Pelvic Floor Rehabilitation and Biofeedback

  • Sandro Danilo SandriEmail author
Part of the Urodynamics, Neurourology and Pelvic Floor Dysfunctions book series (UNPFD)


Pelvic floor rehabilitation and biofeedback have gained an important role in the treatment of lower urinary tract dysfunction in children in the past 20 years. Since the identification and classification by the International Children’s Continence Society of different types of functional dysfunction of the lower urinary tract, the same instrumentation used to make the diagnosis has been used to correct inappropriate behavior. This has gradually led to avoidance of invasive procedures and commencement of rehabilitation with simple methods, gaining more confidence and motivation from children and families. The good results have been rapidly increasing the indications and expanding the modalities to approach the different types of dysfunction. Unfortunately only a few randomized controlled and prospective studies have clearly demonstrated the validity of this approach, and further evaluations in this field should be done. Nevertheless, nowadays the majority of children unresponsive to standard urotherapy can be treated and cured with pelvic floor muscle rehabilitation and/or biofeedback. Only a few cases are still refractory and need further treatment such as psychotherapy, pharmacological therapy, electrical stimulation, or surgery.


Biofeedback Bladder and bowel dysfunction Constipation Dysfunctional voiding Dysfunctional elimination syndrome Encopresis Giggle incontinence Lazy bladder Overactive bladder Pain Pelvic floor muscle training Posterior urethral valves Underactive bladder Urge syndrome Urinary tract infection Vesicoureteral reflux 


  1. 1.
    Combs AJ, Glassberg AD, Gerdes D, Horowitz M. Biofeedback therapy for children with dysfunctional voiding. Urology. 1998;52(2):312–5.CrossRefPubMedGoogle Scholar
  2. 2.
    Chase J, Austin P, McKenna P. The management of dysfunctional voiding in children: a report from the Standardization Committee of the International Children’s Continence Society. J Urol. 2010;183:1296–302.CrossRefPubMedGoogle Scholar
  3. 3.
    Neveus T, von Gontard A, Hoebeke P, Hjiälmås K, Bauer S, Bower W, Jørgensen TM, Rittig S, Vande Valle J, Yeung C-K, Djurhuus JC. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardization Committee of the International Children’s Continence Society. J Urol. 2006;176:314–24.CrossRefPubMedGoogle Scholar
  4. 4.
    Sandri SD, Colletta F, Zanollo L. Normal perineal behavior in pediatric age. Urodinamica. 1997;7(4):223–4.Google Scholar
  5. 5.
    Ab E, Schoenmaker M, van Empelen R, Klijn AJ, de Jong TPVM. Paradoxical movement of the pelvic floor in dysfunctional voiding and the results of biofeedback. BJU Int. 2002;89(Suppl 2):48.Google Scholar
  6. 6.
    Thompson JA, O’Sullivan PB. Levator plate movement during voluntary pelvic floor muscle contraction in subjects with incontinence and prolapse: a cross sectional study and review. Int Urogynecol J. 2001;12(suppl 3):61.Google Scholar
  7. 7.
    Bower WF, Chase JW, Stillman BC. Normative pelvic floor parameters in children assessed by transabdominal ultrasound. J Urol. 2006;176:337–41.CrossRefPubMedGoogle Scholar
  8. 8.
    Sandri SD. Are children with urinary incontinence able to learn how to contract perineal floor muscles? Urodinamica. 1997;7(4):225–6.Google Scholar
  9. 9.
    Birk L. Biofeedback: furor therapeutics. Semin Psychiatry. 1973;5:362.Google Scholar
  10. 10.
    Jerkins GR, Noe HN, Vaughn WR, Roberts E. Biofeedback training for children with bladder sphincter incoordination. J Urol. 1987;138:1113–5.CrossRefPubMedGoogle Scholar
  11. 11.
    Mc Kenna PH, Herndon CDA, Connery S, Ferrer FA. Pelvic floor muscle retraining for pediatric voiding dysfunction using interactive computer games. J Urol. 1999;162:1056–63.CrossRefGoogle Scholar
  12. 12.
    Sandri SD, Fanciullacci F, Politi P, Zanollo A. Applicazione del “biofeedback” nei disturbi della minzione e della continenza in età pediatrica. Urologia. 1988;55(1):42–8.Google Scholar
  13. 13.
    Hellström A-L, Hjälmas K, Jodal U. Rehabilitation of the dysfunctional bladder in children: method and 3-year follow-up. J Urol. 1987;138:847–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Sandri SD. The treatment of paediatric urge incontinence with pelvic floor training: further experience and a longer follow up. Urodinamica. 1999;9(1):42–3.Google Scholar
  15. 15.
    Meijer EFJ, Nieuwhof-Leppink AJ, Dekker-Vasse E, de Joode Smink GCJ, de Jong TPVM. Central inhibition of refractory OAB complaints, results of an inpatient training program. J Pediatr Urol. 2015;11:21e1–5.CrossRefGoogle Scholar
  16. 16.
    Schneider MS, King LR, Surwitt RS. Kegel exercise and childhood incontinence: a new role for an old treatment. J Pediatr. 1994;124:91.CrossRefPubMedGoogle Scholar
  17. 17.
    Pfister C, Dacher JN, Gaucher S, Liard-Zmuda A, Grise P, Mitrofanoff P. The usefulness of a minimal urodynamic evaluation and pelvic floor biofeedback in children with chronic voiding dysfunction. BJU Int. 1999;84:1054–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Wiener JS, Scales MT, Hampton J, King LR, Surwit R, Edwards CL. Long-term efficacy of simple behavioral therapy for daytime wetting in children. J. Urology. 2000;164:786–90.CrossRefGoogle Scholar
  19. 19.
    Cardozo L, Stanton SL, Hafner J, Allan V. Biofeedback in the treatment of detrusor instability. Br J Urol. 1978;50:250–4.CrossRefPubMedGoogle Scholar
  20. 20.
    Hjälmas K, Hellström A-L. Habilitation of dysfunctional bladder in children. Proceedings of the 11th Annual Meeting of the International Continence Society; 1981. p. 48.Google Scholar
  21. 21.
    Bael A, Lax H, de Jong TPVM, Hoebeke P, Nijman RJM, Sixt R, Verlhurst J, Hirche H, van Gool JD, on behalf of the European Bladder Dysfunction Study. The relevance of urodynamic studies for urge syndrome and dysfunctional voiding: a multicenter controlled trial in children. J Urol. 2008;180:1486–95.CrossRefPubMedGoogle Scholar
  22. 22.
    Millard RJ, Oldenburg BF. The symptomatic, urodynamic and psychodynamic results of bladder re-education programs. J Urol. 1983;130:715–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Maizels M, King LR, Firlit CF. Urodynamic biofeedback: a new approach to treat vesical sphincter dyssynergia. J Urol. 1979;122:205–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Sugar EC, Firlit CF. Urodynamic biofeedback: a new therapeutic approach for childhood incontinence/infection (vesical voluntary sphincter dyssynergia). J Urol. 1982;128:1253.CrossRefPubMedGoogle Scholar
  25. 25.
    Norgaard JP, Djurhuus JC. Treatment of detrusor–sphincter dyssynergia by bio-feedback. Urol Int. 1982;37:236–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Wennergren H, Larsson LE, Sandstedt P. Surface electromyography of pelvic floor muscles in healthy children: methodological study. Scand J Caring Sci. 1989;3(2):63–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Wennergren H, Öberg BE, Sandstedt P. The importance of leg support for relaxation of the pelvic floor muscles. Scand J Urol Nephrol. 1991;25:205–13.CrossRefPubMedGoogle Scholar
  28. 28.
    Kjølseth D, Knudsen LM, Madsen B, Norgaard JP, Djuurhuus JC. Urodynamic biofeedback training for children with bladder–sphincter dyscoordination during voiding. Neurourol Urodyn. 1993;12:211–21.CrossRefPubMedGoogle Scholar
  29. 29.
    Hoebeke P, Vande Walle J, Theunis M, De Paepe H, Oosterlink W, Renson C. Outpatients pelvic-floor therapy in girls with daytime incontinence and dysfunctional voiding. Urology. 1996;48(6):923–7.CrossRefPubMedGoogle Scholar
  30. 30.
    Sureshkumar P, Bower W, Craig JC, Knight JF. Treatment of daytime urinary incontinence in children: a systematic review of randomized controlled trials. J Urol. 2003;170:196–200.CrossRefPubMedGoogle Scholar
  31. 31.
    van Gool JD, de Jong TPV, Winkler-Seinstra P, Tamminen Mobius T, Lax-Gross H, Hirche H. Comparison of standard therapy, bladder rehabilitation with biofeedback and pharmacotherapy in children with non-neuropathic bladder-sphincter dysfunction. Neurourol Urodyn. 1999;18:261.CrossRefGoogle Scholar
  32. 32.
    van Gool JD, de Jong TPVM, Winkler-Seinstra P, Tamminen Mobius T, Lax-Gross H, Hirche H, Nijman RJ, Hjälmas K, Jodal U, Bachmann H, Hoebeke P, Walle JV, Misselwitz J, John U, Bael A, on behalf of the European Bladder Dysfunction Study. Multi-center randomized controlled trial of cognitive treatment, placebo, oxybutynin, bladder training, and pelvic floor training in children with functional urinary incontinence. Neurourol Urodyn. 2014;33(5):482–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Wennergren H, Öberg BE. Pelvic floor muscle exercise for girls. Child adapted method. Neurourol Urodyn. 1991;10:387–8.Google Scholar
  34. 34.
    Wennergren H, Öberg BE. Pelvic floor exercises for children: a method of treating dysfunctional voiding. Brit. J Urol. 1995;76:9–15.CrossRefGoogle Scholar
  35. 35.
    De Paepe H, Renson C, Van Laecke E, Raes A, Vande WJ, Hoebeke P. Pelvic-floor therapy and toilet training in young children with dysfunctional voiding and obstipation. BJU Int. 2000;85:889–93.CrossRefPubMedGoogle Scholar
  36. 36.
    Chin-Peuckert L, Pippi Salle JL. A modified biofeedback program for children with detrusor-sphincter dyssynergia: 5-year experience. J Urol. 2001;166:1470–5.CrossRefPubMedGoogle Scholar
  37. 37.
    Sugar E. Bladder control through biofeedback. Am J Nurs. 1983;83:1152–4.PubMedGoogle Scholar
  38. 38.
    Zivkovic V, Lazovic M, Vlajkovic M, Slavkovic A, Dimitrijevic L. Correlation between uroflowmetry parameters and treatment outcome in children with dysfunctional voiding. J Pediatr Urol. 2010;6:396–402.CrossRefGoogle Scholar
  39. 39.
    Vasconcelos M, Lima E, Caiafa L, Noronha A, Cangussu R, Gomes S, Freire R, Filgueiras MT, Araùjo J, Magnus G, Cunha C, Colozimo E. Voiding dysfunction in children. Pelvic-floor exercises or biofeedback therapy: a randomized study. Pediatr Nephrol. 2006;21:1858–64.CrossRefPubMedGoogle Scholar
  40. 40.
    Schulman SL, von Zuben FC, Plachter N, Kodman-Jones C. Biofeedback methodology: does it matter how we teach children how to relax the pelvic floor during voiding? J Urol. 2001;166:2423–6.CrossRefPubMedGoogle Scholar
  41. 41.
    Nelson JD, Cooper CS, Boyt MA, Hawtrey CE, Austin JC. Improved uroflow parameters and post-void residual following biofeedback therapy in pediatric patients with dysfunctional voiding does not correspond to outcome. J Urol. 2004;172:1653–6.CrossRefPubMedGoogle Scholar
  42. 42.
    Kajbafzadeh A-M, Sharifi-Rad L, Ghahestani SM, Ahmadi H, Kajbafzadeh M, Mahboubi AH. Animated biofeedback: an ideal treatment for children with dysfunctional elimination syndrome. J Urol. 2011;186:2379–85.CrossRefPubMedGoogle Scholar
  43. 43.
    Herndon CDA, Decambre M, Mc Kenna PH. Interactive computer games for treatment of pelvic floor dysfunction. J Urol. 2001;166:1893–8.CrossRefPubMedGoogle Scholar
  44. 44.
    Kaye JD, Palmer LS. Animated biofeedback yields more rapid results than nonanimated biofeedback in the treatment of dysfunctional voiding in girls. J Urol. 2008;180:300–5.CrossRefPubMedGoogle Scholar
  45. 45.
    Bower WF, Yew SY, Sit KYF, Yeung CK. Half-day urotherapy improves voiding parameters in children with dysfunctional emptying. Eur Urol. 2006;49:570–4.CrossRefPubMedGoogle Scholar
  46. 46.
    Yucel S, Akkaya E, Guntekin E, Akman S, Melikoglu M, Baykara M. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A prospective study. J Urol. 2005;174:1612–5.CrossRefPubMedGoogle Scholar
  47. 47.
    Desantis DJ, Leonard MP, Preston MA, Barrowman NJ, Guerra LA. Effectiveness of biofeedback for dysfunctional elimination syndrome in pediatrics: a systematic review. J Pediatr Urol. 2011;7:342–8.CrossRefPubMedGoogle Scholar
  48. 48.
    Klijn AJ, Uiterwaal CSPM, Vijverberg MAW, Winkler PLH, Dik P, de Jong TPVM. Home uroflowmetry biofeedback in behavioral training for dysfunctional voiding in school-age children: a randomized controlled study. J Urol. 2006;175:2263–8.CrossRefPubMedGoogle Scholar
  49. 49.
    Van den Broeck C, Roman de Mettelinge T, Deschepper E, Van Laecke E, Renson C, Samijn B, Hoebecke P. Prospective evaluation of the long-term effects of clinical voiding reeducation or voiding school for lower urinary tract conditions in children. J Pediatr Urol. 2016;12:37e1–6.CrossRefGoogle Scholar
  50. 50.
    Hoebeke P, Renson C, De Schryver M, De Schryver L, Leenaerts E, Schoenaers A, Deschepper E, Walle VJ, Van den Broeck C. Prospective evaluation of clinical voiding reeducation or voiding school for lower urinary tract conditions in children. J Urol. 2011;186:648–54.CrossRefPubMedGoogle Scholar
  51. 51.
    De Paepe H, Hoebeke P, Renson C, Van Laecke E, Raes E, Van Hoeke E, Van Daele J, Van de Walle J. Pelvic-floor therapy in girls with recurrent urinary tract infections and dysfunctional voiding. Br J Urol. 1998;81:109–13.CrossRefPubMedGoogle Scholar
  52. 52.
    Yagci S, Kibar Y, Akay O, Kilic S, Erdemir F, Gok F, Dayanc M. The effect of biofeedback treatment on voiding and urodynamic parameters in children with voiding dysfunctions. J Urol. 2005;174:1994–8.CrossRefPubMedGoogle Scholar
  53. 53.
    Wiener JS, Scales MT, Hampton J, King LR, Surwit R, Edwards CL. Long-term efficacy of simple behavioral therapy for daytime wetting in children. J Urol. 2000;164:786–90.CrossRefPubMedGoogle Scholar
  54. 54.
    Palmer LS, Franco I, Rotario P, Reda EF, Friedman SC, Kolligian ME, Brock WA, Levitt SB. Biofeedback therapy expedites the resolution of reflux in older children. J Urol. 2002;168:1699–703.CrossRefPubMedGoogle Scholar
  55. 55.
    Kibar Y, Ors O, Demir E, Kalman S, Sakallioglu O, Dayanc M. Results of biofeedback treatment on reflux resolution rates in children with dysfunctional voiding and vesicoureteral reflux. Urology. 2007;70(3):563–6.CrossRefPubMedGoogle Scholar
  56. 56.
    van der Plas RN, Benninga MA, Buller HA, Bossuyt PM, Akkermans LM, Redekop WK, et al. Biofeedback training in treatment of childhood constipation: a randomized control study. Lancet. 1996;348:776.CrossRefPubMedGoogle Scholar
  57. 57.
    Hoebeke PBB, Van Laecke E, Renson C, Raes A, Dehoorne J, Vermeiren P, Walle VJ. Pelvic floor spasm in children: an unknown condition responding well to pelvic floor therapy. Eur Urol. 2004;46(5):651–4.CrossRefPubMedGoogle Scholar
  58. 58.
    Ansari MS, Srivastava A, Kapoor R, Dubey D, Mandani A, Kumar A. Biofeedback therapy and home pelvic floor exercises for lower urinary tract dysfunction after posterior urethral valve ablation. J Urol. 2008;179:708–11.CrossRefPubMedGoogle Scholar
  59. 59.
    Ladi-Seyedian S, Kajbafzadeh A-M, Sharifi-Had L, Shadgan B, Fan E. Management of non-neuropathic underactive bladder in children with voiding dysfunction by animated biofeedback: a randomized clinical trial. Urology. 2015;85(1):205–10.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Urology and Spinal UnitHospital of LegnanoLegnanoItaly
  2. 2.Department of Urology and Spinal UnitHospital of MagentaMilanItaly

Personalised recommendations