McKenna P H, Herndon C D, Connery S, Ferrer F A
Department of Pediatric Urology, Connecticut Children's Medical Center, Hartford, USA.
J Urol. 1999 Sep;162(3 Pt 2):1056-62; discussion 1062-3. doi: 10.1016/S0022-5347(01)68065-0.
We evaluated a new noninvasive outpatient method of pelvic muscle retraining in children using computer game assisted biofeedback.
All patients in whom voiding dysfunction was confirmed by history, uroflowmetry-electromyography and voiding cystourethrography were enrolled in a pelvic floor muscle retraining program. Patients received a pretreatment, mid treatment and posttreatment survey instrument documenting subjective improvement, including the frequency of diurnal enuresis, nocturnal enuresis, constipation and encopresis. Pretreatment and posttreatment simultaneous uroflowmetry surface electrode electromyography was performed and post-void residual urine volume was determined in all patients.
A total of 8 boys and 33 girls 5 to 11 years old (mean age 7.2) completed 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 was reported by 57% of the patients, diurnal enuresis by 84%, constipation by 83% and encopresis by 91%. End treatment evaluation revealed improvement in nocturnal enuresis by 90% of patients, diurnal enuresis by 89%, constipation 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 contracting tone after performing Kegel exercises, as proved by increased microvoltage values. Initial uroflowmetry-electromyography revealed certain categories of cases, including a flattened voiding curve with a hyperactive pelvic floor and low post-void residual urine in 40%, a flattened voiding curve 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-void residual urine in 3%, and a staccato voiding curve with a hyperactive pelvic floor and high post-void residual urine in 17%. Of the girls 91% presented with the classic spinning top deformity on voiding cystourethrography. A total of 22 patients presented with a significant history of recurrent urinary tract infections, and infection developed in 3 during treatment and followup. Vesicoureteral reflux in 14 patients resolved during treatment in 3, reimplantation was performed in 1 and 10 are still being observed.
A program of conservative medical management with computer game assisted pelvic floor muscle retraining resulted in significant subjective improvement in continence, constipation and encopresis as well as objective improvement in uroflowmetry-electromyography, post-void residual urine volume and the microvoltage value of pelvic floor muscles in the majority of patients with dysfunctional voiding.
我们评估了一种使用电脑游戏辅助生物反馈的针对儿童的新型无创门诊盆底肌再训练方法。
所有经病史、尿流率-肌电图及排尿性膀胱尿道造影确诊存在排尿功能障碍的患者均纳入盆底肌再训练项目。患者接受了一份治疗前、治疗中期及治疗后的调查问卷，记录主观改善情况，包括日间遗尿、夜间遗尿、便秘及大便失禁的频率。对所有患者进行了治疗前及治疗后的同步尿流率表面电极肌电图检查，并测定了排尿后残余尿量。
共有8名男孩和33名5至11岁（平均年龄7.2岁）的女孩完成治疗并可供评估。这些患者完成了2至11次（平均6次）每小时的治疗疗程。随访时间为3至15个月（平均7个月）。在中期评估时，57%的患者报告夜间遗尿有改善，84%的患者日间遗尿有改善，83%的患者便秘有改善，91%的患者大便失禁有改善。治疗结束时的评估显示，90%的患者夜间遗尿有改善，89%的患者日间遗尿有改善，100%的患者便秘有改善，100%的患者大便失禁有改善。42%的患者尿流率-肌电图模式有所改善，57%的患者排尿后残余尿量减少。比较治疗开始与结束时记录的盆底肌毫伏值发现，56%的患者在完成治疗后的疗程开始时静息张力较低，78%的患者在进行凯格尔运动后收缩张力有所改善，微伏值增加证明了这一点。初始尿流率-肌电图显示了某些类型的病例，包括40%的患者排尿曲线变平且盆底肌活跃亢进、排尿后残余尿量低，40%的患者排尿曲线变平且盆底肌活跃亢进、排尿后残余尿量高，3%的患者排尿曲线呈断续状且盆底肌活跃亢进、排尿后残余尿量低，17%的患者排尿曲线呈断续状且盆底肌活跃亢进、排尿后残余尿量高。在排尿性膀胱尿道造影中，91%的女孩表现出典型的陀螺样畸形。共有22例患者有反复尿路感染的显著病史，治疗及随访期间有3例发生感染。14例患者的膀胱输尿管反流在治疗期间有3例得到缓解，1例进行了再植术，10例仍在观察中。
对于大多数排尿功能障碍患者，采用电脑游戏辅助盆底肌再训练的保守医疗管理方案可使尿失禁、便秘及大便失禁在主观上得到显著改善，同时在尿流率-肌电图、排尿后残余尿量及盆底肌微伏值方面也有客观改善。
