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Use of biofeedback in treatment of psychogenic voiding dysfunction
URODYNAMICS
USE OF BIOFEEDBACK IN TREATMENT OF PSYCHOGENIC VOIDING DYSFUNCTION T. J. CHRISTMAS, M.B., ER.C.S. J. G. NOBLE, M.B. G. M. WATSON, M.B., ER.C.S. R. T. TURNER-WARWICK, D.M., ER.C.S. From the Department of Urology, The Middlesex Hospital, London, England
ABSTRACT--A young man with psychologic problems and a long history of social inadequacy presented with voiding dysfunction. Videocystometrography revealed a normal filling phase and normal initiation of voiding interrupted by considerable straining by the patient and marked sphincter electromyographic (EMG) activity. 7bmporary amelioration was achieved by infiltration o] the sphincter with lignocaine hydrochloride and by biofeedback therapy. In such cases optimal results are expected from long-term behavioral therapy.
Biofeedback techniques have been used to treat conditions affecting voluntary striated muscle and autonomieally innervated muscles. Amato, Hermsmeyer, and Kleinman ~ have reported good results in relaxing the muscles of patients with striated muscle spastieity. Biofeedback therapy has also helped in disorders of autonomic function, including migraine, ventrieular taehyeardias, reetosphineterie ineoordination, and detrusor instability. 2-~ Maizels, King, and Firlit 7 have used the technique to educate and train children with vesieal sphincter dyssynergia. Wear, Wear, and Cleeland 8 helped 4 of 8 patients with retention of urine or incontinence bv biofeedback training. T h e concept" for this therapy is to make the Patient aware of his or her own bodily behavior bY:exposing them to visual and auditory stimuli reflecting the activity of the dysfunctioning systern2 Such operant conditioning may bring a ~ u t improvement in problems of psyehologie, a~tonomie, or dyssynergic etiolog?: Case Report '~iAnineteen-year-old man was referred to the Middlesex Hospital for investigation of a voidrdi~OI.OGY... JANUARY199I
I
ing problem. He gave a three-year history of progressive difficulty with initiation of mieturition, and this was more marked when using unfamiliar lavatories. The condition became so severe that he was eventually unable to void at work or other sites, and was compelled to spend all his time in his parental home. He also complained of difficulties at home and would on occasions take over thirty minutes to void, with a poor stream and considerable straining. He is an only child; and although he achieved all his early developmental landmarks, he acquired no academic qualifications on leaving school. He suffers from interpersonal relationship difficulties, and has insight into this, but blames his urinary disorder for these problems. Clinical examination, eystourethroseopy; an intravenous urogram, and external urethral sphincter eleetromyographic (EMG) studies were all normal. However, videoeystometrography through suprapubie cannulae performed synchronously with an anal plug electrode sphincter EMG revealed a marked voiding dysfunction. There was no abnormality during the filling phase, and a normal voiding pattern was initiated but was suddenly interrupted leading
V O I , U M E XXXVII, N U M B E R 1
43
With verbal encouragement and biofeedback
Usual p a t t e r n
m LI_
20t.__ 10
0 O
I l0
I 20
I 30
li 0
I 10
I 20
I 30
I 40
!Seconds E.M.G
I !
FIcum~ 1. Synchronous'flow rate and pelvic floor EMG readings with and without bioJeedback and verbal encouragement.
to a very slow flow rate and considerable straining by the patient. This straining was accompanied by intense activity of the pelvic floor striated musculature as shown by the EMG. A normal voiding pattern could not be maintained, and the flow rate never rose above 7 mL/second. Free flow rates were below 10 mL/s at all times, and this was the ease with voiding volumes of 300 mL or more. The videocystometrogram was repeated after infiltration of the external urethral sphincter with 25 mL of 1% lignocaine hydroehloride. Again the filling phase was stable, and the bladder capacity was 550 mL. However, on this occasion the voiding phase was more normal with an improved flow rate of up to 15 mL/s, and there was less interruption and less prolongation of micturition. We remained suspicious that the underlying problem was of a psychologic nature but could not absolutely exclude a functional bladder neck obstruction on our findings. However, therapeutic trials of both phenoxybenzamine and prazosin failed to bring about symptomatic relief. We decided to attempt a biofeedback technique to relax the external urethral sphincter during voiding. The patient was initially educated in the eoncept by attaching cutaneous EMG electrodes to his forearm. He was made to observe the result of contraction and relaxation of his forearm muscles on the EMG oscilloscope and was also subjected to the auditory stimulus of the "white noise" generated by the machine during muscular contraction. He rapidly mas-
44
tered the technique of complete relaxation and controlled contraction of the forearm muscles. Later the same technique was applied to the perineal musculature. Cutaneous electrodes were applied at the 3 and 9-o'clock positions with respect to the anus. An earth lead was applied to the wrist. The patient was then instructed, with the aid of the EMG machine, to learn pelvic floor muscle contraction and relaxation. Having mastered these exercises he was asked to void into a flow meter with a full bladder and with the perineal EMG leads attached. The initial resuits were disappointing, but again pelvic floor muscle was noted to be abnormally active during attempted voiding. This test was repeated, and the patient was verbally encouraged to relax his sphincter by making the EMG recording flat and the "white noise" silent during each attempt to void. Figure 1 shows the improvement in the flow rate as a result of an increase in verbal encouragement and instruction during voiding. Comments Dysfunctional problems without organic, infective, or structural cause are not uncommon in the urinary tract. Videocystometrography of: such cases may reveal detrusor instability, functional bladder neck obstruction, or detrusor sphincter dyssynergia. The etiology, of these conditions is uncertain; although neurologic conditions are sometimes found to account for the symptoms, psychologic factors are often
UROLOGY
,
JANUARY 1991
,'
V O I , U M E XXXV[I, N U M B E B I
implicated. ~° The diagnosis of a psychogenic disorder is generally one of exclusion. However, when there is a psychologic etiology, behavioral therapy is more likely to be of benefit. Unfortunately relapse is not uncommon and, therefore, several courses of treatment may be required.
London WIN 8AA, England (DR. CHRISTMAS) References 1. Amato A, Hermsmeyer CA, and Klcinman KM: Use of electromyographic feedback to increase inhibitory control of spastic muscles, Phys Ther 53:1063 (1973). 2. Sargent JD, Green EE, and Waiters ED: Preliminary report on the use of autogenic feedback training in the treatment of migraine and tension headaches, Psyehosom Med 35:129 (197,3).
UROLOGY
,' JANUARY 1991
:
3. Weiss T, and Engel BT: Operant conditioning of heart rate in patients with premature ventricular contractions, Psyehosom Med 33:301 (1971). 4. Engel BT, Nikeomanesh P, and Schuster MM: Operant conditioning of reeto-sphincteric responses in the treatment of fecal incontinence, N Engl J Mcd 290:646 (1974). 5. Cardozo LD, Abrams PD, Stanton SL, and Feneney RCL: Idiopathic bladder instability treated by biofeedback, Br J Urol 50:521 (1978). 6. Cardozo LD, Stanton SL, Hafner J, and Allan V: Biofeedback in the treatment of detrusor instability~ Br J Urol 50:250 (1978). 7. Maizels M, King LR, and Firlit CF: Urodynamic biofeedback: a new approach to treat vesical sphincter dyssyner~a, J Urol 122:205 (1979). 8. Wear JB, VCear RB, and Cleeland C: Biofeedback in urology using urodynamics: preliminary observations, J Urol 121:464
(1979). 9. Stroebel CI~ and Glueck BC: Biofeedback treatment in medicine and psychiatry: an ultimate placebo? Sere Psychiat 5:
379 (1973). 10. Frewen WK: An objective assessment of the unstable bladder of psychosomatic origin, Br J Urol 50:521 (1978).
VOLUME X?~LXVII, NUMBER 1
45
USE OF BIOFEEDBACK IN TREATMENT OF PSYCHOGENIC VOIDING DYSFUNCTION T. J. CHRISTMAS, M.B., ER.C.S. J. G. NOBLE, M.B. G. M. WATSON, M.B., ER.C.S. R. T. TURNER-WARWICK, D.M., ER.C.S. From the Department of Urology, The Middlesex Hospital, London, England
ABSTRACT--A young man with psychologic problems and a long history of social inadequacy presented with voiding dysfunction. Videocystometrography revealed a normal filling phase and normal initiation of voiding interrupted by considerable straining by the patient and marked sphincter electromyographic (EMG) activity. 7bmporary amelioration was achieved by infiltration o] the sphincter with lignocaine hydrochloride and by biofeedback therapy. In such cases optimal results are expected from long-term behavioral therapy.
Biofeedback techniques have been used to treat conditions affecting voluntary striated muscle and autonomieally innervated muscles. Amato, Hermsmeyer, and Kleinman ~ have reported good results in relaxing the muscles of patients with striated muscle spastieity. Biofeedback therapy has also helped in disorders of autonomic function, including migraine, ventrieular taehyeardias, reetosphineterie ineoordination, and detrusor instability. 2-~ Maizels, King, and Firlit 7 have used the technique to educate and train children with vesieal sphincter dyssynergia. Wear, Wear, and Cleeland 8 helped 4 of 8 patients with retention of urine or incontinence bv biofeedback training. T h e concept" for this therapy is to make the Patient aware of his or her own bodily behavior bY:exposing them to visual and auditory stimuli reflecting the activity of the dysfunctioning systern2 Such operant conditioning may bring a ~ u t improvement in problems of psyehologie, a~tonomie, or dyssynergic etiolog?: Case Report '~iAnineteen-year-old man was referred to the Middlesex Hospital for investigation of a voidrdi~OI.OGY... JANUARY199I
I
ing problem. He gave a three-year history of progressive difficulty with initiation of mieturition, and this was more marked when using unfamiliar lavatories. The condition became so severe that he was eventually unable to void at work or other sites, and was compelled to spend all his time in his parental home. He also complained of difficulties at home and would on occasions take over thirty minutes to void, with a poor stream and considerable straining. He is an only child; and although he achieved all his early developmental landmarks, he acquired no academic qualifications on leaving school. He suffers from interpersonal relationship difficulties, and has insight into this, but blames his urinary disorder for these problems. Clinical examination, eystourethroseopy; an intravenous urogram, and external urethral sphincter eleetromyographic (EMG) studies were all normal. However, videoeystometrography through suprapubie cannulae performed synchronously with an anal plug electrode sphincter EMG revealed a marked voiding dysfunction. There was no abnormality during the filling phase, and a normal voiding pattern was initiated but was suddenly interrupted leading
V O I , U M E XXXVII, N U M B E R 1
43
With verbal encouragement and biofeedback
Usual p a t t e r n
m LI_
20t.__ 10
0 O
I l0
I 20
I 30
li 0
I 10
I 20
I 30
I 40
!Seconds E.M.G
I !
FIcum~ 1. Synchronous'flow rate and pelvic floor EMG readings with and without bioJeedback and verbal encouragement.
to a very slow flow rate and considerable straining by the patient. This straining was accompanied by intense activity of the pelvic floor striated musculature as shown by the EMG. A normal voiding pattern could not be maintained, and the flow rate never rose above 7 mL/second. Free flow rates were below 10 mL/s at all times, and this was the ease with voiding volumes of 300 mL or more. The videocystometrogram was repeated after infiltration of the external urethral sphincter with 25 mL of 1% lignocaine hydroehloride. Again the filling phase was stable, and the bladder capacity was 550 mL. However, on this occasion the voiding phase was more normal with an improved flow rate of up to 15 mL/s, and there was less interruption and less prolongation of micturition. We remained suspicious that the underlying problem was of a psychologic nature but could not absolutely exclude a functional bladder neck obstruction on our findings. However, therapeutic trials of both phenoxybenzamine and prazosin failed to bring about symptomatic relief. We decided to attempt a biofeedback technique to relax the external urethral sphincter during voiding. The patient was initially educated in the eoncept by attaching cutaneous EMG electrodes to his forearm. He was made to observe the result of contraction and relaxation of his forearm muscles on the EMG oscilloscope and was also subjected to the auditory stimulus of the "white noise" generated by the machine during muscular contraction. He rapidly mas-
44
tered the technique of complete relaxation and controlled contraction of the forearm muscles. Later the same technique was applied to the perineal musculature. Cutaneous electrodes were applied at the 3 and 9-o'clock positions with respect to the anus. An earth lead was applied to the wrist. The patient was then instructed, with the aid of the EMG machine, to learn pelvic floor muscle contraction and relaxation. Having mastered these exercises he was asked to void into a flow meter with a full bladder and with the perineal EMG leads attached. The initial resuits were disappointing, but again pelvic floor muscle was noted to be abnormally active during attempted voiding. This test was repeated, and the patient was verbally encouraged to relax his sphincter by making the EMG recording flat and the "white noise" silent during each attempt to void. Figure 1 shows the improvement in the flow rate as a result of an increase in verbal encouragement and instruction during voiding. Comments Dysfunctional problems without organic, infective, or structural cause are not uncommon in the urinary tract. Videocystometrography of: such cases may reveal detrusor instability, functional bladder neck obstruction, or detrusor sphincter dyssynergia. The etiology, of these conditions is uncertain; although neurologic conditions are sometimes found to account for the symptoms, psychologic factors are often
UROLOGY
,
JANUARY 1991
,'
V O I , U M E XXXV[I, N U M B E B I
implicated. ~° The diagnosis of a psychogenic disorder is generally one of exclusion. However, when there is a psychologic etiology, behavioral therapy is more likely to be of benefit. Unfortunately relapse is not uncommon and, therefore, several courses of treatment may be required.
London WIN 8AA, England (DR. CHRISTMAS) References 1. Amato A, Hermsmeyer CA, and Klcinman KM: Use of electromyographic feedback to increase inhibitory control of spastic muscles, Phys Ther 53:1063 (1973). 2. Sargent JD, Green EE, and Waiters ED: Preliminary report on the use of autogenic feedback training in the treatment of migraine and tension headaches, Psyehosom Med 35:129 (197,3).
UROLOGY
,' JANUARY 1991
:
3. Weiss T, and Engel BT: Operant conditioning of heart rate in patients with premature ventricular contractions, Psyehosom Med 33:301 (1971). 4. Engel BT, Nikeomanesh P, and Schuster MM: Operant conditioning of reeto-sphincteric responses in the treatment of fecal incontinence, N Engl J Mcd 290:646 (1974). 5. Cardozo LD, Abrams PD, Stanton SL, and Feneney RCL: Idiopathic bladder instability treated by biofeedback, Br J Urol 50:521 (1978). 6. Cardozo LD, Stanton SL, Hafner J, and Allan V: Biofeedback in the treatment of detrusor instability~ Br J Urol 50:250 (1978). 7. Maizels M, King LR, and Firlit CF: Urodynamic biofeedback: a new approach to treat vesical sphincter dyssyner~a, J Urol 122:205 (1979). 8. Wear JB, VCear RB, and Cleeland C: Biofeedback in urology using urodynamics: preliminary observations, J Urol 121:464
(1979). 9. Stroebel CI~ and Glueck BC: Biofeedback treatment in medicine and psychiatry: an ultimate placebo? Sere Psychiat 5:
379 (1973). 10. Frewen WK: An objective assessment of the unstable bladder of psychosomatic origin, Br J Urol 50:521 (1978).
VOLUME X?~LXVII, NUMBER 1
45