Pelvic floor muscle retraining for pediatric voiding dysfunction using interactive computer games

Purpose: We evaluated a new noninvasive outpatient method of pelvic muscle retraining in children using computer game assisted biofeedback. Materials and Methods: All patients in whom voiding dysfunction was confirm ed by history, uroflowmetry-electromyography and voiding cystourethrography were enrolled in a pelvic floor muscle retraining program. Patients receiv ed a pretreatment, mid treatment and posttreatment survey instrument docume nting subjective improvement, including the frequency of diurnal enuresis, nocturnal enuresis, constipation and encopresis. Pretreatment and posttreat ment simultaneous uroflowmetry surface electrode electromyography was perfo rmed and post-void residual urine volume was determined in all patients. Results: A total of 8 boys and 33 girls 5 to 11 years old (mean age 7.2) co mpleted therapy and were available for evaluation. These patients completed 2 to 11 (average 6) hourly treatment sessions. Followup was 3 to 15 months (average 7). At the midterm evaluation improvement in nocturnal enuresis w as reported by 57% of the patients, diurnal enuresis by 84%, constipation b y 83% and encopresis by 91%. End treatment evaluation revealed improvement in nocturnal enuresis by 90% of patients, diurnal enuresis by 89%, constipa tion by 100% and encopresis by 100%. Uroflowmetry-electromyography patterns improved in 42% of the patients and post-void residual urine decreased in 57%. Comparison of initial to end recorded millivoltage pelvic floor muscle values demonstrated that 56% of the patients had lower resting tone at the beginning of the session after completing therapy and 78% had improved con tracting tone after performing Kegel exercises, as proved by increased micr ovoltage values. Initial uroflowmetry-electromyography revealed certain cat egories of cases, including a flattened voiding curve with a hyperactive pe lvic floor and low post-void residual urine in 40%, a flattened voiding cur ve with a hyperactive pelvic floor and high post-void residual-urine in 40% , a staccato voiding curve with a hyperactive pelvic floor and low post-voi d residual urine in 3%, and a staccato voiding curve with a hyperactive pel vic floor and high post-void residual urine in 17%. Of the girls 91% presen ted with the classic spinning top deformity on voiding cystourethrography. A total of 22 patients presented with a significant history of recurrent ur inary tract infections, and infection developed in 3 during treatment and f ollowup. Vesicoureteral reflux in 14 patients resolved during treatment in 3, reimplantation was performed in 1 and 10 are still being observed. Conclusions: A program of conservative medical management with computer gam e assisted pelvic floor muscle retraining resulted in significant subjectiv e improvement in continence, constipation and encopresis as well as objecti ve improvement in uroflowmetry-electromyography, post-void residual urine v olume and the microvoltage value of pelvic floor muscles in the majority of patients with dysfunctional voiding.