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European Journal of Physical and Rehabilitation Medicine 2012 September;48(3):413-21


language: English

Diaphragmatic breathing exercises and pelvic floor retraining in children with dysfunctional voiding

Zivkovic V. 1, Lazovic M. 2, Vlajkovic M. 3, Slavkovic A. 4, Dimitrijevic L. 1, Stankovic I. 1, Vacic N. 4

1 Clinic of Physical Medicine, Rehabilitation and Prosthetics, Clinical Centre Nis, Nis, Serbia; 2 Rehabilitation Institute Belgrade, Belgrade, Serbia; 3 Department of Nuclear Medicine, Clinical Centre Nis, Nis, Serbia; 4 Clinic of Paediatric Surgery, Clinical Centre Nis, Nis, Serbia


BACKGROUND: Dysfunctional voiding (DV) in neurologically normal children is characterized by involuntary intermittent contractions of either the striated muscle in external urethral sphincter, or the pelvic floor during voiding. Urinary incontinence, pelvic holding maneuvers, voiding difficulties, urinary tract infections (UTIs), constipation and vesicoureteral reflux are highly associated with DV.
AIM: To investigate the role of abdominal and pelvic floor muscle (PFM) retraining in children with DV.
DESIGN: Prospective clinical controlled study
SETTING: Outpatient clinical facility
POPULATION: Forty-three children, 5-13 years of age, with dysfunctional voiding
METHODS: In addition to standard urotherapy (education, timed voiding, adequate fluid intake, voiding posture and pattern, constipation management and hygiene issues), children were assigned abdominal and PFM retraining. Diaphragmatic breathing exercises were done in lying and sitting positions, for the purpose of achieving abdominal muscle relaxation. PFM retraining consisted of low-level three-second contractions followed by thirty-second relaxation periods. Selected children received pharmacotherapy (anticholinergics or desmopressin). Recurrent symptomatic UTIs were treated with antibiotic prophylaxis. Uroflowmetry with PFM electromyography and ultrasound residual urine volumes were obtained before and at the end of the 12-month treatment period. Clinical manifestations and uroflowmetry parameters were analysed before and after the therapy.
RESULTS: After one year of therapy, urinary incontinence was cured in 20 out of 24 patients (83%), nocturnal enuresis in 12 out of 19 children (63%), while 13 out of 19 children (68%) were UTI free. All 15 patients recovered from constipation. Post-treatment uroflowmetry parameters showed significant improvements and a bell-shaped curve was observed in 36 out of 43 children.
CONCLUSION: In combination with standard urotherapy, abdominal and pelvic floor muscle retraining is beneficial for curing urinary incontinence, nocturnal enuresis and UTIs in children with DV, as well as for normalizing urinary function. Further trials are needed to define the most effective treatment program which would result in the best treatment outcome.
CLINICAL REHABILITATION IMPACT: To improve clinical and objective treatment outcome in dysfunctional voiders. Diaphragmatic breathing and pelvic floor muscle exercises are simple and easy to learn and could be assigned to children aged 5 or older. As they do not require special equipment, they can be performed at all health care levels.

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