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UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4 193
The pelvic floor contains
a group of muscles –
pelvic floor muscles
(PFMs) – that extend
from the symphysis pubis (ante-
rior) to the back (posterior) of the
bony pelvis, forming a hammock
that supports the pelvic organs
(Newman & Wein, 2009). The
PFMs are composed of the leva-
tor ani group and includes the
pubococcygeus, puborectalis,
and ileococcygeus muscles (see
Table 1 and Figure 1). PFMs are
composed primarily of skeletal
muscle that differs from other
skeletal muscle because they not
only provide support for all the
organs of the pelvis, they have a
higher resting muscle tone so as
to support the external urinary
sphincter. PFMs are entirely
under voluntary control and play
an important role in maintaining
continence, and can become
weakened from pregnancy and
childbirth, lack of use, a decrease
in the hormone estrogen, aging,
surgery, and injury (Maserejian et
al., 2014).
Pelvic Floor Muscle Exercises
Weakness in PFMs can lead
to problems with both bladder
and rectal support because fecal
and urinary continence are diffi-
cult to maintain without ade-
Pelvic Floor Muscle Rehabilitation
Using Biofeedback
Diane K. Newman
Diane K. Newman, DNP, ANP-BC, FAAN,
BCB-PMD, is an Adjunct Professor of
Urology in Surgery and Research
Investigator Senior, Perelman School of
Medicine, University of Penn sylvania’ and
Co-Director, Penn Center for Continence and
Pelvic Health, Division of Urology, Penn
Medicine, Philadelphia, PA.
Advanced Clinical Practice
© 2014 Society of Urologic Nurses and Associates
Newman, D.K. (2014). Pelvic floor muscle rehabilitation using biofeedback.
Urologic Nursing, 34(4), 193-202. doi:10.7257/1053-816X.2014.34.4.193
Pelvic floor muscle exercises have been recommended for urinary incontinence
since first described by obstetrician gynecologist Dr. Arnold Kegel more than six
decades ago. These exercises are performed to strengthen pelvic floor muscles,
provide urethral support to prevent urine leakage, and suppress urgency. In clin-
ical urology practice, expert clinicians also teach patients how to relax the mus-
cle to improve bladder emptying and relieve pelvic pain caused by muscle spasm.
When treating lower urinary tract symptoms, an exercise training program com-
bined with biofeedback therapy has been recommended as first-line treatment.
This article provides clinical application of pelvic floor muscle rehabilitation using
biofeedback as a technique to enhance pelvic floor muscle training.
Key Words: Pelvic floor muscle training, biofeedback therapy, electro myo -
gram, vaginal and rectal sensors, pelvic floor muscle electrical
stimulation.
Figure 1.
Muscles of the Pelvic Floor
Source: © Diane K. Newman. Used with permission.
Clitoris
Urethra
Vagina
Anus
Coccyx
Sacrum
Ischiocavernous Muscle
Bulboocavernous Muscle
Deep Transverse
Perineal Muscle
Perineal Body
Superficial Transverse
Perineal Muscle
Ischial Tuberosity
External Anal Sphincter
Levator Ani Muscle
(iliococcygeus)
Anococcygeal Ligament
Symphysis
Pubis Pubic
Bone
Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
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194 UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4
quate strength and support. Cor -
recting PFM weakness through
muscle rehabilitation is helpful
in treating urinary incontinence
(UI) if lack of pelvic support is
the causative factor. Increasing
functionality of PFMs has also
been shown to help with alleviat-
ing urinary urgency and frequen-
cy, and has been linked to activa-
tion of the sacral micturition cen-
ter, which in turn results in uri-
nary urge inhibition (Moore et
al., 2013; Wyman, Burgio, &
Newman, 2009).
Pelvic floor muscle training
(PFMT) is based on the presump-
tion that exercising can both
increase the capacity of existing
muscle and hypertrophy the
muscle (aerobic and anaerobic
capacity); thus, strong repeated
exercise increases muscle bulk,
and prolonged muscle contrac-
tion at moderate intensity in -
creases endurance. Hypertrophy
of the muscle might take weeks
to months before it is apparent
(McLean et al, 2013). In addition
to PFMT with biofeedback, clini-
cians with expertise in behav-
ioral treatments for UI and relat-
ed lower urinary and pelvic
symptoms add other interven-
tions, including bladder training
with urgency inhibition or sup-
pression, and diet and fluid man-
agement to maximize outcomes
(Greer, Smith, & Arya, 2012;
Newman & Wein, 2013; Wyman
et al, 2009).
Biofeedback Therapy
Biofeedback (BF) therapy is a
technique in which physiologi-
cal activity (neuromuscular and
autonomic activity) is monitored,
amplified, and conveyed to the
patient (feedback) as visual or
acoustic signals (Newman &
Wein, 2009). As a result, BF gives
an individual immediate feed-
back about normal body process-
Table 1.
Muscles of the Pelvic Floor
Origin Insertion Action Relevance
Pelvic Floor Muscle
Coccygeus Pelvic surface of
the ischial spine
Side of the coccyx and
lower sacrum
Elevates the
pelvic floor
• Cases of pain associated with
sitting, vaginal delivery, or chronic
constipation due to prolonged,
repetitive, or traumatic irritation
and compression.
Levator ani (LA) Posterior surface
of the body of the
pubis, arcus
tendineus levator
ani, ischial spine
Anococcygeal raphe
and coccyx
Elevates the
pelvic floor, mid-
urethral vaginal
vault, and anus
• Serves as an inner-core muscle
to provide lumbopelvic stability,
and it protects the pelvic girdle
by resisting increases in intra-
abdominal pressure.
• Contracts during orgasm.
• Ability to relax volitionally to
assist normal urination and
defecation.
Layers of the Levator Ani
Illiococcygeus
(IC)
Arcus tendineus
levator ani, and
the ischial spine
Anococcygeal raphe
and the coccyx
(clinically called the
levator plate)
Elevates the
pelvic floor
• Creates a supportive diaphragm
posteriorly to resist elevated
intra-abdominal pressures.
Pubococcygeus
(PC)
Posterior aspect
of the superior
pubic ramis
Passes backward along
the puborectalis muscle
and inserts into the
anococcygeal and the
superior surface of the
coccyx.
Elevates the
pelvic floor
• Fibers create a band (often
referred to as a hammock).
• Provides essential support to the
proximal bladder neck and
urethra.
Puborectalis
(PR)
Posterior aspect
of the body of the
pubis
Proceeds backward
along the edge of the
genital hiatus in contact
with the side of the
vagina and loops
around the rectum
(anorectal junction)
creating the anorectal
angle below the coccyx
Draws the distal
rectum forward
and superiorly
• Pulls rectum forward during
contraction and assisting with
providing anal continence.
Source: Adapted from Corton, 2009.
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UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4 195
es of which they may not be
aware. It provides instantaneous
information to the patient about
the status of the PFM. While
some consider BF part of comple-
mentary therapy, it is also
viewed as an adjunct to PFM
rehabilitation for persons with
lower urinary tract symptoms
(LUTS) (e.g., irritative and emp-
tying symptoms) and pelvic floor
dysfunction (e.g., pelvic pain).
Figure 2 outlines a Decision Tree
for instituting PFM rehabilitation
for LUTS, neurogenic bladder
dysfunction, and pelvic pain.
BF therapy that involves
neuromuscular training is an
instrument-based learning pro -
cess based on “operant condi-
tioning” techniques. The govern-
ing principal is that any behavior
(whether it is a complex maneu-
ver, such as eating, or a simple
task, such as muscle contrac-
tion), when reinforced, its likeli-
hood of being repeated and per-
fected increases.
One goal of BF-assisted
behavioral treatment of LUTS is
to alter physiologic responses of
the detrusor and PFM that medi-
ate urine loss and cause urinary
urgency, such as with individu-
als experiencing urgency UI
and/or overactive bladder (OAB).
BF can also be used to teach per-
sons new skills for preventing UI,
assist them in relearning previ-
ous bladder control behaviors,
and how to relax a muscle that
may be in spasm. Therefore, BF
can be a vital component of a
behavioral program to treat stress
and urgency UI (Hay-Smith,
Henderschee, Dumoulin, &
Herbison, 2012; Herderschee,
hay-Smith, Herbison, Roovers, &
Heineman, 2011; Newman &
Wein, 2013).
Biofeedback is also used in
patients with bowel dysfunction,
such as fecal (anal) incontinence
(FI) (Heymen et al., 2009; Norton
& Cody, 2012). In these patients,
the goal is to strengthen the anal
sphincter to restore a normal pat-
tern of defecation. In patients
with dyssynergic defecation and
loss of stool, the goal of neuro-
muscular training is two-fold: 1)
to correct the dyssynergia or in -
coordination of the abdominal,
rectal, puborectalis, and anal
sphincter muscles to achieve a
normal and complete evacuation;
and 2) to enhance rectal sensory
perception in patients with im -
paired rectal sensation (Markland
et al., 2008).
Use of BF in Specialty
Clinical Practice
Applying BF in a specialty
clinical practice (e.g., urology,
urogynecology) is a dynamic
process because there is transfer-
ence of information to the
patient. This process begins with
a pelvic floor muscle assessment
(see Figure 3). The patient learns
to control bladder, sphincter,
PFMs, and intra-abdominal pres-
sure by responding to visual or
auditory signals generated
through the activity of an inter-
nal physiologic process. As pre-
viously noted, the advantage for
both the patient and the clinician
is that information is immediate
and can be in terpreted simulta-
neously, allow ing the patient to
control re sponses of which they
may have little or no knowledge
or awareness. For example, BF
can provide motivation to
patients who may be frustrated
over inability to isolate PFMs or
who lack sensation of muscle
contraction.
A patient education handout
that provides information on BF
(see Figure 4) may be given to all
patients prior to treatment. BF
therapy is most useful when the
patient is motivated, wants to be
actively involved in their therapy,
can follow directions, and when
there is a readily identified and
measurable muscle re sponse. The
clinician, though, is integral to a
Figure 2.
Lower Urinary and Pelvic Floor Disorders Decision Tree
Urinary Incontinence
Stress, urgency, or mixed
Neurogenic Detrusor Overactivity
(NDO) Chronic Pelvic Pain/Spasm
Stress
Urgency, mixed,
or overactive
bladder (OAB)
Urgency,
frequency
Incomplete bladder
emptying (detrusor
sphincter dysynergia)
Pelvic floor
muscle relaxation
Pelvic floor muscle
training (PFMT) with
biofeedback
knack/stress strategies
Lifestyle modifications
Behavioral therapy (bladder training,
urge suppression techniques, PFMT with
biofeedback, knack/stress strategies)
Intermittent
catheterization
based on PVR
Source: © 2013 Diane K. Newman. Used with permission.
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196 UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4
• Prior to examination, the patient should have voided.
• Have the participant undress from the waist down and lie supine (women with
hips and knees flexed; men should lie on left side with knees drawn up). Use a
draw sheet to drape participant from waist to knees to maximize privacy but still
allow necessary observation of pelvic floor muscle (PFM) contractions. The use
of stirrups in women should be considered.
• Before starting the internal examination, ask the patient to contract PFMs using
cues such as “squeeze your pelvic muscle and try to pull in and up,” “tighten up
like you are trying to not pass gas.”
• Observe externally the perineum (see illustration to the right) to assess if the
patient is bearing down, using accessory muscles, or performing a correct con-
traction (perineal body, including vaginal introitus in women, and anus move
inward [in men, the penis may lift]).
•Muscle Assessment Vaginally: Insert one (or two) gloved, lubricated index fin-
gers into the vagina to the depth of the proximal inter-phalangeal joint (see illus-
tration to the right).
• If vaginal stenosis or atrophy is present and/or patient expresses concern or dis-
comfort/pain about undergoing examination, only insert one finger into the vagina.
a. Muscle Location: Finger(s) are inserted into the vagina, finger pads down,
in a posterior direction; eventually, they will encounter the edge of the leva-
tor ani (LA) (if proceeding more posteriorly, fingers will drop off the edge).
Once at the edge, fingers should be retracted such that they rest on the
muscle belly of the LA. Palpate the LA muscle laterally, at the four and eight
o’clock position, just superior to the hymenal ring. Discomfort or tenderness
to palpation should be noted.
•Muscle Assessment Rectally: Inspect outside of anus to determine presence
of hemorrhoids. Ask the patient to bear down or cough.
a. Muscle Location: As the sphincter relaxes, gently insert index finger into the anal canal in a direction pointing toward
the umbilicus. Note the resting sphincter tone of the anus. Normally, the muscles of the anal sphincter close snugly
around the entire circumference of the examiner’s finger. In the rectum, the distal external sphincter is felt just inside
the anal canal. The PR portion of the LA muscle can be palpated about 2.5 to 4 centimeters from the anal verge. To
assess the strength of the sphincter muscle, ask the patient to tighten his or her rectum around your finger. The exam-
iner should feel a griping pulling in around entire circumference of finger.
b. Insert the index finger farther into the rectum to examine as much of the rectal wall as possible. Palpate in sequence
the right lateral surfaces, noting any induration, nodules, or irregularities.
•Assessing Muscle Isolation: Ask the patient to contract PFMs around examiners finger(s) with as much muscle force
as possible. Say to the patient:
“I am going to count to 3, and when I say 3, I want you to contract your pelvic floor muscle for as long and as hard as
you can.”
a. The following qualities of the muscle contraction should be assessed and noted:
1. Ability to produce force in the PFMs.
2. Ability to coordinate a PFM contraction. The patient should be able to contract PFMs without contraction of
abdominal, hip adductors, and/or gluteal muscles. In addition, full muscle relaxation should follow a contraction.
3. Duration the participant can hold the contraction consistently.
b. If no PFM activity is palpated, encourage the patient to contract again focusing on the PFMs, avoiding thigh and
gluteal contractions. The examiner can palpate and gently (and if needed, repeatedly) press on the LA or rectal
muscle to help the patient identify and activate this muscle.
Figure 3.
Pelvic Floor Muscle Assessment
Source: © 2010 Diane K. Newman. Used with permission.
BF-assisted PFM rehabilitation
program because more intensive
supervised programs taught by
health professionals have been
shown to be better than self-
directed programs (Moore et al.,
2013). This service model is used
in many urology practices or
pelvic floor centers, which
employ trained health care spe-
cialists (usually registered nurses,
nurse practitioners, physical ther-
apists). In these types of specialty
practices, patients who receive BF
and other conservative treatment
have more contact with the health
care provider and receive more
intensive treatment. Contact and
interaction with a pelvic floor spe-
cialist can be an important com-
ponent of BF-assisted PFMT. A
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UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4 197
Figure 4.
Patient Education Tool: Biofeedback Treatment
Biofeedback is a painless, effective treatment to help you identify and strengthen your pelvic floor muscles. Most men and
women do not exercise these muscles the right way. Biofeedback will help you learn about your muscles and how to use them
to prevent incontinence, bladder or bowel
urgency, and frequency. Using biofeedback to
retrain your pelvic muscles has been shown to
help 8 out of 10 people and is the recommend-
ed “first-line” treatment for bladder and pelvic
problems.
What Is Biofeedback?
Biofeedback uses a computer that records your
muscle activity, the muscle contraction, relax-
ation, and strength. It produces computer-gen-
erated graphs that are displayed on a monitor.
Biofeedback helps you find your pelvic muscles
by showing changes when you squeeze or
tighten the right muscle. Much like an athlete
uses special equipment to train, you can use
biofeedback equipment to reach a new level of
strength in your pelvic muscles. Biofeedback
can also use sound to help you identify the
muscles you are to train. It teaches you not to
tighten other muscle groups, such as your
stomach muscles.
How Is It Done?
There are two different ways to provide the
“feedback.” One is to place two “skin patches”
that have adhesive at your anus (the opening to
your rectum). A second way is to insert a small
sensor in your vagina (used in women) or your
rectum (used in men or women). Either way,
these pick up signals from your muscle and
measure the muscle contraction and the relax-
ation. The sensors are connected to a comput-
er that displays muscle changes on a monitor.
You will immediately see when you are con-
tracting the correct set of muscles and doing
the exercise the right way. You will be able to fol-
low your progress as your pelvic muscles gets
stronger with each biofeedback session.
How Long Is Each Biofeedback Visit?
The biofeedback treatments are usually 20 to
30 minutes long, once or twice a month.
How Many Biofeedback Treatment Visits
Will I Need?
To get the best results, you should have
biofeedback visits over a six-month period and
then follow-up treatments periodically, depend-
ing on your symptom improvement. But the fre-
quency of biofeedback visits will depend on
your muscle assessment at your first visit. In
the beginning, you may need to come more fre-
quently, maybe twice a week or more. For
“homework” you will be given an “Exercise
Prescription” to follow for exercising at home.
You will also be asked to keep a Bladder Diary.
Your progress will be discussed during your
office visits, and the biofeedback will show you
how your muscle is progressing.
Vaginal
Sensor
Rectal
Sensor
Source: © 2010 Diane K. Newman. Used with permission. This patient education tool may be photocopied.
Ground
Electrode
Active
Electrodes
Skin
Patches
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198 UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4
2011 Cochrane review noted that
BF may add benefit to PFMT, but
the observed effect could well be
related to another variable, such
as the amount of clinician contact
rather than the actual BF
(Herderschee et al., 2011, 2013).
The International Consultation
on Incontinence (ICI) Committee
on Adult Conservative Treatment
(Moore et al., 2013) also noted
that it is not known if regular vis-
its with the clinician vs. the actu-
al treatment using BF is more
effective.
Biofeedback Equipment
And Parameters
Dr. Arnold Kegel developed
the first biofeedback device, the
perineometer, which was a pres-
sure manometric sensor inserted
into the vagina. One of its uses
was to assist female patients with
stress UI in identifying the PFM
muscle and to visualize the feed-
back when contracting (Kegel,
1948). Since then, there have
been no studies that have pro-
posed the best equipment and/or
technology to use when perform-
ing biofeedback for PFM dys-
function. In this author’s experi-
ence, the system needs to be ver-
satile because it should be opera-
tor- and patient-friendly. Optimal
BF therapy includes visualiza-
tion of both pelvic and abdomi-
nal muscle movement; thus, a
two-channel system is available
(Newman & Wein, 2013). A mul-
tichannel system allows for both
pressure manometry and elec-
tromyography (EMG) channels.
EMG is the measure of electrical
activity of skeletal muscle – the
PFM. Increased electrical activity
is a result of more muscle activi-
ty; however, it is not a measure of
force. Audio feedback can also be
an attractive component of BF
equipment.
For information to be accu-
rate and helpful, instrumentation
must be accurate and dynamic.
In reference to PFM training, the
instrument must be both sensi-
tive and have little lag time in
both displaying and recording
information. Immediate, accurate
“feedback” is the goal of the
biofeedback instrument.
Cost and ease of use are also
important considerations in bio -
feedback instrumentation. High -
er cost does not always translate
into better equipment. To date,
there is no research, which has
compared cost, ease of use, and
accuracy of any BF system avail-
able for PFM dysfunction.
When looking into the
instrument for use in delivering
BF, careful consideration of the
patient population is paramount.
For example, if using this instru-
ment with older adult patients,
visual displays that can be seen
by the aging eye are needed, or
the instrument’s auditory compo-
nents should have a lower fre-
quency sound that the aging ear
can appreciate. Biofeedback dis-
plays that utilize games may be
appropriate in children and
younger adults.
Biofeedback parameters in -
clude measurement of resting
tone, muscle strength (maximal
and submaximal contractions),
contractility, power, and endur -
ance (ability to sustain a muscle
contraction) (see Table 2). At
least a five-second muscle relax-
ation period should be used
between each contraction be -
cause easily fatigable muscles
need a chance to recover, without
permitting excessive rest periods
for strong muscles. Measurement
of EMG muscle activity is usual-
ly in microvolts, and measure-
ment of manometric muscle
activity is a measurement of pres-
sure in millimeters of mercury.
EMG provides information on
the ability of the PFM to contract
and manometry quantifies PFM
strength. Electromyography, the
electrical activity of a muscle, is a
practical indicator of muscle
activity and is defined as:
• The study of electrical poten-
tials generated by the depo-
larization of muscle.
• A monitor of bioelectrical
activity correlating to motor
unit activity; it does not
measure the muscle contrac-
tility itself, but the electrical
correlate of the muscle con-
traction.
• An indicator of the physio-
logical activity of the muscle.
The advantage of EMG over
manometric pressure is that pro-
vided the machinery is of suffi-
cient sophistication with ade-
quate filtering, the EMG appara-
tus can accommodate the newer
types of electrodes that are light-
weight and designed to stay in
place, hence allowing more func-
tional positions during assess-
ment and treatment.
Table 2.
Measurement Parameters by Electromyography
(EMG) or Manometry
• Rest
– The ability of the muscle to return to a resting state between each
contraction.
• Strength
– Recorded as the peak maximum pressure (the maximal
contraction) and the ability to sustain or hold the contraction.
• Contractibility
– The rate of the original rise of the muscle contraction.
•Power
– The ability of the muscle to “contract–relax” as quickly and strongly
as possible, until the muscle fatigues; these are often called “quick flicks.”
• Endurance
– The time that a sub-maximum muscle contraction can be
maintained or repeated before a 50% or more reduction in power is
detected (the muscle contraction is timed until the muscle fatigues).
• Repetitions
– The number of repetitions (up to 10) of the muscle contraction
of equal force that can be achieved which indicate muscle coordination and
function.
• Fatigue
– Failure to maintain the required or expected force of the PFM
contraction for more than one or two times in succession.
Source: Adapted from Newman & Wein, 2009.
Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
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UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4 199
Frequency of Sessions
Biofeedback sessions may be
weekly, biweekly, and even
monthly. Frequency of sessions
should be individualized, and
patients may need frequent ses-
sions initially to aide in identifi-
cation and isolation of PFMs.
On the converse, less frequent
sessions are helpful because
changes in PFMs and lower uri-
nary tract symptoms occur slow-
ly. Improvement in pelvic sup-
port can be seen in one month,
but significant changes occur
after three to six months. Symp -
toms improve slowly, and track-
ing symptom improvement is
essential to PFMT. Establishing
realistic goals and expectations at
the beginning of treatment can
contribute to successful patient-
centered outcomes.
During BF sessions, patients
are taught quick muscle contrac-
tions (referred to as the “knack”
or stress strategies) for use prior
to the event that causes urine
leakage (Miller, Ashton-Miller, &
DeLancey, 1996, 1998). For
example, if urine leakage occurs
with a sneeze or cough, the
patient contacts the PFM prior to
or at the time of the event. For
practice, the clinician will have
the patient cough while viewing
the BF screen and contract the
PFM prior to and during the
cough. Quick pelvic floor muscle
contractions at the time of blad-
der urgency can suppress a
strong urge, delay voiding and
prevent an urge UI episode
(Wyman et al., 2009).
Measuring PFM Response
There are several approaches
for measuring PFM activity to
ensure effective BF. First, PFMs
as a group should be identified
during a vaginal and/or rectal dig-
ital examination (see Figure 3,
second illustration). It is helpful
to guide the patient toward isola-
tion of the PFM with minimal use
of accessory muscle groups. In
this author’s experience, it is
more effective that the clinician
assist to confer success and sup-
port the patient rather than to
focus solely on isolation of PFMs
at any cost.
In specialty clinical practice,
EMG measurement of gross neu-
romuscular function of the PFM
is often performed by using elec-
trodes that are placed on the skin
surface (see Figure 3, second
illustration) or sensors (probes)
inserted in the vagina or rectum
(see Figure 4, third illustration).
Because the deep PFMs lie adja-
cent to the vaginal walls, a vagi-
na sensor positioned against the
lateral vaginal walls is a conven-
Table 3.
ICI Grade of Recommendation
Treatment Recommendations Grade
PFMT Clinicians should provide the most intensive
program possible (in terms of exercise dose,
health professional teaching, and supervision).
Supervised programs taught by health
professionals are better than self-directed
programs; more health professional contact is
better than less.
A
Although studies are inconsistent, there does not
appear to be a clear benefit of adding clinic OR
Home-based biofeedback to a PFMT program.
A
B
PFMT Supervised PFMT should be offered as first-line
conservative therapy to women with stress, urge,
or mixed UI.
A
PFMT in women
with SUI
PFMT is better than electrical stimulation as first-
line conservative therapy, particularly if PFMT is
intensively supervised.
PFMT is better than BT as first line conservative
therapy.
B
B
PFMT in men
post-
prostatectomy
Some pre-operative or immediate post-operative
instruction in PFMT for men undergoing radical
prostatectomy may be helpful.
The use of BF to assist PFMT is currently a
clinician/patient decision based on economics and
preference.
B
B
PFMT + BT in
women with UUI
or MUI
PFMT and BT are effective first line conservative
therapy.
For women with SUI or MUI, a combination of
PFMT/BT may be better than BT alone in the
short-term.
B
C
PFMT + BF Use of BF for the treatment of FI after other
behavioral and medical has been tried, if
adequate relief has not been obtained.
B
Notes: BF = biofeedback, BT = bladder training, PFMT = pelvic floor muscle train-
ing, SUI = stress urinary incontinence, MUI = mixed urinary incontinence, FI = fecal
incontinence, UI = urinary incontinence, UUI = urge urinary incontinence.
A = Recommendation usually depends on consistent evidence from meta-analyses
of RCTs or high quality individual RCTs.
B = Recommendation usually depends on majority of evidence from RCTs or
prospective cohort (case-controlled) studies.
C = Recommendation usually depends on retrospective cohort (case-control) stud-
ies, case series, or low quality RCTs.
Source: Adapted from Abrams, Khoury, & Grant, 2013; Moore et al., 2013.
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200 UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4
ient means to record EMG activi-
ty in female patients (Keshwani
& McLean, 2013). The longitudi-
nal (lengthwise, not circular)
detection electrodes on the sen-
sor maintain the proper orienta-
tion to muscle fibers for highest
accuracy. Manometry or pressure
biofeedback can only be accom-
plished using intravaginal or
intrarectal sensors. Patients often
identify their PFMs with a sensor
simply because the resistive
device gives them something to
contract against. All electrodes
and sensors can be adapted for
use with most commercially
available instruments. Vaginal or
rectal sensors are single use, and
when in active therapy, patients
use the same internal sensor at
each session. An added benefit of
internal sensors is that they can
be used for both EMG and PFM
electrical stimulation.
Figure 5 is the smallest, most
comfortable female EMG sensor
available, and features gold
detection electrodes that provide
consistently superior measure-
ments and are also hypoaller-
genic. This sensor is inserted
similar to a tampon and posi-
tioned above the urogenital
diaphragm. It is able to measure
muscle activity even when the
patient is moving.
Evidence-Based Biofeedback
Recommendations
The ICI Committee on Adult
Conservative Treatment made evi-
dence-based recommendations
for PFMT and bladder training
(BT), alone or in combination,
(see Table 3), but the research is
inconclusive to the improved effi-
cacy of adding BF therapy as an
adjunct method for PFMT for any
dysfunction in the pelvic floor
(Ayeleke, Hay-Smith, & Omar,
2013; Moore et al., 2013). A 2011
Cochrane review (Herderschee et
al., 2011; Herderschee, Hay-
Smith, Herbison, Roovers, &
Heineman, 2013) on feedback or
biofeedback to augment PFMT
included 24 trials involving 1,583
women and concluded that
women who received PFMT with
BF were significantly more likely
to report their UI was cured or
improved compared to those
who received PFMT alone. How -
ever, as with other research in
this area, treatment groups dif-
fered on parameters other than
BF, such as preparation of the cli-
nician providing the therapy. A
recent Cochrane review (Ayeleke
et al., 2013) noted there was not
enough evidence to say whether
or not the addition of BF to
PFMT in women with UI results
in more benefits when compared
to the same active treatment
alone.
Since the 1980s, this author
has used BF as an adjunct to
PFMT in patients with PFM dys-
function. She conducted research
in a community health center and
home care setting (Baigis-Smith,
Smith, Rose, & Kaschak, 1989;
Newman, Lynch, Smith, & Cell,
1991; Rose, Baigis-Smith, Smith,
& Newman, 1990). In a study con-
ducted in a New Jersey public
health center (Baigis-Smith et al.,
1989), a portable EMG perineome-
ter that provided feedback via the
use of lights was used to provide
biofeedback-assisted PFMT to 54
subjects, men and women, ages 60
to 86 years, with UI (Baigis-Smith
et al., 1989). In addition to PFMT,
subjects were also taught BT. The
mean reduction in incontinence
episodes was 78% from baseline,
with 50% of subjects showing a
90% improvement. A second
study (Rose et al., 1990) reported
on 21 elderly homebound
patients who were visited in their
home and treated with PFM exer-
cises and BF. Improvement in
weekly incontinent episodes was
78% from baseline.
Use of Pelvic Floor Muscle
Electrical Stimulation
Pelvic floor muscle electrical
stimulation (PFMES) involves the
application of low-grade electrical
stimulation to the PFM. Electrical
stimulation can activate inhibito-
ry nerve fibers, causing reflex
inhibition of the detrusor muscle,
thereby preventing bladder over-
activity (Newman & Wein, 2009).
There is also an effect on the stri-
ated PFM, causing hypertrophy of
the muscles by recruiting the PFM
fast-twitch fibers. The delivery of
the electric current to the PFM is
via vaginal or rectal sensors, and
the technique is often used in con-
junction with biofeedback (Starr
et al., 2013). Clinicians who spe-
cialize in pelvic floor dysfunction
use PFMES as adjunct treatment
to:
• Assist with identification
and isolation of PFM.
• Increase PFM strength.
• Decrease unwanted or unin-
hibited detrusor muscle con-
tractions.
• Assist with normalizing PFM
relaxation.
Summary
This article is a short review
of clinical application of biofeed-
back therapy in a pelvic floor
muscle rehabilitation program.
Clinicians providing this treat-
ment should understand spe -
cifics about pelvic floor muscle
Figure 5.
IVS Vaginal Sensor
Source: T-Doc. Used with permission.
continued on page 202
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without the written permission of the Society of Urologic Nurses and Associates. doi 10.7257/1053-816X.2014.34.4.193
UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4 201
Figure 6.
Case Studies
Case Study #1
J.O. is a 56-year-old female diagnosed with mul-
tiple sclerosis eight years ago. She was referred to
urology because of lower urinary tract symptoms,
including incomplete bladder emptying and urinary
tract infections. Patient’s most bothersome lower uri-
nary tract symptoms (LUTS) included urgency and
frequency with incontinence. She reported poor blad-
der emptying, decreased force of stream, and a diffi-
cult time initiating voiding. She strains to void.
Urodynamics studies indicated detrusor overactivity
with incontinence, EMG activity indicated poor
dyssynergia. Post-void residual was 450 mLs. Since
then, she has been performing self-catheterization at
least three times per day; catheterization volumes
average 350 mLs. Cathe terization has not changed
her LUTS of urgency and frequency. PFM assess-
ment indicated fair sensation, no discomfort, and lev-
ator ani palpation bilaterally, weak muscle contraction
with length of fingers lifted and drawn in. Contraction
duration was four seconds. Slight discomfort was
noted during digital examination; it appeared as
though muscle spasm was present. The patient pur-
chased the vaginal sensor for use at weekly biofeed-
back (BF) sessions. Initial EMG BF session noted ele-
vated muscle relaxation with generalized weakness.
At this visit, BF was used solely to allow the patient to
isolate muscle and to concentrate on relaxation. The
patient was primarily prescribed a stepped strength-
ening exercise program with emphasis on muscle
relaxation. Over a two-month period during the BF
session, the patient worked to increase muscle
strength and endurance. She continued on the pre-
scribed muscle strength training and used muscle
relaxation to aid voiding. By four months, the patient’s
urgency and voiding initiation improved. By five
months, the patient was only self-catheterizing once a
day because volumes had decreased to less than
200 mLs. She also stopped straining to void. EMG BF
indicated very little muscle spasm, and muscle
strength had increased by 40%.
Case Study #2
S.A. is a 64-year-old female with a history of
adenosquamous carcinoma of the uterus with inva-
sion. She underwent abdominal hysterectomy with
subsequent vaginal chemotherapy and pelvic radia-
tion. The patient presented with both urinary and anal
incontinence. The patient was told that cancer treat-
ments resulted in PFM weakness causing her bowel
and bladder symptoms. The patient also had urinary
and bowel urgency and frequency. Her most bother-
some symptoms were urgency; she lacked “control”
and feared being in a situation where she would not
be able to manage urinary and/or stool leakage. The
patient was on a prescribed bowel regimen to keep
stools soft, but she would have multiple daily bowel
movements over a very short period of time.
Endoscopy indicated that the patient had irritable
bowel symptoms with alternating constipation and
diarrhea, and the rectal scan revealed decreased
sphincter tone. She kept daily records of bladder and
bowel symptoms. The patient’s oncologist recom-
mended the patient undergo BF therapy, but she
delayed seeking treatment because of ongoing can-
cer treatments and a generalized sense of hopeless-
ness and embarrassment. Physical examination
reviewed normal post-void residual and significant
vaginal stenosis. Levator ani was palpated bilaterally
with poor contraction of only one-second duration.
Rectal sphincter tone was weak, and there was dis-
comfort with the digital rectal examination. Because of
the vaginal stenosis and rectal discomfort, the URway
Intravaginal EMG Sensor®was used to provide BF. At
the first session, the patient exhibited a very weak
muscle with little sensation of contraction; the biofeed-
back EMG graph indicated a weak contraction of 2.0
to 2.5 microvolts. PFMES was attempted but was
uncomfortable for the patient, so it was abandoned.
For two months, the patient was seen weekly and
received a 30-minute BF session. At the end of the
two months, muscle sensation had improved, and
strength had increased. At eight months, EMG testing
indicated increased muscle strength (averaged 8.5
microvolts), normal relaxation (< 1 microvolt), and
ability to sustain contract for eight to 10 seconds with-
out accessory muscle contraction. The first symptoms
to improve were urinary frequency and UI. The patient
felt her rectal muscle becoming stronger, allowing her
to use the muscle to suppress fecal urgency and pre-
vent fecal leakage. There were ongoing instances
where the patient reported being able to retain stool,
such as when bending over, a cause of incontinence
prior to starting the BF program. Stools also became
more formed, aiding in control. The patient continues
to use the intravaginal sensor as a training or resistive
device for exercising at home.
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202 UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4
anatomy, examination, measure-
ment through EMG or manome-
try, and understand the parame-
ters for providing appropriate
feedback. Two case studies
where biofeedback was integral
to successful pelvic floor muscle
rehabilitation are included (see
Figure 6).
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Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the Society of Urologic Nurses and Associates. doi 10.7257/1053-816X.2014.34.4.193