Urotherapy: a critical evaluation

Over the last two decades, urotherapy has become the mainstay treatment of bladder and bowel problems in children and adolescents. Urotherapy uses non-pharmacological, non-surgical methods and focuses on behavioral interventions, largely based on cognitive-behavioral psychotherapy. Previous studies show that urotherapy leads to a significant reduction in symptoms for all forms of functional incontinence. It has a success rate of 56% within one year, compared to a spontaneous recovering rate of 15% per year. Because of the multidisciplinary nature, it is not clear which elements of the therapy are most effective. The aim of this thesis was to study different elements of urotherapy, in order to improve care for incontinent children. In the first part, we described the etiology, definition, and treatment of daytime urinary incontinence. In part 2, we evaluated the outcome of the inpatient urotherapy program at the Wilhelmina Children's Hospital, for therapy-resistant children with an overactive bladder. Overactive bladder (OAB), a subtype of incontinence that is characterized by symptoms of urgency, often combined with frequent urgency urinary incontinence or nocturnal enuresis. Approximately 20% of children with OAB are considered to be therapy resistant for urotherapy. The effect of inpatient urotherapy for refractory OAB complaints has demonstrated to cure or improve 74.3% of patients and conveyed favorable long-term results in approximately 70.5% of patients. In part 3, we discussed current practices and innovations in urotherapy. We compared urotherapy with and without pelvic floor rehabilitation by biofeedback with anal balloon expulsion (BABE). We included children with functional incontinence and inadequate pelvic floor control. The children were divided into two groups; a group that received BABE prior to inpatient urotherapy consisted, and a group that received BABE after inpatient urotherapy. There was no significant additional effect of BABE on specific inpatient urotherapy. Of the children that received BABE, 58% showed improvement in pelvic floor control. This implies that training pelvic floor control in combination with inpatient urotherapy does not influence treatment effectiveness on incontinence. We investigated whether new technology such as a portable ultrasound bladder sensor (SENS-U) and a bladder training-app are valuable additions to the treatment. The SENS-U is a small, wireless ultrasonic sensor, which continuously monitors the bladder filling and provides a personalized notification when it is time to go to the toilet. The SENS-U was able to monitor the natural bladder filling, during regular physical activity in children. It notified the child of a full bladder with a median notification rate of 92.9% and a median level of response equal to 100%. A bladder training-app could make the training more appealing and rewarding. We included children that were allowed to choose between receiving inpatient urotherapy with or without the bladder training app. Results showed that children who received treatment with the addition of a training-app did not differ in terms of intrinsic motivation from children who underwent bladder training only. Treatment outcomes were equal in both groups, with 80% good or improved. Incontinence related quality of life improved accordingly