Biofeedback, Pelvic Floor Reeducation, And Bladder Training

[A. Melon]

BIOFEEDBACK, PELVIC FLOOR REEDUCATION, AND BLADDER TRAINING FOR MALE
CHRONIC PELVIC PAIN SYNDROME

J. QUENTIN CLEMENS, ROBERT B. NADLER, ANTHONY J. SCHAEFFER, JAY
BELANI, JEFF ALBAUGH, AND WADE BUSHMAN

ABSTRACT

Objectives. Pelvic floor tension myalgia may contribute to the
symptoms of male patients with chronic pelvic pain syndrome (CPPS).
Therefore, measures that diminish pelvic floor muscle spasm may
improve these symptoms. Based on this hypothesis, we enrolled 19
patients with CPPS in a 12week program of biofeedback directed pelvic
floor reeducation and bladder training.

Methods. Pretreatment and posttreatment symptom assessments included
daily voiding logs, American Urological Association (AUA) symptom
score, and 10point visual analog pain and urgency scores. Pressureflow
studies were obtained before treatment in most patients. Instruction
in pelvic floor muscle contraction and relaxation was achieved using a
noninvasive form of biofeedback at biweekly sessions. Home exercises
were combined with a progressive increase in timedvoiding intervals.

Results. Mean age of the 19 patients was 36 years (range 18 to 67).
Four patients completed less than three treatment sessions, 5 patients
completed three to five sessions, and 10 attended all six sessions.
Mean followup was 5.8 months. Median AUA symptom scores improved from
15.0 to 7.5 (P 5 0.001), and median bother scores decreased from 5.0
to 2.0 (P 5 0.001). Median pain scores decreased from 5.0 to 1.0 (P 5
0.001), and median urgency scores decreased from 5.0 to 2.0 (P 5
0.002). Median voiding interval increased from 0.88 hours to 3.0 hours
(P 5 0.003). Presence of detrusor instability, hypersensitivity to
filling, or bladdersphincter pseudodyssynergia on pretreatment
urodynamic studies was not predictive of treatment results.

Conclusions. This preliminary study confirms that a formalized program
of neuromuscular reeducation of the pelvic floor muscles together with
interval bladder training can provide significant and durable
improvement in objective measures of pain, urgency, and frequency in
patients with CPPS. UROLOGY 56: 951-955, 2000.

Chronic pelvic pain syndrome (CPPS), or NIH type IIIA/IIIB
prostatitis,1 is characterized by pelvic pain and voiding symptoms.
The source of these symptoms is still poorly understood, but pain
associated with chronic tension and spasm of the pelvic floor muscles
(pelvic floor tension myalgia) has been hypothesized to be a
contributing factor. 2,3 We and others have observed that patients
with CPPS frequently exhibit tenderness of the levator ani muscles on
rectal examination and that measures that decrease pelvic floor muscle
tension, such as sitz baths and relaxation techniques, may be used to
treat CPPS with anecdotal success.

Biofeedback-assisted techniques of neuromuscular reeducation have been
used successfully to treat chronic pain syndromes,4-6 including those
with a tension myalgia component.7 We hypothesized that a formalized
program that combines biofeedback-assisted pelvic floor reeducation
with interval bladder training may improve symptoms in patients with
CPPS.

MATERIAL AND METHODS

Between July 1995 and July 1998, 19 patients were treated with the
biofeedback regimen described below. Mean age was 38 years (range 18
to 67). All patients were diagnosed with nonbacterial CPPS based on
the presence of symptoms with a negative expressed prostatic fluid
(EPF) or VB3 urine culture. Symptoms included pain (perineal,
testicular, suprapubic, scrotal, ejaculatory, abdominal) and voiding
complaints (frequency, urgency, nocturia, decreased force of stream,
hesitancy, sense of incomplete emptying). Six patients had pain only,
6 had voiding symptoms only, and 7 had both pain and voiding symptoms.
Six patients were diagnosed with inflammatory CPPS (NIH type IIIA
prostatitis) and 13 were diagnosed with noninflammatory CPPS (NIH type
IIIB prostatitis) based on the presence or absence of white blood
cells in the EPF, respectively. All patients had failed prior
treatments, including antibiotics (16 patients), alphaadrenergic
blockers (10), anticholinergic agents (7), pentosan polysulfate (1),
and transurethral resection of the prostate (1).

Pretreatment evaluation included pressureflow urodynamic studies,
24hour voiding diaries, American Urological Association (AUA) symptom
scores, and 10point visual analog pain and urgency scores with ranges
of 0 (no pain/urgency) to 9 (unbearable pain/urgency). Pressureflow
studies were performed by infusing sterile 0.9% normal saline into the
bladder through a 10F triple channel urethral catheter at a rate of 50
mL/min. Abdominal pressure was recorded through a 9F rectal catheter.
Sphincter activity was recorded from cutaneous electrodes placed on
the perineum. The presence or absence of bladder outlet obstruction
was determined according to the Abrams and Griffiths nomogram.8
Detrusor instability was defined as an involuntary rise in detrusor
pressure of more than 15 cmH2 O; diminished bladder capacity was
defined as a bladder capacity of less than 250 mL. Detrusorsphincter
pseudodyssynergia was defined as the presence of increased
electromyographic (EMG) activity during voiding in the absence of
abdominal straining.

The biofeedback program is a standardized protocol of bladder training
combined with pelvic floor reeducation. It is an 11week program
comprised of six biweekly visits, each lasting 1 hour. During the
course of the program, the nurse therapist works with the patient to
accomplish three goals: (1) teach the patient to focus attention on
the pelvic floor, and to learn to selectively contract and relax these
muscles; (2) teach the patient to perform these exercises on a daily
basis to interrupt a syndrome of chronic pelvic myofascial pain; and
(3) work with the patient to progressively increase the voiding
interval toward a target of not less than 4 hours. At all visits, a
noninvasive method of biofeedback monitoring of pelvic floor muscular
activity is used to help the patient identify muscular activity in the
pelvic floor muscles. The biofeedback apparatus is an EMPI Innova
Clinical EMG System, Version 1.25. This apparatus is used with a
specially designed brief that contains surface electrodes for EMG
recording. We elected to use this device rather than internal probes
because its noninvasive character increased patient acceptance of the
therapy. The EMPI biofeedback program is used as recommended by the
manufacturer to instruct the patient in contraction and relaxation of
the pelvic floor musculature. The patient is instructed to perform the
exercises at home, three times daily, using the same combination of
fast and slow contractions and relaxations as during the instructional
session. At the first visit, the patient's 24hour voiding diary is
reviewed and a target voiding interval, which is the 75th percentile
of the patient's maximum daytime voiding interval, is selected as the
initial target. The patient is instructed to try to void at that
interval or greater throughout the waking hours for the next 2 weeks.
The patient is instructed to use pelvic floor contractions as the
mechanisms to delay voiding. No attempt is made to regulate the
patient's voiding after retiring to bed. He is asked to maintain a
daily voiding log that records the time (but not volume) of each
micturition. At each subsequent visit, the patient's voiding log is
reviewed and if the compliance is greater than 80%, the interval is
increased by 30 minutes. If compliance is less than 80%, the reasons
for lack of compliance are explored and a determination made whether
to reattempt the same goal or alter the goal. Throughout the program,
patients are encouraged to pursue the integrated goal of increased
voiding interval, a more physiologic voiding effort, and decreased
pelvic floor spasm and pain. Patients are instructed to continue
pelvic floor exercises after the formal protocol is completed to
maintain therapeutic efficacy.

Following treatment, questionnaires and voiding logs were repeated to
assess the success of therapy. Differences between pretreatment and
posttreatment symptom scores and voiding frequencies were calculated
using the Wilcoxon signedranks test.

RESULTS

Fourteen of the 19 patients underwent pretreatment urodynamics in our
laboratory. Five exhibited detrusor instability (DI) and an additional
4 had diminished bladder capacity. No patients were obstructed based
on AbramsGriffiths criteria,8 but 6 patients demonstrated
dysfunctional voiding as evidenced by incomplete relaxation of the
external urethral sphincter with voiding (pseudodyssynergia). Despite
these findings, no postvoid residual urine volume was more than 60 mL.
Three patients had a combination of cystometric abnormalities and
pseudodyssynergia.

Ten patients completed all six biofeedback sessions, 5 completed three
to five sessions, and 4 completed fewer than three sessions. Reasons
for noncompliance in these last 4 patients were sufficient improvement
(2 patients), insurance issues (1), and unknown (1). Complete
posttreatment followup was obtained in 16 patients with a mean
followup of 5.8 months after the last biofeedback session (median 3.5,
range 1.6 to 14.8). No follow up information was available for 3
patients who attended two, three, and six sessions, respectively.

Comparisons of pretreatment and posttreatment results are shown in
Figures 1 through 3. There was a statistically significant improvement
in all outcomes. No patient reported a higher AUA symptom score after
treatment. Eleven of 16 patients reported improvement by more than
five points, and the median symptom scores decreased from 15.0 before
treatment to 7.5 at followup. Eleven patients reported a decrease in
pain scores of at least three points; 3 patients reporting no change
from pretreatment values had very low initial pain scores (0, 1, and
2, respectively). The median values for pretreatment and posttreatment
pain scores were 5.0 and 1.0, respectively. Ten patients reported at
least a threepoint improvement in urgency scores; 3 patients reporting
no improvement had very low initial urgency scores (0, 1, and 2,
respectively). The median urgency score decreased from 5.0 before
treatment to 2.0 at followup.

Most responses from the 7 patients with both voiding symptoms and pain
showed significant reductions in both complaints. Four patients
demonstrated at least 3point reductions in pain and urgency scores
combined with at least 6point reductions in AUA symptom scores.
Another had a 2point reduction in pain score, a 3point reduction in
urgency score, and a 6point reduction in AUA symptom score. Two
patients had significant improvements in pain scores (4 and 7 points,
respectively), with less improvement in voiding symptoms. The first
had a 5point improvement in urge score, but only a 3point improvement
in AUA symptom score. The second had no change in either score
(urgency 7, AUA score 19). Overall quality of life was not assessed by
the present study, so it is not known whether these patients with
improvement in only one area were satisfied with their treatment
outcomes.

Patients were grouped according to the presence or absence of
cystometric abnormalities (DI or decreased bladder capacity) and the
presence or absence of pseudodyssynergia. For each subgroup analysis,
there was no difference in median pretreatment or posttreatment scores
for all measured outcomes (data not shown).

COMMENT

The connection between pelvic pain and voiding dysfunction is poorly
understood. In a recent study of 103 men with pelvic pain, Zermann et
al.9 found pathologic tenderness of the pelvic floor muscles
associated with the inability to contract and relax the pelvic floor
muscles in 88%. Urodynamic testing on 84 of these men demonstrated
abnormal pelvic floor function, including increased urethral
sensitivity and tonicity, and pseudodyssynergia during attempted
voiding. They hypothesized that functional compromise of the pelvic
floor musculature may trigger aberrant plasticity changes within the
central nervous system and result in a chronic pain state.9 If true,
this hypothesis provides a rationale for the success of
biofeedback-assisted pelvic floor reeducation in treating both voiding
dysfunction and pain.

Biofeedback is frequently recommended as treatment for CPPS,10-12 but
few data have been published to support that recommendation. Kaplan et
al.13 reported excellent shortterm results using biofeedback to treat
43 men with bladdersphincter pseudodyssynergia who had previously been
diagnosed with CPPS. In that study, biofeedback was used to teach
patients to recognize and correct pelvic floor contraction during
voiding. The goal of our treatment protocol was different. We first
taught patients to identify the pelvic floor muscle group and then use
contraction/relaxation exercises to put the muscle through its normal
dynamic range. These range of motion exercises help break the cycle of
spasm and pain. We encouraged home exercises to strengthen the muscles
because better muscle health may result in less spasm and pain. We
taught patients to perform voluntary pelvic floor muscle relaxation, a
technique that is used during episodic exacerbations of pain. Finally,
we combined pelvic floor reeducation with voiding interval training
aimed at achieving a gradual, progressive increase in voiding
interval. This method addresses the problem of urinary frequency and
obviates the dysfunctional voiding efforts that many patients display
when attempting to void at small bladder volumes. Our results, albeit
in a small patient cohort, suggest that a formalized pelvic floor
reeducation program together with interval bladder training can
provide significant improvement in objective measures of pain and
voiding symptoms in patients with CPPS. These benefits were seen
regardless of the presence or absence of pseudodyssynergia or
cystometric abnormalities on urodynamic testing. There are three
possibilities: (1) abnormalities seen during urodynamic testing
represent clinically insignificant testing artifacts; (2) urodynamic
abnormalities resolve as a result of improved control of the pelvic
floor muscles and voiding interval training; or (3) urodynamic
abnormalities persist despite treatment but do not preclude
symptomatic improvement.

Our positive results are encouraging but must be viewed with a
realistic appreciation that the treat ment regimen described requires
a high level of commitment by the patients and the nurses who
administer the training. Furthermore, some insurance carriers do not
cover the expenses. We make a specific effort to counsel patients
about these issues prior to referring them for biofeedback. Despite
our efforts to maximize patient compliance, nearly half of the
patients did not complete all six sessions. Interestingly, 2 of the 4
patients who attended fewer than half of the treatments cited
sufficient improvement as their reason for not attending further. All
patients continued to use the exercises intermittently for symptomatic
exacerbations following completion of the formal biofeedback program,
but it is not known how many continued performing the exercises on a
daily basis.

The longterm durability of biofeedback is not known, nor is it known
whether attendance for the entire teaching regimen or longterm daily
performance of pelvic floor exercises results in improved longterm
results.

None of our patients who were treated with biofeedback had overt
bladder neck obstruction. In young men with longstanding, refractory
voiding dysfunction, as many as 50% may be found to have obstruction
on pressureflow studies.14 These patients' symptoms usually respond
well to transurethal incision of the prostate,15,16 albeit at the
possible expense of retrograde ejaculation. It is not known whether
biofeedback would be beneficial in these patients.

To accurately compare the efficacy of treatments for a given disease
process, it is mandatory to have a standard outcome measure.
Subsequent to the accrual and treatment of our patient cohort, a
validated qualityoflife instrument for male CPPS has been developed
and published.17 We encourage the use of this instrument in future
analyses of treatment results for this enigmatic condition.

CONCLUSIONS

At 6 months' followup, a structured program of biofeedback-assisted
pelvic floor exercises and timed voiding resulted in significant
improvement in voiding symptoms and pain in a group of men with CPPS
refractory to other treatments. Measurable effects were seen following
as few as two treatments. Our results suggest that this treatment
approach may benefit CPPS patients with dysfunctional voiding,
detrusor instability, and/or chronic pelvic pain. The longterm
durability of these outcomes is unknown.

REFERENCES

1. Executive summary: NIH Workshop on Chronic Prostatitis. Bethesda,
National Institutes of Health, 1995.

2. Sinaki M, Merritt JL, and Stillwell GK: Tension myalgia of the
pelvic floor. Mayo Clin Proc 52: 717-722, 1977.

3. Segura JW, Opitz JL, and Greene LF: Prostatosis, prostatitis or
pelvic floor tension myalgia? J Urol 122: 168-169, 1979.

4. Grimaud JC, Bouvier M, Naudy B, et al: Manometric and radiologic
evaluation and biofeedback treatment of chronic idiopathic anal pain.
Dis Colon Rectum 34: 690-695, 1991.

5. Heah SM, Ho YH, Tan M, et al: Biofeedback is effective treatment
for levator ani syndrome. Dis Colon Rectum 40: 187-189, 1997.

6. Glazer HI, Rodke G, Swencionis C, et al: Treatment of vulvar
vestibulitis syndrome with electromyographic biofeedback of pelvic
floor musculature. J Reprod Med 40: 283-290, 1995.

7. Flor H, and Birbaumer N: Comparison of the efficacy of
electromyographic biofeedback, cognitivebehavioral therapy, and
conservative medical interventions in the treatment of chronic
musculoskeletal pain. J Consult Clin Psychol 61: 653-658, 1993.

8. Abrams PH, and Griffiths DJ: The assessment of prostatic
obstruction from urodynamic measurements and from residual urine. Br J
Urol 51: 129-134, 1979.

9. Zermann DH, Ishigooka M, Doggweiler R, et al: Neurourological
insights into the etiology of genitourinary pain in men. J Urol 161:
903-908, 1999.

10. Nickel JC: Effective office management of chronic prostatitis.
Urol Clin North Am 25: 677-684, 1998.

11. Britton JJ Jr, and Carson CC: Prostatitis. AUA Update Series
17(Lesson 20): 154-159, 1998.

12. Rosen SI, and Seidmon EJ: Lower urinary tract infections in men,
in Hanno PM, and Wein AJ (Eds): Clinical Manual of Urology, 2nd ed.
New York, McGrawHill, 1994, pp 189-204.

13. Kaplan SA, Santarosa RP, Meade D'Alisera P, et al:
Pseudodyssynergia (contraction of the external sphincter during
voiding) misdiagnosed as chronic nonbacterial prostatitis and the role
of biofeedback as a therapeutic option. J Urol 157: 2234-2237, 1997.

14. Kaplan SA, Ikeguchi EF, Santarosa RP, et al: Etiology of voiding
dysfunction in men less than 50 years of age. Urology 47: 836-839,
1996.

15. Norlen LJ, and Blaivas JG: Unsuspected proximal urethral
obstruction in young and middleaged men. J Urol 135: 972-976, 1986.

16. Kaplan SA, Te AE, and Jacobs BZ: Urodynamic evidence of vesical
neck obstruction in men with misdiagnosed chronic nonbacterial
prostatitis and the therapeutic role of endoscopic incision of the
bladder neck. J Urol 152: 2063- 2065, 1994.

17. Litwin MS, McNaughtonCollins M, Fowler FJ, et al: The National
Institutes of Health chronic prostatitis symptom index: development
and validation of a new outcome measure. J Urol 162: 369-375, 1998.

_____________________________________________________
Questions about CPPS/CP/Prostatitis?
Visit http://cpps.jumphealth.com

Ad astra per aspera