British Journal of Urology (1978). 50. 250-254
Biofeedback in the Treatment of Detrusor Instability L. CARDOZO, S. L. STANTON, J. HAFNER and V. ALLAN Department of Obstetrics and Gynaecology, St George's Hospital Medical School, London
Summary- Detrusor instability has remained resistant to conventional forms of treatment. An attempt to use biofeedback methods in its management is described. Six female patients with symptoms of frequency, urgency and urge incontinence due to detrusor instability were conditioned to auditory and visual stimuli for 6 to 8 1 h sessions. They were assessed clinically and urodynamically. The results are presented as well as detailed case studies of 3 patients. Subjectively, 3 were cured, 2 improved and 1 remained the same; objectively, 3 were cured, 1 improved and 2 remained the same. No significant side effects were encountered.
Urinary incontinence, urgency and frequency, associated with detrusor instability are distressing complaints both to the patient and to the doctor as they are often resistant to the more usual forms of treatment such as surgery and drugs. Frewen (1972) suggests that urge incontinence, which may be due to detrusor instability, is a psychosomatic disorder in which emotional factors play a predominant role. Biofeedback training is a form of learning or reeducation in which the patient is placed in a closed feedback loop where information about 1 or more of her normally unconscious physiological processes is made available to her as a visual, auditory or tactile signal (Stroebel and Glueck, 1973). It has previously been used to treat other disorders of autonomic function with moderate degrees of success. These include hypertension (Love et al., 1974) and longstanding faecal incontinence (Engel et al., 1974). Its successful use in a female patient with hysterical urinary retention was described by Stanton (1976).
In this ongoing study, biofeedback training was used to re-educate female patients with urinary symptoms associated with detrusor instability, in order that these symptoms might be alleviated.
Method Patients in this study were diagnosed on videocystourethrography (VCU) (Bates and Corney, 197 1) as having detrusor instability if a detrusor Received 12 September 1977. Accepted for publication 16 January 1978.
pressure rise of more than 15 cm of water was recorded during any of the provocative tests. These included fast bladder filling, coughing during filling, standing up and coughing when erect. Cystoscopy was performed to exclude organic bladder pathology and a neurological opinion was sought to rule out any occult neurological lesion. When the patient attended for the first session of biofeedback training the procedure was explained to her and she was put at her ease as much as possible. Using a clean procedure, 2 catheters were introduced into the bladder; a 14 F.G. urethral catheter was used for filling and a 1 mm fluid-filled catheter measured the total bladder pressure. A 2 mm fluid-filled catheter, protected from faecal blockage by a finger stall, was introduced into the rectum to measure the rectal pressure which was taken to be equivalent to the abdominal pressure. The rectal pressure was electronically subtracted from the total bladder pressure to give the detrusor pressure and all 3 parameters were recorded on a chart recorder (Fig. 1). A voltage to frequency converter was connected to the detrusor pressure strain gauge amplifier, which emitted an auditory signal. The gain and frequency range of this could be altered to suit the individual patient but once a baseline tone was decided upon, the note emitted through the loudspeaker increased in pitch as the detrusor pressure rose, and decreased as the pressure fell. Thus a patient with an unstable detrusor would hear a rise in pitch as the detrusor pressure increased. A mirror was positioned in such a way that the patient, lying supine, could look into it and see the detrusor pressure pen deflection. 250
RECTAL LlM
BLADDER Llhc
.
DIFFEREMIAL TRANSDUCER
-
~
STRAIN GAUGE AMPLIFIER
CHART
INTRINSIC BUDDER PRESSURE
STRAINGAUGE A M R l F l E R 1 ~
MIRROR IVISUAL SIGNAL)
WFSET (BASE FREQUENCY) AMPLIFIER GAIN (FREQUENCY RANGE) VOLTAGE TO FREQUENCY CONVERTOR
VOLUM
$*-=
AUD 10 AMPLlF IER
LOUDSPEAKER lAUD ITORY 5 IGNALI
Fig. 1 Biofeedback circuit.
With the patient lying comfortably, bladder filling was commenced using 0.9% saline, prewarmed to body temperature, at a rate of 100 ml per min. The patient was asked to listen to the auditory signal and to watch the chart recording and to say when she had the first sensation of desire to void and again when her bladder was absolutely full. She was also asked to notify the attendant if she leaked. When full capacity was reached the bladder was emptied and filling was recommenced at a slower rate; this time the patient was asked to try to control the rise in pitch of the auditory signal by concentrating, deep breathing, fist clenching, general relaxation or any other method which she found helpful. This varied from patient t o patient, some preferring to talk, others finding that tightening certain muscle groups helped. When the bladder was full it was again emptied. Each session was planned to last about an hour, during which time the bladder might be filled 2 or 3 times, depending upon the rate of filling. Most patients attended for about 6 to 8 sessions at weekly intervals and as they became used to the training and were better able to control the pressure rise on filling, provocative tests such as laughing, tap running, standing up with a full bladder and coughing when erect were used. Between sessions the patient was asked to keep a “urinary diary” in which she recorded the number of “urges” to void during each day and whether or not she was incontinent at any time. She also kept a record of her urinary frequency. Patients were encouraged to void only when absolutely necessary. Subjective improvement
I
was recorded week by week as the treatment progressed and at the end of treatment a further videocystourethrogram was performed, as was a Urilos Nappy Test (Stanton and Ritchie, 1977) to assess the patient’s objective improvement. Midstream specimens of urine from all patients were sent regularly for culture and sensitivity.
Results To date 6 female patients have been treated and have completed 3 months’ follow-up. Their average age was 39 years (range 22 to 47 years). A patient is thought to be subjectively cured if she no longer complains of frequency, urgency or urge incontinence. Frequency is taken to be the passage of urine 7 or more times during the day and twice or more at night. An objective cure exists if the patient no longer exhibits detrusor contractions at any time during cystometry, the detrusor pressure does not rise above I5 cm of water and the patient does not leak at any time. Using these criteria the results are shown in Table 1. Only 1 of the 6 patients failed to respond and she has since been referred to the psychiatrists after an attempted suicide. Table 1 Preliminary Results-6 Patients Subjective
Objective
Cured
3
3
Improved
2
1
Failed
1
2
BRITISH JOURNAL OF UROLOGY
252 Table 2 Subjective C h a nge s4 Patients w o r e treatment 4fter treatment
Symptom
(No.of Frequency: diurnal
patients)
(No.of
6 5
2 1
UrgZncy
6
2
Urge incontinence
5
2
nocturnal
patients)
Table 2 shows the symptomatic changes. If frequency is assessed as the number of times micturition occurs, then prior t o treatment the mean diurnal frequency was 15.7 (S.D.=5.2) and the mean nocturnal frequency was 1.8 (S.D.= 1.2). After treatment these figures were reduced t o 5.5 (S.D.=2.4) and 0.3 (S.D.=0.5) respectively.
bladder capacity of 400 ml with a pressure rise on filling of 10 cm of water and on standing of 12 cm of water. She had detrusor contractions up to 36 cm of water following coughing and exhibited stress incontinence. Initially she was treated unsuccessfully with Urispas 200 mg qds. Two months later she started biofeedback training. She was given 7 sessions, during which time she gradually improved. At the end of this time she voided only 3 times during the day and not at all at night and was no longer incontinent. Follow-up videocystourethrogram showed a first sensation at 180 ml and a bladder capacity of 500 ml. Her pressure rise on filling was 7 cm of water and on standing 1 cm of water. There were no detrusor contractions. Slight stress incontinence was noted but the patient was not concerned about this. The Urilos Nappy Test was negative. At 3 months’ follow-up the situation was unchanged. case2
Table 3 .Objective C h ange s4 Patients
vcu First sensation (rnl) Capacity (rnl) Pressure rise on filling (ern H P )
Pressure rise on standing (cm H P ) Detrusor contractions+ leakage of urine
Before treatment rlfrer treatment Mean
(S.D.)
Mean
(S.D.)
143 405
(83) (67)
156 467
(82) (52)
28
(25)
25
(26)
18
(10)
2
(4)
5 patients
2 patients
The objective changes are shown in Table 3. The change in mean total detrusor pressure rise (the pressure rise on filling plus the pressure rise on standing) was 46 cm H P to 27 cm H@. If, however, the 2 patients who failed objectively are excluded, then the mean total detrusor pressure rises before and after treatment are 33 cm H P and 13 cm H P respectively. At VCU prior t o treatment 5 of the 6 patients exhibited detrusor contractions with simultaneous leakage of urine; after treatment only 2 did. No urinary tract infections were encountered. The case studies of 3 of the patients are presented in detail: clue1
Mrs I. B. (age 47 years) presented with a history of 14 years’ incontinence which was worsening. She complained of stress incontinence, urgency and urge incontinence, and also of frequency, micturating 8 times during the day and 3 times at night. Videocystourethrography showed a first sensation at 110 ml and a
Mrs J. S. (age 42 years) complained of stress incontinence and frequency, micturating 15 times during the day but not at all at night. Her initial videocystourethrogram showed a pressure rise on filling of 8 cm of water and on standing of 16 cm of water. She also exhibited stress incontinence. After 6 sessions of biofeedback she was greatly improved; she was never incontinent and micturated only 6 times during the day. Follow-up videocystourethrogram showed a pressure rise of 4 cm of water on filling and no pressure rise on standing. Stress incontinence was not present during the test nor during the Urilos Nappy Test. She remained the same when seen at 3 months’ follow-up.
case3 Mrs A. J. (age 22 years) complained of increasing frequency of micturition for the last 2 years. She said she voided up to 20 times during the day and 3 times at night. Videocystourethrogram showed a first sensation at 25 ml and a capacity of 400 ml with a pressure rise of 18 cm of water on filling and 6 cm of water on standing. She leaked urine on standing and on coughing. At first she was very apprehensive about biofeedback training, but after 8 sessions she said that she micturated only 4 to 5 times during the day and not at all at night and that she was never incontinent. Videocystourethrography showed that she still had a pressure rise on filling of 19 cm of water but no pressure rise on standing. Her first sensation was at 75 ml and capacity 500 ml. Stress incontinence did not occur on this occasion nor on Urilos Nappy Test. When seen at 3 months’ follow-up she was symptomatically cured.
Discussion Many forms of treatment have been tried in the
BIOFEEDBACK IN THE TREATMENT OF DETRUSOR INSTABILITY
hope of finding a cure for detrusor instability. This in itself indicates that none is completely successful. Surgery originally aimed at denervating the bladder (Ingelman-Sundberg, 1959) but this did not produce lasting improvement. Sacral neurectomy was tried (Torrens and Griffiths, 1974) but was found to be successful only in carefully selected cases. Beck et al. (1976) postulate that abnormal bladder neck funnelling may cause detrusor instability in some women and by surgical correction of this fault they have obtained a cure in about 50% of their cases and an improvement in 77%. However, they recommend surgery only as a last resort in the treatment of detrusor instability. More recently cystodistension (Dunn et al., 1975)has been attempted, and as yet the long-term results of this form of treatment are unknown. It does, however, have a risk of bladder rupture. Drug therapy is still the mainstay of treatment in this condition and it, too, is unsatisfactory in many cases. The drugs in common use try to control uninhibited detrusor contractions either by direct anticholinergic activity or by stimulating the beta-adrenergic receptors (Moolgaoker et al., 1972; Brown et al., 1973; Stanton, 1973). Bladder drill and supportive psychotherapy have been attempted (Frewen, 1978) and the results of this non-invasive treatment are promising. Biofeedback treatment avoids the morbidity of surgery and the sideeffects of drug therapy, but it does hold certain problems of its own. There is a risk of urinary tract infection, although we have not yet encountered this. Some patients find the sensation of catheterisation unpleasant and others are resistant to the implication that their urinary problem might be psychosomatic. The treatment involves several visits to the hospital, and this is reflected in about a 15Vo incidence of failure to attend for sessions. In assessing the “costeffectiveness” of this technique, account must be taken of the need for both a doctor or highly trained nurse and technician to be present during most of the training time. It is intcresting to note that although not all of the patients have been cured, or even improved, by biofeedback training, frequency was universally less after treatment. Possibly this is due to the patient’s greater awareness, brought about by the use of the urinary diary. It is concluded that the successful treatment of urological symptoms associated with detrusor instability by biofeedback methods and its lack
253
of complications are shown in this preliminary report. Although only 6 patients have completed treatment and 3 months’ follow-up, others are currently undergoing treatment. In view of the modest success achieved by other forms of treatment, some of which have a significant morbidity, we feel that biofeedback methods of therapy should be evaluated further.
Acknowledgements We would like to thank Mr Don Ritchie of the Department of Physics, St George’s Hospital, London. for building the apparatus and for his department’s invaluable help with technical problems encountered. Our thanks are also due to Nurse Leila Bickaroo for her care of the patients.
References Bates, C. P. and Corney, C. E. (1971). Synchronous cine/ pressure/flow cystograpy: a method of routine urodynamic investigation. British Journal of Radiology, 44,44-50. Beck, R. P., Arnusb, D. and King, C. (1976). Results in treating 210 patients with detrusor overactivity incontinence of urine. American Journal of Obstetrics, 125, 593-596. Brown, A. D. G., Arnold, E. P. and Worth, P. H. L. (1973). The unstable bladder: a study of drug treatment in women. Paper read at the 3rd International Continence Society Meeting, Copenhagen (unpublished). Dunn, M.,Smltb, J. C. and Ardran, G.M. (1975). Prolonged bladder distension as a treatment of urgency and urge incontinence of urine. British Journal of Obstetrics and Gynaecology, 82,254. Engel, B. T., Nikoomanesb, P. and %buster, M. M. (1974). Operant conditioning of rectosphincteric responses in the treatment of fecal incontinence. New England Journal of Medicine, 290.646-649. Frewen, W. K. (1972). Psychosomatic urgency incontinence of urine. Journal of Obstetrics and Gynaecology of the British Commonwealth, 19, 77-79. Frewen. W. K. (1978). The unstable bladder. (In press.) ~ngelman-Sundberg, A. (1959). Partial denervation of the bladder. Acta obstetricia et gynecologica Scandinavica, 38, 487-501. Love, W. A., Montgomery, D. D. and Moeller, T. A. (1974). A post-hoc analysis of correlates of blood pressure reduction (abstract). Proceedings of the Biofeedback Research Society, Colorado Springs, p . 35. Moolgaoker, A. S., Ardran, G. M., Smith, J. C. and Stallwortby, J. A. (1972). The diagnosis and management of urinary incontinence in the female. Journal of Obstetrics and Gynaecology of the British Commonwalth, ’19, 481497. Stanton, S. L. (1973). A comparison of emepronium bromide and flavoxate hydrochloride in the treatment of urinary incontinence. Journal of Urology, 110, 529-532. Stanton, S. L. (1976). Communication to 6th International Continence Society Meeting, Antwerp (unpublished). Stanton, S . L. and Ritcbie, D. (1977). Urilos: the practical detection of urine loss. American Journal of Obstetrics and Gynecology, 128,461465.
254
BRITISH JOURNAL OF UROLOGY
The Authors
Obstetrics and Gynaecology, St George’s Hospital Medical School, London. Julian Hafner, MD, MPhil.. MRC Psych., formerly Senior Lecturer and Consultant, Department of Adult Psychiatry, St George’s Hospital, London. Now Department of Psychiatry, Hinders Medical Centre, South Australia. Valerie Allan, Technician, Department of Obstetrics and Gynaecology. St George’s Hospital Medical School, London.
Linda Cardozo, MBChB, Clinical Research Fellow, Urodynamic Unit, Department of Obstetrics and Gynaecology, St George’s Hospital Medical School, London. Stuart L. Stanton, FRCS, MRCOG, Senior Lecturer and Honorary Consultant, Urodynamic Unit, Department of
Requests for reprints to: Dr Linda Cardozo, Urodynamic Unit, Department of Obstetrics and Gynaecology, St George’s Hospital Medical School, Cranmer Terrace, London SW I7 ORE.
C. F. and Claeck, B. C. (1973). Biofeedback treatment in medicine and psychiatry. An ultimate placebo. Seminars in Psychiatry, 5, 379-393. Torrem, M. J. and Critlithr, H. B. (1974). The control of the uninhibited bladder by selective sacral neurectomy. British Journal of Urology, 46,639-644. Stroebel,
Biofeedback in the Treatment of Detrusor Instability L. CARDOZO, S. L. STANTON, J. HAFNER and V. ALLAN Department of Obstetrics and Gynaecology, St George's Hospital Medical School, London
Summary- Detrusor instability has remained resistant to conventional forms of treatment. An attempt to use biofeedback methods in its management is described. Six female patients with symptoms of frequency, urgency and urge incontinence due to detrusor instability were conditioned to auditory and visual stimuli for 6 to 8 1 h sessions. They were assessed clinically and urodynamically. The results are presented as well as detailed case studies of 3 patients. Subjectively, 3 were cured, 2 improved and 1 remained the same; objectively, 3 were cured, 1 improved and 2 remained the same. No significant side effects were encountered.
Urinary incontinence, urgency and frequency, associated with detrusor instability are distressing complaints both to the patient and to the doctor as they are often resistant to the more usual forms of treatment such as surgery and drugs. Frewen (1972) suggests that urge incontinence, which may be due to detrusor instability, is a psychosomatic disorder in which emotional factors play a predominant role. Biofeedback training is a form of learning or reeducation in which the patient is placed in a closed feedback loop where information about 1 or more of her normally unconscious physiological processes is made available to her as a visual, auditory or tactile signal (Stroebel and Glueck, 1973). It has previously been used to treat other disorders of autonomic function with moderate degrees of success. These include hypertension (Love et al., 1974) and longstanding faecal incontinence (Engel et al., 1974). Its successful use in a female patient with hysterical urinary retention was described by Stanton (1976).
In this ongoing study, biofeedback training was used to re-educate female patients with urinary symptoms associated with detrusor instability, in order that these symptoms might be alleviated.
Method Patients in this study were diagnosed on videocystourethrography (VCU) (Bates and Corney, 197 1) as having detrusor instability if a detrusor Received 12 September 1977. Accepted for publication 16 January 1978.
pressure rise of more than 15 cm of water was recorded during any of the provocative tests. These included fast bladder filling, coughing during filling, standing up and coughing when erect. Cystoscopy was performed to exclude organic bladder pathology and a neurological opinion was sought to rule out any occult neurological lesion. When the patient attended for the first session of biofeedback training the procedure was explained to her and she was put at her ease as much as possible. Using a clean procedure, 2 catheters were introduced into the bladder; a 14 F.G. urethral catheter was used for filling and a 1 mm fluid-filled catheter measured the total bladder pressure. A 2 mm fluid-filled catheter, protected from faecal blockage by a finger stall, was introduced into the rectum to measure the rectal pressure which was taken to be equivalent to the abdominal pressure. The rectal pressure was electronically subtracted from the total bladder pressure to give the detrusor pressure and all 3 parameters were recorded on a chart recorder (Fig. 1). A voltage to frequency converter was connected to the detrusor pressure strain gauge amplifier, which emitted an auditory signal. The gain and frequency range of this could be altered to suit the individual patient but once a baseline tone was decided upon, the note emitted through the loudspeaker increased in pitch as the detrusor pressure rose, and decreased as the pressure fell. Thus a patient with an unstable detrusor would hear a rise in pitch as the detrusor pressure increased. A mirror was positioned in such a way that the patient, lying supine, could look into it and see the detrusor pressure pen deflection. 250
RECTAL LlM
BLADDER Llhc
.
DIFFEREMIAL TRANSDUCER
-
~
STRAIN GAUGE AMPLIFIER
CHART
INTRINSIC BUDDER PRESSURE
STRAINGAUGE A M R l F l E R 1 ~
MIRROR IVISUAL SIGNAL)
WFSET (BASE FREQUENCY) AMPLIFIER GAIN (FREQUENCY RANGE) VOLTAGE TO FREQUENCY CONVERTOR
VOLUM
$*-=
AUD 10 AMPLlF IER
LOUDSPEAKER lAUD ITORY 5 IGNALI
Fig. 1 Biofeedback circuit.
With the patient lying comfortably, bladder filling was commenced using 0.9% saline, prewarmed to body temperature, at a rate of 100 ml per min. The patient was asked to listen to the auditory signal and to watch the chart recording and to say when she had the first sensation of desire to void and again when her bladder was absolutely full. She was also asked to notify the attendant if she leaked. When full capacity was reached the bladder was emptied and filling was recommenced at a slower rate; this time the patient was asked to try to control the rise in pitch of the auditory signal by concentrating, deep breathing, fist clenching, general relaxation or any other method which she found helpful. This varied from patient t o patient, some preferring to talk, others finding that tightening certain muscle groups helped. When the bladder was full it was again emptied. Each session was planned to last about an hour, during which time the bladder might be filled 2 or 3 times, depending upon the rate of filling. Most patients attended for about 6 to 8 sessions at weekly intervals and as they became used to the training and were better able to control the pressure rise on filling, provocative tests such as laughing, tap running, standing up with a full bladder and coughing when erect were used. Between sessions the patient was asked to keep a “urinary diary” in which she recorded the number of “urges” to void during each day and whether or not she was incontinent at any time. She also kept a record of her urinary frequency. Patients were encouraged to void only when absolutely necessary. Subjective improvement
I
was recorded week by week as the treatment progressed and at the end of treatment a further videocystourethrogram was performed, as was a Urilos Nappy Test (Stanton and Ritchie, 1977) to assess the patient’s objective improvement. Midstream specimens of urine from all patients were sent regularly for culture and sensitivity.
Results To date 6 female patients have been treated and have completed 3 months’ follow-up. Their average age was 39 years (range 22 to 47 years). A patient is thought to be subjectively cured if she no longer complains of frequency, urgency or urge incontinence. Frequency is taken to be the passage of urine 7 or more times during the day and twice or more at night. An objective cure exists if the patient no longer exhibits detrusor contractions at any time during cystometry, the detrusor pressure does not rise above I5 cm of water and the patient does not leak at any time. Using these criteria the results are shown in Table 1. Only 1 of the 6 patients failed to respond and she has since been referred to the psychiatrists after an attempted suicide. Table 1 Preliminary Results-6 Patients Subjective
Objective
Cured
3
3
Improved
2
1
Failed
1
2
BRITISH JOURNAL OF UROLOGY
252 Table 2 Subjective C h a nge s4 Patients w o r e treatment 4fter treatment
Symptom
(No.of Frequency: diurnal
patients)
(No.of
6 5
2 1
UrgZncy
6
2
Urge incontinence
5
2
nocturnal
patients)
Table 2 shows the symptomatic changes. If frequency is assessed as the number of times micturition occurs, then prior t o treatment the mean diurnal frequency was 15.7 (S.D.=5.2) and the mean nocturnal frequency was 1.8 (S.D.= 1.2). After treatment these figures were reduced t o 5.5 (S.D.=2.4) and 0.3 (S.D.=0.5) respectively.
bladder capacity of 400 ml with a pressure rise on filling of 10 cm of water and on standing of 12 cm of water. She had detrusor contractions up to 36 cm of water following coughing and exhibited stress incontinence. Initially she was treated unsuccessfully with Urispas 200 mg qds. Two months later she started biofeedback training. She was given 7 sessions, during which time she gradually improved. At the end of this time she voided only 3 times during the day and not at all at night and was no longer incontinent. Follow-up videocystourethrogram showed a first sensation at 180 ml and a bladder capacity of 500 ml. Her pressure rise on filling was 7 cm of water and on standing 1 cm of water. There were no detrusor contractions. Slight stress incontinence was noted but the patient was not concerned about this. The Urilos Nappy Test was negative. At 3 months’ follow-up the situation was unchanged. case2
Table 3 .Objective C h ange s4 Patients
vcu First sensation (rnl) Capacity (rnl) Pressure rise on filling (ern H P )
Pressure rise on standing (cm H P ) Detrusor contractions+ leakage of urine
Before treatment rlfrer treatment Mean
(S.D.)
Mean
(S.D.)
143 405
(83) (67)
156 467
(82) (52)
28
(25)
25
(26)
18
(10)
2
(4)
5 patients
2 patients
The objective changes are shown in Table 3. The change in mean total detrusor pressure rise (the pressure rise on filling plus the pressure rise on standing) was 46 cm H P to 27 cm H@. If, however, the 2 patients who failed objectively are excluded, then the mean total detrusor pressure rises before and after treatment are 33 cm H P and 13 cm H P respectively. At VCU prior t o treatment 5 of the 6 patients exhibited detrusor contractions with simultaneous leakage of urine; after treatment only 2 did. No urinary tract infections were encountered. The case studies of 3 of the patients are presented in detail: clue1
Mrs I. B. (age 47 years) presented with a history of 14 years’ incontinence which was worsening. She complained of stress incontinence, urgency and urge incontinence, and also of frequency, micturating 8 times during the day and 3 times at night. Videocystourethrography showed a first sensation at 110 ml and a
Mrs J. S. (age 42 years) complained of stress incontinence and frequency, micturating 15 times during the day but not at all at night. Her initial videocystourethrogram showed a pressure rise on filling of 8 cm of water and on standing of 16 cm of water. She also exhibited stress incontinence. After 6 sessions of biofeedback she was greatly improved; she was never incontinent and micturated only 6 times during the day. Follow-up videocystourethrogram showed a pressure rise of 4 cm of water on filling and no pressure rise on standing. Stress incontinence was not present during the test nor during the Urilos Nappy Test. She remained the same when seen at 3 months’ follow-up.
case3 Mrs A. J. (age 22 years) complained of increasing frequency of micturition for the last 2 years. She said she voided up to 20 times during the day and 3 times at night. Videocystourethrogram showed a first sensation at 25 ml and a capacity of 400 ml with a pressure rise of 18 cm of water on filling and 6 cm of water on standing. She leaked urine on standing and on coughing. At first she was very apprehensive about biofeedback training, but after 8 sessions she said that she micturated only 4 to 5 times during the day and not at all at night and that she was never incontinent. Videocystourethrography showed that she still had a pressure rise on filling of 19 cm of water but no pressure rise on standing. Her first sensation was at 75 ml and capacity 500 ml. Stress incontinence did not occur on this occasion nor on Urilos Nappy Test. When seen at 3 months’ follow-up she was symptomatically cured.
Discussion Many forms of treatment have been tried in the
BIOFEEDBACK IN THE TREATMENT OF DETRUSOR INSTABILITY
hope of finding a cure for detrusor instability. This in itself indicates that none is completely successful. Surgery originally aimed at denervating the bladder (Ingelman-Sundberg, 1959) but this did not produce lasting improvement. Sacral neurectomy was tried (Torrens and Griffiths, 1974) but was found to be successful only in carefully selected cases. Beck et al. (1976) postulate that abnormal bladder neck funnelling may cause detrusor instability in some women and by surgical correction of this fault they have obtained a cure in about 50% of their cases and an improvement in 77%. However, they recommend surgery only as a last resort in the treatment of detrusor instability. More recently cystodistension (Dunn et al., 1975)has been attempted, and as yet the long-term results of this form of treatment are unknown. It does, however, have a risk of bladder rupture. Drug therapy is still the mainstay of treatment in this condition and it, too, is unsatisfactory in many cases. The drugs in common use try to control uninhibited detrusor contractions either by direct anticholinergic activity or by stimulating the beta-adrenergic receptors (Moolgaoker et al., 1972; Brown et al., 1973; Stanton, 1973). Bladder drill and supportive psychotherapy have been attempted (Frewen, 1978) and the results of this non-invasive treatment are promising. Biofeedback treatment avoids the morbidity of surgery and the sideeffects of drug therapy, but it does hold certain problems of its own. There is a risk of urinary tract infection, although we have not yet encountered this. Some patients find the sensation of catheterisation unpleasant and others are resistant to the implication that their urinary problem might be psychosomatic. The treatment involves several visits to the hospital, and this is reflected in about a 15Vo incidence of failure to attend for sessions. In assessing the “costeffectiveness” of this technique, account must be taken of the need for both a doctor or highly trained nurse and technician to be present during most of the training time. It is intcresting to note that although not all of the patients have been cured, or even improved, by biofeedback training, frequency was universally less after treatment. Possibly this is due to the patient’s greater awareness, brought about by the use of the urinary diary. It is concluded that the successful treatment of urological symptoms associated with detrusor instability by biofeedback methods and its lack
253
of complications are shown in this preliminary report. Although only 6 patients have completed treatment and 3 months’ follow-up, others are currently undergoing treatment. In view of the modest success achieved by other forms of treatment, some of which have a significant morbidity, we feel that biofeedback methods of therapy should be evaluated further.
Acknowledgements We would like to thank Mr Don Ritchie of the Department of Physics, St George’s Hospital, London. for building the apparatus and for his department’s invaluable help with technical problems encountered. Our thanks are also due to Nurse Leila Bickaroo for her care of the patients.
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The Authors
Obstetrics and Gynaecology, St George’s Hospital Medical School, London. Julian Hafner, MD, MPhil.. MRC Psych., formerly Senior Lecturer and Consultant, Department of Adult Psychiatry, St George’s Hospital, London. Now Department of Psychiatry, Hinders Medical Centre, South Australia. Valerie Allan, Technician, Department of Obstetrics and Gynaecology. St George’s Hospital Medical School, London.
Linda Cardozo, MBChB, Clinical Research Fellow, Urodynamic Unit, Department of Obstetrics and Gynaecology, St George’s Hospital Medical School, London. Stuart L. Stanton, FRCS, MRCOG, Senior Lecturer and Honorary Consultant, Urodynamic Unit, Department of
Requests for reprints to: Dr Linda Cardozo, Urodynamic Unit, Department of Obstetrics and Gynaecology, St George’s Hospital Medical School, Cranmer Terrace, London SW I7 ORE.
C. F. and Claeck, B. C. (1973). Biofeedback treatment in medicine and psychiatry. An ultimate placebo. Seminars in Psychiatry, 5, 379-393. Torrem, M. J. and Critlithr, H. B. (1974). The control of the uninhibited bladder by selective sacral neurectomy. British Journal of Urology, 46,639-644. Stroebel,
