1. 功能性排尿障礙之生理迴饋及物理治療
洪于琇
慈濟綜合醫院復健科

3. Pelvic floor (PF) hypertonicity/overactivity
Synonymy
PF essential /episodic hypertonicity
Sphincter dyssynergia/ pseudodyssynergia-excessive PF activity during voiding
Clinical diagnosis
Spastic Urethral Sphincter(HPLF)
Poor Pelvic Floor Relaxation (LPLF)
Dysfunctional voiding
Detrusor instability
Frequency urgency syndrome

4. Etiology
Persistence of a reaction phase to noxious stimulus of LUTs (e.g. inflammation, infection, irritation, post-surgery)
learned dysfunctional voiding behavior
Persistent transitional phase in the development of micturition control
Sexual abuse

5. Urologic menifestation
Lower urinary tract symptoms( LUTS)
storage symptom: Urgency, frequency, urge incontinence
emptying symptoms: poor stream, hesitancy, need to strain, a feeling of incomplete bladder emptying
Childhood: enuresis, recurrent urinary tract infection (UTI), reflux, hydronephrosis
Adult: LUTS, recurrent UTI, incomplete emptying, incontinence.
Cocommittent symptoms: constipation, pelvic/ perianal pain

6. Diagnosis Clinical history Urinalysis: infection
Cystourethroscopy: exclude bladder cancer/anatomic bladder outlet obstruction
Uroflowmetry with EMG+ ultrosonography Videourodynamic study:
sphincter EMG during voiding

8. Frequency urgency syndrome
NPLF and poorly relaxed urethral sphincter

9. electrical stimulation
-incontinence
-reflux
-mucosal ischaemia
-diet regulation
-drinking and voiding
chart
-pharmacotherapy
Bladder
dysfunction
Overtraining of the
pelvic floor muscles
Pelvic floor
dysfunction
Biofeedback
electrical stimulation
manual technique
-milk-back of urine
-residual urine
-pelvic pain

10. EVALUATION—history Current symptoms:
micturition, pain, defecation, sex life
Childhood: prolonged bedwetting, excessive e’x to achieve urinary continence, punishment for bedwetting, retentive voiding habit, sexual abuse
Adolescence: painful menses, frequent UTI
Adulthood: childbirth, vaginal delivery, pelvic surgery, voids habits, profession, social life

11. Evaluation A complete history Frequency /volume chart for 3 days
Neurological examination (lower quarter)
proprioception, sensation
Peripheral reflexes
Physical examination
Sacroiliac & coccygeal position /mobility
PF assessment:
External observation
Digital per vagina or anus
Periometry
EMG assessment

12. Pelvic floor assessment
Digital examination: tone,contractility,endurance
-Poor muscle isolation,impaired contract and
relax voluntarily
-trigger point, tenderness, spasm
EMG assessment:
-abnormal tension and instability at rest
-slow recruitment and recovery time
-weak and instability during phasic, Tonic and endurance voluntary contraction

13. Management-Behavioral modification
Education on urinary system and PF dysfunction
Individually adapted drinking/voiding schedule
Diet: avoid bladder stimulants, high fiber
adequate daily intake of water
General recommendations for changing wrong voiding behavior
take time for micturition, do not push
Instruct a proper toilet posture:
--sit or squat for voiding every time (men also)
no straining
timed voiding (2~4 hours)

15. Pelvic floor retraining with EMG biofeedback
A series of contraction to enhance awareness of levels of relaxation
Goal:
to help identify pelvic floor musculature
to perceive difference between
contraction, relaxation, and straining
to voluntary relax pelvic floor during
voiding

16. Pelvic floor retraining with EMG biofeedback

17. EMG biofeedback

18. 陰道壓力法
直腸壓力法
肛門內電極器
陰道內電極

23. EMG biofeedback Surface or Intravaginal/intra-anal EMG sensor
Protocol:
One minute rest, pre baseline
Ten rapid contraction (phasic) with 10-s rest between each
Ten 10-s contraction with 10-s rest between each (tonic)
A single endurance contraction of 60-s
One minute rest, post baseline

26. PF relaxation training Voiding biofeedback

27. Home program : Home sEMG unit
5-s contract/10-s relax, 20 reps twice daily
10-s contract/10-s relax, 60 reps twice daily
Diaphragmatic breathing
Visualization: the ischial tuberosity seperating,
a hole getting larger
Perineal bulging
Relaxing environment: guiet, relaxing music…
Total body relaxation, progression relaxation
Practice in different posture and during voiding

29. Combination therapy for concomitant urologic symptoms
Detrusor instability: anticholinergic drugs
Recurrent UTI: antibiotics
Chronic constipation:
regulation of diet,
bowel training
drug therapy

30. clinical effect 51-83% improve for the long-term follow- up
normal flow curve & good pelvic floor relaxation
no significant residual urine
decrease occurrences of UTI, enuresis,
hydronephrosis
-- improve constipation
Tzu-Chi general hospital, 2001 Nov~2003Mar
70.7% achieve normal flow pattern
significant symptom improvement

31. Important factors for successful biofeedback training
--good motivation and cooperation
--Appropriate selection of patients
Intact nervous system

32. Electrical stimulation TENS/IFC/NMES: 5-20Hz, 210μs, --sacral dermatome, suprapubic, posterior tibial n. --Large skin afferents suppress spontaneous reflex activity within the dermatome

33. Electrical stimulation High voltage electrogalvanic DC, Hz, --intravaginal /Rectal probe --induce tentanic and fatique of levator ani to break the spasm-pain high relapse rate in 6 months Effectiveness depend on frequent, ongoing treatment

34. Manual technique To restore sacroiliac & sacrococcygeal alignment
Manual therapy to Realign sacroiliac & sacrococcygeal joint
To  tension and promote m. relaxation, improve m. awareness
Trigger point pressure (sustain sec)
Myofascial massage(10-15 sweeps)
Muscle energy technique

37. Treatment consideration
Behavioral modification
Pelvic floor retraining (Biofeedback)
Electrical stimulation
Manual technique
pharmacotherapy

38. Thanks