infection and recurrent vaginitis must be controlled to reduce persistent inflammatory stimulus to the bladder. This may include oral antibiotics in addition to external anti-inflammatory/antibiotic ointments applied locally to control vulvo-vaginitis. The patient and family must be highly motivated, and willing to spend the time and effort involved in this bladder retraining program. A well defined detrusor external sphincter incoordination must be present for the patients to benefit from the biofeedback. When incontinence is present and the external sphincter is well coordinated during detrusor contraction, biofeedback treatment will be of minimal benefit. Bladder hyperactivity, whether associated with repeat infections or poorly inhibited contractions, must be controlled to allow for a coordinated sphincter-detrusor pattern to develop. Of the 13 patients who either failed the program or showed only moderate response 12 failed as a result of patient and/or family resistance or noncooperation with the program. These families usually demonstrated a high level of frustration because of the long-standing problem, which was reflected frequently in the child as a noncooperative attitude. There also was a higher likelihood in these families of noncompliance with recommendations for long-term suppressive antibiotics for repeat urinary tract infections. Young patients may not be good candidates for this treatment if they appear to be frightened by the process and unable to cooperate with the technique. However, 1 child not quite 5 years old responded well to the biofeedback treatment. We believe that this was owing not only to the child's cooperative attitude but also to the mother's at_tentiveness to pursuing this program. In the 22 patients with an initial good response of daytime dryness and a normal voiding pattern 3 suffered relapse within 3 months following cessation of the home training. All 3 children improved with a refresher course in which the biofeedback regimen was used once again for 1 month at home. Followup after 6 months has demonstrated no further relapse in these children. We realize that any study that is not prospectively done with proper control is suspect especially when sweeping conclusions are drawn. This study represents our experience with 35 hard core patients with persistent wetting problems who had shown minimal to no response to other forms of treatment. The biofeedback technique offered an additional supportive tool that we thought could assist in this special group of problem patients. Our experience has been encouraging and we believe that it is worthwhile to pursue biofeedback in this group of patients. Hopefully in the future a more formal prospective study will confirm our impressions.
1115 Although the number of our ,-,~,o,v,,.vu presented here is not large, there were some trends suggested in the children who improved on this treatment. Of the 7 children with reflux who had not undergone surgical correction reflux resolved in 5 during followup after treatment of the bladder sphincter incoordination. Of the remaining 2 patients reflux resolved before treatment in 1 and the other is being followed. Subjectively, the parents of these children frequently mentioned the decreased incidents of urinary infection and the decreased need for antibiotics. These observations are consistent with the findings of Koff and associates that a sterile urine was easier to achieve when bladder hyperactivity was controlled and sphincter activity was coordinated with bladder emptying. It would seem reasonable that this stabilization of bladder function and improvement of infection control also could have a favorable affect on the child with associated vesicoureteral reflux. 10 In light of our review of recent literature and experience with these patients, we conclude that in selected children with documented external sphincter-detrusor incoordination biofeedback is an effective adjunct in developing a normal coordinated voiding pattern. We also believe that this technique may benefit secondarily these children in achieving better control of urinary tract infection and reducing the tendency for reflux.
REFERENCES 1. Allen, T. D. and Bright, T. C., III: Urodynamic patterns in children
with dysfunctional voiding problems. J. Urol., 119: 24 7, 1978. 2. Webster, G.D., Koefoot, R. B., Jr. and Sihelnik, S.: Urodynamic abnormalities in neurologically normal children with micturition dysfunction. J. Urol., 132: 74, 1984. 3. Maizels, M., Kaplan, W. E., King, L. R. and Firlit, C. F.: The vesical sphincter electromyogram in children with normal and abnormal voiding patterns. J. Urol., 129: 92, 1983. 4. Maizels, M. and Firlit, C. F.: Pediatric urodynamics: a clinical comparison of surface versus needle pelvic floor/external sphincter electromyography. J. Urol., 122: 518, 1979. 5. Health and Public Policy Committee, American College of Physicians: Biofeedback for neuromuscular disorders. Ann. Intern. Med., 102: 854, 1985. 6. Maizels, M., King, L. R. and Firlit, C. F.: Urodynamic biofeedback: a new approach to treat vesical sphincter dyssynergia. J. Urol., 122: 205, 1979. 7. Sugar, E. C. and Firlit, C. F.: Urodynamic biofeedback: a new therapeutic approach for childhood incontinence/infection (vesical voluntary sphincter dyssynergia). J. Urol., 128: 1253, 1982. 8. Koff, S. A.: Bladder-sphincter dysfunction in childhood. Urology, 19: 457, 1982. 9. Hinman, F.: Nonneurogenic neurogenic bladder (the Hinman syndrome)-15 years later. J. Urol., 136: 769, 1986. 10. Koff, S. A., Lapides, J. and Piazza, D. H.: Association of urinary tract infection and reflux with uninhibited bladder contractions and voluntary sphincteric obstruction. J. Urol., 122: 373, 1979.
m-
Vol. Printed
UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
October U.S. _,4_.__
BIOFEEDBACK TRAINING FOR CHILDREN WITH BLADDER SPHINCTER INCOORDINATION GERALD R JERKINS, H. NORMAN NOE, WILLIAM R. VAUGHN
AND
ED ROBERTS
From the Department of Pediatric Urology, The University of Tennessee, Memphis, Tennessee
ABSTRACT
We studied 35 children with voiding dysfunction and detrusor-sphincter incoordination. More than 90 per cent of these patients had a history of repeat urinary tract infections, and medication and surgical treatment of the voiding dysfunction had failed. Of the patients 22 (63 per cent) experienced significant improvement or resolution of the voiding dysfunction when biofeedback was usPd to teach normal bladder sphincter coordination as part of the over-all treatment regimen. A review of our experience with these patients indicates that with proper patient selection an even higher rate of success may be possible. (J. Ural., part 2, 138: 1113-1115, 1987) One of the most frustrating problems the pediatric urologist deals with is the child with persistent voiding dysfunction and urinary incontinence without significant underlying urological or neurological abnormalities. Usually these children also have a history of recurrent urinary tract infections, and they have been treated with a variety of medical and surgical approaches. Voiding dysfunction in children may have several patterns, and treatment depends on the type of voiding abnormality encountered. 1• 2 Of particular interest to us has been the application of biofeedback techniques to those children with identified detrusor-sphincter incoordination. The application of biofeedback training to children with bladder external sphincter incoordination is based on the hypothesis that inappropriate relaxation and contraction of the urinary external sphincter are learned phenomena. The child attempts to control the irritable or spastic bladder with contraction of the external sphincter usually at the same time a detrusor contraction is occurring. If, indeed, this is a learned phenomenon, then it would seem logical that a normal coordination between the detrusor and the sphincter also could be learned. Biofeedback training is a method by which the child learns to coordinate external sphincter function with detrusor activity rather than having the sphincter act as an antagonist to the bladder during contractions. With improvement of diagnostic urodynamic studies, we are now able to identify abnormalities of detrusor external sphincter coordination, which may be present in more than 30 per cent of the children with abnormal voiding patterns. 3 • 4 Although the etiology of this pattern is unclear, less invasive diagnostic techniques allow for easier documentation. Once identified, specific therapy, including biofeedback, can be used to correct this voiding abnormality. METHODS
Patient population. The study included 33 girls and 2 boys 3 to 15 years old, with a mean age of 7.5 years. All patients had a history of recurrent urinary tract infection and/or urinary incontinence. Of the children 32 (91 per cent) had a history of repeat urinary tract infection. Endoscopic evaluation revealed cystitis cystica in 15 (43 per cent) and vesicoureteral reflux was identified in 12 (34 per cent), 2 of whom did not have a history of urinary tract infection. Duration of symptoms ranged from 1 to 9 years. All children had undergone 1 or more previous endoscopic evaluations before referral. Diurnal and nocturnal urinary incontinence was noted in 24 patients, 5 had only diurnal incontinence and 1 had only nocturnal incontinence. Five children had recurrent urinary infections and persistent abnormal voiding without inconti-
nence patterns, including a slow urinary stream and infrequent voiding. Bowel symptoms were significant in 8 patients, including 4 with bowel incontinence and 4 with constipation. Biofeedback technique. All 35 children treated with biofeedback during the last 5 years were reviewed retrospectively. These 35 patients represented failures of medical and surgical attempts to improve bladder control and to reduce episodes of infection. A history suggesting detrusor-sphincter incoordination usually included urinary incontinence and a poor urinary stream during voiding. Previous medical treatment usually included a combination of suppressive antibiotics and antispasmodic medication. Surgical procedures included cystoscopy with or without urethral dilation. All patients were evaluated with excretory urography, a voiding cystourethrogram, and a complete history and physical examination. Initially, urodynamic studies, including a cystometrogram with measurement of sphincter electromyography and intra-abdominal pressures, were obtained. The cystometrogram patterns obtained were those of hyperactivity with, at times, uninhibited contractions and poor coordination between detrusor contraction and the external sphincter. After these initial studies a complete urodynamic evaluation, including cystometry, was not obtained on each patient unless physical examination or the voiding cystourethrogram suggested a neurogenic etiology of the voiding dysfunction. All patients underwent simultaneous uroflow with measurement of electromyography activity of the external sphincter. Sphincter electromyography was obtained with surface electrode pads placed in the perineal area. Similar results were obtained with measurement of the external sphincter muscle group by surface or needle electrodes. Obviously in children use of surface electrodes facilitated the test. The uroflow electromyography study was repeated until a satisfactory and representative study with an adequate voided volume could be obtained. Histories from all patients and families included information concerning repeat urinary tract infections, diurnal and nocturnal urinary incontinence, bowel symptoms, urinary symptoms and duration of the voiding problem. The procedure of biofeedback training was explained carefully to the child and the family in an individualized session with the physical therapist. The use of the machine (StoeltingCyberg EMG-J33) (see figure) involved placement of surface electrode pads at the perineal area. The electrical activity of the external sphincter was noted by an audio and visual feedback. Outpatient instruction of the children in voluntary contraction and relaxation of the perineal muscle groups was accomplished easily. However, a few patients underwent a combination of diagnostic studies and initial instruction in the hospital.
1113
1114
JERKINS AND ASSOCIATES
Biofeedback machine for home use
The child and family were instructed to use the biofeedback machine 2 to 3 times per day during voiding at home. Followup at monthly intervals included a repeat interview with the family and examination of the child. Repeat urinalysis and uroflow electromyography study also were obtained. Adjunctive measures used during biofeedback training included control of urinary tract infections with suppressive antibiotics and, when the bladder hyperactivity had been identified or suspected, an antispasmodic also was given. After a normal daytime voiding pattern without incontinence was achieved use of the machine was discontinued and the patient was followed at 3-month intervals. RESULTS
A carbon dioxide cystometrogram evaluation in 10 patients demonstrated a hyperactive pattern with episodes of apparent uninhibited contraction. A simultaneous uroflow and electromyography study showed an incoordinated pattern in all 35 patients. Criteria for successful treatment included primarily daytime bladder control without incontinence or persistent urinary infection. Reduction of the incidence of urinary tract infections and episodes of incontinence was considered as an improvement. A successful result with daytime dryness and normal daytime voiding pattern was achieved in 22 patients (63 per cent). Of the remaining patients 6 (17 per cent) demonstrated improvement with fewer episodes of incontinence and better control of infections, and 7 (20 per cent) demonstrated no significant improvement. In those patients in whom no improvement was noted there was a high incidence of resistance by the patient and/or parents. Psychological counseling was recommended to these families. Of the 12 children with reflux 5 underwent successful surgery, 6 showed resolution of the reflux and 1 is still being followed. DISCUSSION
Electromyography biofeedback is not a new technique. It has been used to train patients with a variety of neuromuscular disorders to inhibit motor activity in certain muscle groups. The mechanism of electromyography biofeedback is unclear but it appears to enhance the patient's own feedback of proprioception and observation. Motivational factors also appear to be important, including the individualized nature of the treatment and the interaction of the physical therapist with the patient. 5 The use of electromyography biofeedback to retrain bladder sphincter incoordination has been described with good results. 6 • 7 In light of our own observations and these reports,
we applied this technique in an attempt to normalize voiding in selected patients in whom surgical and medical treatment had failed. Recent reviews of learned voiding dysfunction in children by Koff and Hinman have outlined elegantly some of the significant problems that can be encountered when normal detrusorsphincter coordination goes awry. 8 • 9 These problems may range from persistent voiding abnormalities with incontinence to progressive changes of the bladder and upper urinary tracts related to long-standing obstruction of the bladder outlet. The experience of treating these 35 patients certainly underscores Hinman's observation that treatment is limited infrequently to 1 modality. 9 In addition to biofeedback, all of these children required antispasmodics and/or antibiotics as part of the treatment program to normalize voiding. We are encouraged that the electromyography biofeedback technique is a useful adjunctive modality in treating the child with detrusor-sphincter incoordination. As with any treatment proper selection of the patients is the key to ultimate success, and many factors appear to be important in selecting the child who can benefit from biofeedback. Urinary tract infection and recurrent vaginitis must be controlled to reduce persistent inflammatory stimulus to the bladder. This may include oral antibiotics in addition to external anti-inflammatory/antibiotic ointments applied locally to control vulvo-vaginitis. The patient and family must be highly motivated, and willing to spend the time and effort involved in this bladder retraining program. A well defined detrusor external sphincter incoordination must be present for the patients to benefit from the biofeedback. When incontinence is present and the external sphincter is well coordinated during detrusor contraction, biofeedback treatment will be of minimal benefit. Bladder hyperactivity, whether associated with repeat infections or poorly inhibited contractions, must be controlled to allow for a coordinated sphincter-detrusor pattern to develop. Of the 13 patients who either failed the program or showed only moderate response 12 failed as a result of patient and/or family resistance or noncooperation with the program. These families usually demonstrated a high level of frustration because of the long-standing problem, which was reflected frequently in the child as a noncooperative attitude. There also was a higher likelihood in these families of noncompliance with recommendations for long-term suppressive antibiotics for repeat urinary tract infections. Young patients may not be good candidates for this treatment if they appear to be frightened by the process and unable to cooperate with the technique. However, 1 child not quite 5 years old responded well to the biofeedback treatment. We believe that this was owing not only to the child's cooperative attitude but also to the mother's at_tentiveness to pursuing this program. In the 22 patients with an initial good response of daytime dryness and a normal voiding pattern 3 suffered relapse within 3 months following cessation of the home training. All 3 children improved with a refresher course in which the biofeedback regimen was used once again for 1 month at home. Followup after 6 months has demonstrated no further relapse in these children. We realize that any study that is not prospectively done with proper control is suspect especially when sweeping conclusions are drawn. This study represents our experience with 35 hard core patients with persistent wetting problems who had shown minimal to no response to other forms of treatment. The biofeedback technique offered an additional supportive tool that we thought could assist in this special group of problem patients. Our experience has been encouraging and we believe that it is worthwhile to pursue biofeedback in this group of patients. Hopefully in the future a more formal prospective study will confirm our impressions.
1115 Although the number of our ,-,~,o,v,,.vu presented here is not large, there were some trends suggested in the children who improved on this treatment. Of the 7 children with reflux who had not undergone surgical correction reflux resolved in 5 during followup after treatment of the bladder sphincter incoordination. Of the remaining 2 patients reflux resolved before treatment in 1 and the other is being followed. Subjectively, the parents of these children frequently mentioned the decreased incidents of urinary infection and the decreased need for antibiotics. These observations are consistent with the findings of Koff and associates that a sterile urine was easier to achieve when bladder hyperactivity was controlled and sphincter activity was coordinated with bladder emptying. It would seem reasonable that this stabilization of bladder function and improvement of infection control also could have a favorable affect on the child with associated vesicoureteral reflux. 10 In light of our review of recent literature and experience with these patients, we conclude that in selected children with documented external sphincter-detrusor incoordination biofeedback is an effective adjunct in developing a normal coordinated voiding pattern. We also believe that this technique may benefit secondarily these children in achieving better control of urinary tract infection and reducing the tendency for reflux.
REFERENCES 1. Allen, T. D. and Bright, T. C., III: Urodynamic patterns in children
with dysfunctional voiding problems. J. Urol., 119: 24 7, 1978. 2. Webster, G.D., Koefoot, R. B., Jr. and Sihelnik, S.: Urodynamic abnormalities in neurologically normal children with micturition dysfunction. J. Urol., 132: 74, 1984. 3. Maizels, M., Kaplan, W. E., King, L. R. and Firlit, C. F.: The vesical sphincter electromyogram in children with normal and abnormal voiding patterns. J. Urol., 129: 92, 1983. 4. Maizels, M. and Firlit, C. F.: Pediatric urodynamics: a clinical comparison of surface versus needle pelvic floor/external sphincter electromyography. J. Urol., 122: 518, 1979. 5. Health and Public Policy Committee, American College of Physicians: Biofeedback for neuromuscular disorders. Ann. Intern. Med., 102: 854, 1985. 6. Maizels, M., King, L. R. and Firlit, C. F.: Urodynamic biofeedback: a new approach to treat vesical sphincter dyssynergia. J. Urol., 122: 205, 1979. 7. Sugar, E. C. and Firlit, C. F.: Urodynamic biofeedback: a new therapeutic approach for childhood incontinence/infection (vesical voluntary sphincter dyssynergia). J. Urol., 128: 1253, 1982. 8. Koff, S. A.: Bladder-sphincter dysfunction in childhood. Urology, 19: 457, 1982. 9. Hinman, F.: Nonneurogenic neurogenic bladder (the Hinman syndrome)-15 years later. J. Urol., 136: 769, 1986. 10. Koff, S. A., Lapides, J. and Piazza, D. H.: Association of urinary tract infection and reflux with uninhibited bladder contractions and voluntary sphincteric obstruction. J. Urol., 122: 373, 1979.