Diaphragmatic Breathing Exercises and Pelvic Floor Retraining in Children With Dysfunctional Voiding

University of Nis

Status: Unknown

Conditions: Dysfunctional Voiding

Treatments: Behavioral: Standard urotherapy; Behavioral: Diaphragmatic breathing

Study type: Interventional

Funder types: Other

Identifiers

NCT04981340

43011

Details and patient eligibility

About

According to the 2016 International Children's Continence Society standardization of terminology of lower urinary tract function in children, dysfunctional voiding (DV) is a "urodynamic entity characterized by an intermittent and/or fluctuating uroflow rate due to involuntary intermittent contractions of the striated muscle of the external urethral sphincter or pelvic floor during voiding in neurologically normal individuals" . Symptoms vary from mild daytime frequency and urgency to daytime and nighttime wetting, pelvic holding maneuvers, voiding difficulties, urinary tract infections and vesicoureteral reflux (VUR).

There are several ways of treating DV, including urotherapy, pharmacotherapy, surgery in the most severe cases, and even Botulinum toxin type A application in certain children. ''Urotherapy'' stands for non-surgical, non-pharmacologic treatment of lower urinary tract function and can be defined as a bladder re-education or rehabilitation program aiming at correction of filling and voiding difficulties. It involves the change of habits that a child has acquired during the period of toilet training and the development of motor control of the micturition reflex. Urotherapy starts with both parental and child education about the importance of regular hydratation and voiding, constipation treatment and genital hygiene. Together with this standard treatment, the pelvic floor muscle (PFM) retraining is initiated, and it includes pelvic floor exercises and various forms of biofeedback (visual, tactile, auditory, electromyography) with the same aim in mind - to help the child establish pelvic floor awareness and control, and relearn pelvic floor muscle relaxation.

During the past decade, it has been shown that the PFMs are not an isolated unit, but a part of the abdominal capsule, which they form together with the diaphragm, superficial and deep abdominal muscles. As lower abdominal and PFM act synergistically, it is important that both be relaxed during voiding. Diaphragmatic breathing exercises are easy to learn and serve to teach the children abdominal relaxation.

Enrollment: 100 estimated patients

Sex: All

Ages: 5 to 18 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

1. Proven dysfunctional voiding according to the ICCS criteria
2. Signed informed consent by parents motivated to participate in the study
3. Previous treatment by pediatricians in primary care with timed voiding, hydratation and constipation management for three months with no significant success

Exclusion criteria

1. Neurological disorders
2. Monosymptomatic nocturnal enuresis
3. Mental retardation
4. Structural abnormalities of the lower urinary tract -

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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100 participants in 2 patient groups

Standard urotherapy + Diaphragmatic breathing exercises+ pelvic floor exercises

Experimental group

Description:

Diaphragmatic breathing exercises will be demonstrated by a qualified physiotherapist. Exercises will be done in lying and sitting positions respectively. In supine, with the lower extremities supported over a pillow and hands positioned on the abdominal muscles, children will be asked to inhale the air through the nose, bulge the abdomen outwards as much as possible, hold their breath for a few seconds, and then exhale slowly through pursed lips. The same exercise will be then performed in both side-lying positions and in a sitting position in front of the mirror. Children will be instructed to watch the anterior abdominal wall movement during inspiration and to repeat the same action while seated on the toilet to initiate voiding. They will be asked to perform the diaphragmatic breathing exercises daily at home.

Treatment:

Behavioral: Standard urotherapy

Behavioral: Diaphragmatic breathing

Standard urotherapy

Active Comparator group

Description:

Standard urotherapy will start with the education of the children and their parents about the normal function of the bladder and external urinary sphincter and the nature of their voiding disorder. The importance of regular fluid intake (200 ml 5-6 times per day) and regular voiding will be explained. Special voiding and defecation diaries that a child has to fill out at home will be provided. An optimal voiding posture will be demonstrated in front of a mirror: a sitting position, with feet supported, hips abducted and abdominal muscles relaxed.

Treatment:

Behavioral: Standard urotherapy