**3. Discussion**

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

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

300 Electrodiagnosis in New Frontiers of Clinical Research

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

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 (Gunnarsson, Ahlmann et al. 1999).

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 systematically performed.

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

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 with an efficacy ranging between 17 and 84% (Cammu, van Nylen et al. 1991 Oct; Workman, Cassisi et al. 1993 Jan; Lorenzo-Gómez, Silva-Abuín et al. 2008).

only verbal or written instructions, fewer than half of the patients could correctly and effec‐ tively contract their pelvic floor muscles and in 25% of the case the symptoms worsened. (Theofrastous, Wyman et al. 2002; Gray and David 2005 Jul-Aug) likely due to the strengthen

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The somatic and the vegetative (with the sympathetic and the parasympathetic components) nervous system are implicated in the micturition cycle. There is an inhibition-excitation balance at any time in this system, the so called "balancing" principle by Schimdt, which explains the hypo-contractile detrusor of women with urethral hyper-activity. In the conscious component of the voiding cycle, the periurethral muscles can influence this balance, re-establishing the correct voiding cycle, and this is the principle for the conservative techniques in voiding re-

Biofeedback can be helpful in the treatment of pelvic floor pain in the process of recognising the muscles' action. EMG is one of the most used input methods for biofeedback (Romanzi, Polaneczky et al. 1999). A study in patients with chronic pelvic pain syndrome participating in a pelvic floor BFB re-education program reported a correlation between the decline in EMG

In a study among patients with levator ani syndrome, biofeedback was found to be the most effective therapy. Other modalities used were electrostimulation and massage. Adequate relief was reported by 87% in the biofeedback group, 45% for electrostimulation, and 22% for

Treating the pelvic floor muscles is recommended as the first line of treatment in patients with chronic pelvic pain syndrome. In patients with an overactive pelvic floor, BFB is recommended as adjuvant therapy to muscle exercises (Engeler, Baranowski et al. 2012).None of the present existing treatments have effect on any BPS subtypes or phenotypes. Bladder training may be

Multimodal behavioural, physical and psychological techniques should always be considered alongside pharmacological or invasive treatments. Manual and physical therapy should be

Investigations on chronic spams of the pelvic floor muscles in patients with chronic pelvic pain syndrome revealed that all patients had significant voiding symptoms (urgency, frequency, incontinence due to final dripping) and ureteral hypersensitivity concomitant to chronic pain at the perineal area. Up to the 44.3% of patients had previous voiding problems in childhood

Verbal or written instructions for patients using practise equipment at home can be less effective because patients cannot exactly remember the training given at the office or they can

The main limitations shown by the BFB-EMG are that minimum muscular activity intensity is needed in order to register and visualize any activity at the BFB screen. It is an active technique that requires motivation and a minimum intellectual level that is not suitable for patients with mental problems or retarded. High-quality, reliable and valid equipment is necessary to avoid

(enuresis, constipation and retarded urination habit learning) (Bo, Larsen et al. 1988).

have problems following the treatment protocol (Aukee, Immonen et al. 2002).

effective in patients with predominant urinary symptoms and little pain.

considered as a first approach (Engeler, Baranowski et al. 2012).

of the antagonist muscles (Llorca-Miravet 1990).

education (González-Chamorro and Lledó 2001).

massage (Chiarioni, Nardo et al.).

values and symptoms relief (Cornel, van Haarst et al. 2005).

We wish to emphasize the benefit that the BFB-EMG gives to patients with chronic lower urinary tracts disorders, whether of an infectious nature or not. Several explanations can be offered. There is a demonstrated benefit in the collagen type changes that the pelvic floor's muscles after BFB-EMG, which increases the contractile capability of the levator ani and strengthen the type I (slow contraction, high resistance) and type II fibres (quick contraction, quick fatigue) (Arlandis-Guzmán and Martínez-Agulló 2002). In addition the detrusor activity is inhibited by the voluntary perineal contraction (activating the Mahony's reflex #3 or perineal-detrusor reflex (Mahony, Laferte et al. 1977 Jan) in a more natural and physiological manner than with other more aggressive therapeutic methods.

Until now, UTI and chronic cystitis have not been included within the specific pathologies of the pelvic floor. However, we find that in clinical practise patients have frequent concomitant UTI.

In this study, we investigated the relationship between UTI and incontinence. Scientists agree that UTI facilitates the development of incontinence. Recurrent UTI is defined as at least three episodes of uncomplicated infection documented by culture in a 12-month period in women with no structural/functional abnormalities(Naber 1999). This assertion is maybe challenged since many women diagnosed with recurrent UTI have urethral hyper-motility, stress or urgency incontinence, voiding urgency or subclinical cystocele.

BFB-EMG has shown to be of benefit for women with painful bladder using the same protocol (Borrego Jiménez, Lorenzo Gómez et al. 2007), but also in women with vaginism, pelvic floor myalgia and other similar conditions. (Arlandis-Guzmán and Martínez-Agulló 2002).

There is little information about the importance of the anatomy of the pelvic floor in patients with incontinence. It has been postulated that the irritative voiding symptoms in patients with incontinence can be aggravated by a higher tonicity of the pelvic floor muscles (Griebling and Takle 1999). BFB-EMG program can be an useful adjuvant to the treatment of patients with incontinence (Borrego Jiménez, Lorenzo Gómez et al. 2007). On the other hand, neuromodu‐ lation is still finding its role in pelvic pain management. There has been growing evidence in small case series or pilot studies but more detailed research is required (Fariello and Whit‐ more). Published papers show an important role of BFB for impotence, premature ejaculation, perineal pains and vaginism treatment. For these reasons, a consensus was reached in our Pelvic Floor Unit in order to use BFB-EMG as an adjuvant treatment in patients with chronic inflammatory diseases, both infectious and non-infectious, of the lower urinary tract. Results have been satisfactory.

These findings are in agreement with the experts' opinion contained in the European Associ‐ ation of Urology's guidelines, relating to the design of individual therapeutic protocols for each patient (Grabe, Bjerklund-Johansen et al. 2012).

Biofeedback-EMG is an essential element in the functional treatment of the pelvic floor, providing information about other hidden muscular functions. It has been shown that giving only verbal or written instructions, fewer than half of the patients could correctly and effec‐ tively contract their pelvic floor muscles and in 25% of the case the symptoms worsened. (Theofrastous, Wyman et al. 2002; Gray and David 2005 Jul-Aug) likely due to the strengthen of the antagonist muscles (Llorca-Miravet 1990).

with an efficacy ranging between 17 and 84% (Cammu, van Nylen et al. 1991 Oct; Workman,

We wish to emphasize the benefit that the BFB-EMG gives to patients with chronic lower urinary tracts disorders, whether of an infectious nature or not. Several explanations can be offered. There is a demonstrated benefit in the collagen type changes that the pelvic floor's muscles after BFB-EMG, which increases the contractile capability of the levator ani and strengthen the type I (slow contraction, high resistance) and type II fibres (quick contraction, quick fatigue) (Arlandis-Guzmán and Martínez-Agulló 2002). In addition the detrusor activity is inhibited by the voluntary perineal contraction (activating the Mahony's reflex #3 or perineal-detrusor reflex (Mahony, Laferte et al. 1977 Jan) in a more natural and physiological

Until now, UTI and chronic cystitis have not been included within the specific pathologies of the pelvic floor. However, we find that in clinical practise patients have frequent concomitant

In this study, we investigated the relationship between UTI and incontinence. Scientists agree that UTI facilitates the development of incontinence. Recurrent UTI is defined as at least three episodes of uncomplicated infection documented by culture in a 12-month period in women with no structural/functional abnormalities(Naber 1999). This assertion is maybe challenged since many women diagnosed with recurrent UTI have urethral hyper-motility, stress or

BFB-EMG has shown to be of benefit for women with painful bladder using the same protocol (Borrego Jiménez, Lorenzo Gómez et al. 2007), but also in women with vaginism, pelvic floor

There is little information about the importance of the anatomy of the pelvic floor in patients with incontinence. It has been postulated that the irritative voiding symptoms in patients with incontinence can be aggravated by a higher tonicity of the pelvic floor muscles (Griebling and Takle 1999). BFB-EMG program can be an useful adjuvant to the treatment of patients with incontinence (Borrego Jiménez, Lorenzo Gómez et al. 2007). On the other hand, neuromodu‐ lation is still finding its role in pelvic pain management. There has been growing evidence in small case series or pilot studies but more detailed research is required (Fariello and Whit‐ more). Published papers show an important role of BFB for impotence, premature ejaculation, perineal pains and vaginism treatment. For these reasons, a consensus was reached in our Pelvic Floor Unit in order to use BFB-EMG as an adjuvant treatment in patients with chronic inflammatory diseases, both infectious and non-infectious, of the lower urinary tract. Results

These findings are in agreement with the experts' opinion contained in the European Associ‐ ation of Urology's guidelines, relating to the design of individual therapeutic protocols for

Biofeedback-EMG is an essential element in the functional treatment of the pelvic floor, providing information about other hidden muscular functions. It has been shown that giving

myalgia and other similar conditions. (Arlandis-Guzmán and Martínez-Agulló 2002).

Cassisi et al. 1993 Jan; Lorenzo-Gómez, Silva-Abuín et al. 2008).

302 Electrodiagnosis in New Frontiers of Clinical Research

manner than with other more aggressive therapeutic methods.

urgency incontinence, voiding urgency or subclinical cystocele.

UTI.

have been satisfactory.

each patient (Grabe, Bjerklund-Johansen et al. 2012).

The somatic and the vegetative (with the sympathetic and the parasympathetic components) nervous system are implicated in the micturition cycle. There is an inhibition-excitation balance at any time in this system, the so called "balancing" principle by Schimdt, which explains the hypo-contractile detrusor of women with urethral hyper-activity. In the conscious component of the voiding cycle, the periurethral muscles can influence this balance, re-establishing the correct voiding cycle, and this is the principle for the conservative techniques in voiding reeducation (González-Chamorro and Lledó 2001).

Biofeedback can be helpful in the treatment of pelvic floor pain in the process of recognising the muscles' action. EMG is one of the most used input methods for biofeedback (Romanzi, Polaneczky et al. 1999). A study in patients with chronic pelvic pain syndrome participating in a pelvic floor BFB re-education program reported a correlation between the decline in EMG values and symptoms relief (Cornel, van Haarst et al. 2005).

In a study among patients with levator ani syndrome, biofeedback was found to be the most effective therapy. Other modalities used were electrostimulation and massage. Adequate relief was reported by 87% in the biofeedback group, 45% for electrostimulation, and 22% for massage (Chiarioni, Nardo et al.).

Treating the pelvic floor muscles is recommended as the first line of treatment in patients with chronic pelvic pain syndrome. In patients with an overactive pelvic floor, BFB is recommended as adjuvant therapy to muscle exercises (Engeler, Baranowski et al. 2012).None of the present existing treatments have effect on any BPS subtypes or phenotypes. Bladder training may be effective in patients with predominant urinary symptoms and little pain.

Multimodal behavioural, physical and psychological techniques should always be considered alongside pharmacological or invasive treatments. Manual and physical therapy should be considered as a first approach (Engeler, Baranowski et al. 2012).

Investigations on chronic spams of the pelvic floor muscles in patients with chronic pelvic pain syndrome revealed that all patients had significant voiding symptoms (urgency, frequency, incontinence due to final dripping) and ureteral hypersensitivity concomitant to chronic pain at the perineal area. Up to the 44.3% of patients had previous voiding problems in childhood (enuresis, constipation and retarded urination habit learning) (Bo, Larsen et al. 1988).

Verbal or written instructions for patients using practise equipment at home can be less effective because patients cannot exactly remember the training given at the office or they can have problems following the treatment protocol (Aukee, Immonen et al. 2002).

The main limitations shown by the BFB-EMG are that minimum muscular activity intensity is needed in order to register and visualize any activity at the BFB screen. It is an active technique that requires motivation and a minimum intellectual level that is not suitable for patients with mental problems or retarded. High-quality, reliable and valid equipment is necessary to avoid interference present in machines of lesser quality. The instructor is a integral part of the method and must evaluate and study how to reach the patient and to devise the therapeutic protocol.

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From our experience, the following lower urinary tract inflammatory disorders are eligible for combined treatment including BFB-EMG:

