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Urotherapy: definitions and evidence

Urotherapy: definitions and evidence. Ann Raes Department of Pediatric Nephrology, University Hospital Ghent, Belgium. Spring School 01-06 June 2018. History of urotherapy. Hoebeke et al. Outpatient training Succes 92%/82 %. US/ Mc Kenna et al. Sophisticated games Succes 90 %.

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Urotherapy: definitions and evidence

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  1. Urotherapy: definitions and evidence Ann Raes Department of Pediatric Nephrology, University Hospital Ghent, Belgium Spring School 01-06 June 2018

  2. History of urotherapy Hoebeke et al. Outpatient training Succes 92%/82 % US/ Mc Kenna et al. Sophisticated games Succes 90 % Hellstrom et al. Bladder rehabilitation Urotherapy Urotherapist Vijverberg et al. Inpatient training Succes 80 % ICCS standardization document

  3. What is urotherapy ? • Nonsurgical, nonpharmacological treatment for • LUT dysfunction • Boweldysfunction • Combination of cognitive, behavioral and fysical training • Multidisciplinary approach • wide field of healthcare professionals

  4. Standard urotherapy • Information anddemystification • Education (family + child) on howtoresolve the LUT (bowel) dysfunction • Life-styleadvice • Bladder /boweldiary • Motivationandreward

  5. Advance urotherapy • Pelvic floor muscleretraining • Awareness andcoordination • (Uroflow)Biofeedbacktraining • Electricalstimulation (Neuromodulation) • TENS/PENS • Clean intermittentcatheterization (>> residual volume) • Psychotherapy • Psychologicalcomorbidity

  6. Sign/symptom Goal Clinicalapplication • Incontinence • Urinary urgency • Urinary tract infection • Dysfunctional voiding • Vesicoureteral reflux • Reduced or enlarged EBC • Fecal incontinence Long-term dryness Voidwhenconvenient No relaps of UTI Normaluroflow curve, post-void residual volume < 10 ml Reduction in grade of VUR Normal bladder capacity Regularbowelemptying, no soiling

  7. Urotherapy in nocturnal enuresis • Appropriate fluid intake • regular fluid intake during the day • minimization of fluid and solute intake 1-2 hours before sleep • Regular voiding during daytime • Good voiding posture • Emptying the bladder before going to bed • A diary of dry and wet nights should be kept for • Selfmonitoring and motivation • Treatment of constipation

  8. Urotherapy in nocturnal enuresis

  9. Urotherapy in diurnal incontinence • Design: Retrospectiveevaluationof 98 children with DI (outpatient program) (ICCS treatment outcome definitions) 8 sessions during 15 weeks (standard BBA + uroflowmetry) • Results 1) 2) Significant reduction in daily voiding frequency (P<0.0001) Reduction in mean post-void residual (P<0.003), Improvement in flow pattern (P<0.05) Improvement DI in 78 % at the end of training and improvement of other voiding symptoms Mulders et al, 2011

  10. Urotherapy in diurnal incontinence • Assessment of urotherapy in overactive bladder and DI • RCT: 4 weeks standard uroTx before randomization • Group A: N=30, 12 weeks of standard UroTxwith a Timer watch • Group A: N=28, 12 weeks of standard UroTx without a Timer watch • Long-term response was evaluated at 7 months • Results : 60% > 50% reduction (A) 18% > 50% reduction (B) 7 months: 60% complete dry (A) Timer watch assisted uroTx is superior to standard uroTx Hagstroem et al, 2010

  11. Urotherapy in diurnal incontinence • Schafer et al, 2017: meta-analysis • 18 studies (154) • N: 1502 treatedwith standard urotherapy (SU) • Effectiveness of SU in reductionin DI in childrenandadolescents Standard urotherapy is considered to be an effective intervention in comparison to expected cure rates based on spontaneous remission

  12. Urotherapy in dysfunctional voiding • Prospective evaluation of 86 children with DV and incontinence • A: N=43: standard urotherapy + diaphragmatic breathing + PFM • B: N=32: standard urotherapy • In both groups : R/ for reduced BC, constipation and UTI • Results: PFM and standard urotherapy are superior to standard urotherapy alone for cure of DI and NE, but comparable to resolve UTI and constipation Zivkovic et al, 2011

  13. Biofeedback in dysfunctional voiding • Desantis et al., 2011: systematic review • effectiveness in reduction in UTI andID • 27 studies (1 RCT and 26 case series) Positiveresults 80 % benefited from this treatment • Fazeli et al., 2015: meta-analysis of RCT • effectiveness in reduction in UTI and ID • 5 eligible studies (382 participants) were pooled Negative results Similar in incontinence in biofeedback and control groups No significant difference in likelihood of urinary tract infection

  14. Urotherapy in BB dysfunction • RCT: Group A: N=25, individual urotherapy Group B: N=24, group urotherapy • Results : Urotherapy, regardless of modality, effectively improves BBD Brownrigg et al , 2015

  15. Lessonsfromthirtyyears of urotherapy • Standard urotherapy is a validtherapeuticstrategyforchildrenwith LUTS, but recommendation in MNE is questioned. • Despite adequate work-up a core of 20-40% of children with LUTS at long-term follow up are resistant to standard urotherapy and need advanced urotherapy. • Treatment of defaecation problems in children with BBD enhances successful management of LUTS • Urotherapy effectively reduces symptoms related to BBD

  16. Lessonsfromthirtyyears of urotherapy • There is needfor RCT • Withcleardefinedstudygroups • Withstandardized treatment modalities • Withlonger treatment- and follow-up periods • Tobeabletoevaluate the effectiveness of eachmodality • Tobeabletocompare the results of different programs • Todefine the best program

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