**2.1. Method and tools used**

We conducted a retrospective study of 548 women diagnosed with inflammatory, infec‐ tious and non-infectious disorders of the lower urinary tract treated between March 2003 and May 2012.

Patients were divided into 2 groups according to whether or not they had UTIs. Each group received conventional treatment and were further divided into 2 subgroups, one receiving biofeedback with electromyography and the other not.

**Group A** consisted of 270 patients with repeated urinary tract infections managed with prophylactic Sulfamethoxazole/Trimethoprim 40/200mg/day for a period of 6 months versus sublingual bacterial vaccine Uromune® for a period of 3 months.

**Subgroup A1** (n=112) no biofeedback.

**Subgroup A2** (n=158) treatment was supplemented with biofeedback and electromyography.

**Group B** consisted of 278 patients with non-infectious chronic inflammatory diseases of the inferior urinary tract who were managed with Perphenazine 2mg/ Amitriptyline 25 mg orally daily and intravesical Hyaluronic acid weekly for 4 weeks.

to avoid fatigue (figure 2). In this position the patient could see the screen of the biofeedback equipment (figures 3 and 4). The electrodes used were paediatric pre-gelled electrodes. After explaining the anatomy and physiology of the pelvic floor, the patient was instructed to contract the perineal musculature during 3-5 seconds and relaxing to relax it during 6-8 seconds. Each signal was recorded continuously with a polygraph the power, muscle tone and

Biofeedback with Pelvic Floor Electromyography as..

http://dx.doi.org/10.5772/56237

297

the duration were recorded in the perineal electromyography (figures 2-4).

**Figure 1.** Position of electrodes for BFB-EMG session.

**Figure 2.** BFB session.

**Subgroup B1** (n= 99) received no biofeedback.

**Subgroup B2** (N=179) treatment was supplemented with biofeedback and electromyography.

Age, secondary diagnoses, concomitant treatments, medical and surgical background, response to treatment, answers to the King's Health Questionnaire (Kelleher, Cardozo et al. 1997 Dec) and SF-36 QoL Questionnaire Spanish Version (Vilagut, Ferrer et al. 2005 Mar-Apr) were recorded. The interpretation of results of the questionaires was as follows:for of Kings Health questionnaire the range varied between 25 points (normal status, healthy) to 97 points (critical illness perception). For the SF-36 questionnaire the range varied from 149 points (normal status, healthy) to 36 points (critical illness perception).

For subgroups A2 and B2, the program of biofeedback with electromyography (BFB-EMG) consisted of 20 sessions of therapy. Two surface electrodes were placed on the perineum over the pelvic floor musculature and a neutral or ground electrode was placed on the inner aspect of the thigh.

In the first 3 sessions the electrodes were placed near anal external sphincter. In the subsequent sessions the electrodes were placed closer and closer to the urethra. We considered the correct position of the electrodes very important (Figure 1).

The contractions lasted 3-5 seconds followed by a relaxation period of 8-10 seconds Patients were trained to manage the signal in the screen by using the appropriate perineal muscles. The goal was to bring the two perineal electrodes closer together. The weekly session lasted 20 minutes.

Sessions took place at the urodynamics office with Medicina y MercadoTM equipment. The patient lay supine, with light flexion of the hips and protection of the lumbar lordosis in order

**Figure 1.** Position of electrodes for BFB-EMG session.

**2.1. Method and tools used**

296 Electrodiagnosis in New Frontiers of Clinical Research

biofeedback with electromyography and the other not.

**Subgroup A1** (n=112) no biofeedback.

sublingual bacterial vaccine Uromune® for a period of 3 months.

daily and intravesical Hyaluronic acid weekly for 4 weeks.

(normal status, healthy) to 36 points (critical illness perception).

position of the electrodes very important (Figure 1).

**Subgroup B1** (n= 99) received no biofeedback.

and May 2012.

of the thigh.

minutes.

We conducted a retrospective study of 548 women diagnosed with inflammatory, infec‐ tious and non-infectious disorders of the lower urinary tract treated between March 2003

Patients were divided into 2 groups according to whether or not they had UTIs. Each group received conventional treatment and were further divided into 2 subgroups, one receiving

**Group A** consisted of 270 patients with repeated urinary tract infections managed with prophylactic Sulfamethoxazole/Trimethoprim 40/200mg/day for a period of 6 months versus

**Subgroup A2** (n=158) treatment was supplemented with biofeedback and electromyography.

**Group B** consisted of 278 patients with non-infectious chronic inflammatory diseases of the inferior urinary tract who were managed with Perphenazine 2mg/ Amitriptyline 25 mg orally

**Subgroup B2** (N=179) treatment was supplemented with biofeedback and electromyography.

Age, secondary diagnoses, concomitant treatments, medical and surgical background, response to treatment, answers to the King's Health Questionnaire (Kelleher, Cardozo et al. 1997 Dec) and SF-36 QoL Questionnaire Spanish Version (Vilagut, Ferrer et al. 2005 Mar-Apr) were recorded. The interpretation of results of the questionaires was as follows:for of Kings Health questionnaire the range varied between 25 points (normal status, healthy) to 97 points (critical illness perception). For the SF-36 questionnaire the range varied from 149 points

For subgroups A2 and B2, the program of biofeedback with electromyography (BFB-EMG) consisted of 20 sessions of therapy. Two surface electrodes were placed on the perineum over the pelvic floor musculature and a neutral or ground electrode was placed on the inner aspect

In the first 3 sessions the electrodes were placed near anal external sphincter. In the subsequent sessions the electrodes were placed closer and closer to the urethra. We considered the correct

The contractions lasted 3-5 seconds followed by a relaxation period of 8-10 seconds Patients were trained to manage the signal in the screen by using the appropriate perineal muscles. The goal was to bring the two perineal electrodes closer together. The weekly session lasted 20

Sessions took place at the urodynamics office with Medicina y MercadoTM equipment. The patient lay supine, with light flexion of the hips and protection of the lumbar lordosis in order to avoid fatigue (figure 2). In this position the patient could see the screen of the biofeedback equipment (figures 3 and 4). The electrodes used were paediatric pre-gelled electrodes. After explaining the anatomy and physiology of the pelvic floor, the patient was instructed to contract the perineal musculature during 3-5 seconds and relaxing to relax it during 6-8 seconds. Each signal was recorded continuously with a polygraph the power, muscle tone and the duration were recorded in the perineal electromyography (figures 2-4).

**Figure 2.** BFB session.

**Figure 3.** Screens showing several scenes for BFB-EMG.

**2.2. Results**

Median age were Group A

**Figure 5.** EMG registry at BFB session.

**Pelvic floor condition Subgroup A1**

There were no difference in the age (p=0.2615), medical history of diabetes (p=2365), arterial hypertension (p=0.1629), smoking, alcohol and caffeine consumption (p=0.8317), obesity (p=0.6732), occupation (p=0.4319) and marital status (p=0.0729) between the four groups.

Table 1 shows the prevalence of urinary incontinence (UI) grade 1, 2 and 3, cystocele>2,

**Subgroup A2 (n= 158)**

**Subgroup B1 (n= 99)**

Biofeedback with Pelvic Floor Electromyography as..

http://dx.doi.org/10.5772/56237

299

**Subgroup B2 (n= 179)**

cystocele>2+rectocele, colpocele, cystocele>2+UI, rectocele in the 4 groups:

**(n= 112)**

SIGNIFICANCE *p*=0.4507 *p*=0.7886

cc); grade 3: uncontrollable leakage of big urine quantities (> 200 cc).

**Table 1.** Pelvic floor conditions in the inferior urinary tract chronic inflammations (Incontinence grade 1:

uncontrollable urine leakage, dripping (< 50 cc); grade 2: uncontrollable leakage of moderate urine quantities (50-120

Incontinence grade 1 4 6 10 6 Incontinence grade 2 11 8 2 3 Incontinence grade 3 8 13 1 2 Cystocele"/>2 11 20 11 10 Rectocele and cystocele 9 15 1 2 Colpocele 7 11 3 15 Cystocele and Incontinence 8 10 3 12 Rectocele 6 5 1 5

**Figure 4.** Screens showing several scenes for BFB-EMG.

Figure 5 shows fragments of the graphics obtained from the EMG activity registry at a biofeedback session.

Statistical analysis was as follows: Results from the answers in Kings´Health and SF-36 QoL questionnaires yielded qualitative and quantitative variables which were analysed by NCSS-2000TM statistic program. Descriptive and inferential studies included analysis of cross tabulation, Fisher exact test, Chi-square, Student's t-test, Pearson correlation test. *p*<0.05 was accepted as statistically significant.

**Figure 5.** EMG registry at BFB session.

#### **2.2. Results**

**Figure 3.** Screens showing several scenes for BFB-EMG.

298 Electrodiagnosis in New Frontiers of Clinical Research

**Figure 4.** Screens showing several scenes for BFB-EMG.

accepted as statistically significant.

biofeedback session.

Figure 5 shows fragments of the graphics obtained from the EMG activity registry at a

Statistical analysis was as follows: Results from the answers in Kings´Health and SF-36 QoL questionnaires yielded qualitative and quantitative variables which were analysed by NCSS-2000TM statistic program. Descriptive and inferential studies included analysis of cross tabulation, Fisher exact test, Chi-square, Student's t-test, Pearson correlation test. *p*<0.05 was There were no difference in the age (p=0.2615), medical history of diabetes (p=2365), arterial hypertension (p=0.1629), smoking, alcohol and caffeine consumption (p=0.8317), obesity (p=0.6732), occupation (p=0.4319) and marital status (p=0.0729) between the four groups. Median age were Group A

Table 1 shows the prevalence of urinary incontinence (UI) grade 1, 2 and 3, cystocele>2, cystocele>2+rectocele, colpocele, cystocele>2+UI, rectocele in the 4 groups:


**Table 1.** Pelvic floor conditions in the inferior urinary tract chronic inflammations (Incontinence grade 1: uncontrollable urine leakage, dripping (< 50 cc); grade 2: uncontrollable leakage of moderate urine quantities (50-120 cc); grade 3: uncontrollable leakage of big urine quantities (> 200 cc).

The results of the questionaires before and after treatment are shown in the figures below.

**Graphic 3.** Histogram showing Group B2 King´s score after treatment.

treated with suppressive antibiotic protocol (*p*<0.001).

**3. Discussion**

(Gunnarsson, Ahlmann et al. 1999).

systematically performed.

results. We found similar findings in the SF-36 questionnaire.

In the King´s Health Questionnaire, Group B2 shows better results compared with Group B1 (p<0.0003). Group A2 shows better results than group A1 (p<0.0042). Group B2 shows the best

Biofeedback with Pelvic Floor Electromyography as..

http://dx.doi.org/10.5772/56237

301

Pelvic floor dysfunction can lead to urinary incontinence and to other lower urinary tract symptoms (LUTS). A neuromuscular disorder has been found in women with incontinence or traumatic delivery, with a good response to the functional treatment of the pelvic floor

In our unit, we decided to combine the BFB-EMG program for patients with LUTS who were refractory to conventional treatments. We have not found any adverse effects caused by the treatment, but we have recorded surprisingly good results with the quality of life tests test we

Regarding the patient allocation between antibiotic treatment and immunological modulators (bacterial vaccines), there was an homogeneous distribution of treated recurrent UTIs between both groups, but patients treated with bacterial vaccine showed a better response than those

Pelvic floor exercises are an essential part of the bladder-sphincter re-education. Pelvic floor's functional treatment with or without BFB has been used to treat stress urinary incontinence

**Graphic 1.** King´s Health Test before and after treatment.

**Graphic 2.** Histogram showing Group B1 King´s score after treatment.

**Graphic 3.** Histogram showing Group B2 King´s score after treatment.

In the King´s Health Questionnaire, Group B2 shows better results compared with Group B1 (p<0.0003). Group A2 shows better results than group A1 (p<0.0042). Group B2 shows the best results. We found similar findings in the SF-36 questionnaire.
