Urinary incontinence remains one of the most common problems in modern urogynecology. According to published data, urinary incontinence is observed in approximately 24% of women between the ages of 30 and 60 and in more than 50% of women over 60.

Recently, urinary disorders have received greater attention. This is due to the pronounced negative consequences of this pathology on a woman’s quality of life, resulting in reduced social interaction, depression, neuroses and sexual dysfunction.

The International Continence Society (ICS) defined the disorder as «involuntary loss of urine that is a social or hygienic problem» accompanied by signs of uncontrollable release of urine. 

As of today, there are three general types of urinary incontinence: 

1. Stress incontinence is an involuntary loss of urine when the intravesical pressure exceeds the maximal urethral pressure in the absence of detrusor contractions. Stress urinary incontinence (SUI) is a generally accepted term, where «stress» refers to all factors triggering a sudden increase in intra-abdominal pressure, such as coughing, laughing, sneezing, heavy lifting, running or changing from a horizontal position to a vertical position. It is frequently referred to as effort incontinence. 
2. Urge urinary incontinence (UUI) is characterized by a sudden urge to urinate followed by involuntary loss of urine. A distinguishing feature of urge incontinence is the integrity of the sphincters and normal urethral resistance. 
3. Mixed urinary incontinence (MUI) is a combination of urge and stress incontinence symptoms.

According to various literature, the most significant risk factors for urinary incontinence in women are: 

• pregnancy and childbirth (especially traumatic); 
• genetics (indications of connective tissue dysplasia); 
• neurological disorders (cerebral ischemia, stroke, multiple sclerosis, Parkinson’s disease, injuries, tumors, brain or spinal cysts); chronic cystitis, urethritis; 
• gynecological or endourethral surgery; 
• estrogen deficiency;
• diabetes mellitus, obesity.

The choice of treatment method depends on the type and severity of the disorder.

One modern and effective method for treating different types of urinary incontinence is biofeedback (BFB) training of the pelvic floor muscles, which uses the compensatory reserves of the human body.

The biofeedback method started being successfully applied in gastroenterology and urogynecology in different countries in the 1970s. Subsequently, there was a development of procedures for treating eye and nerve diseases as well as for orthopedic rehabilitation. Currently, the biofeedback method is widely used in many countries, including Russia.

The basis of modern urinary incontinence treatment with the Callibri BeFit PRO biofeedback system is a program of pelvic floor muscle exercises aimed at improving the tone of the muscles and developing strong reflexive contraction in response to a sudden increase in intra-abdominal pressure. 

The main challenge is the inability of 40–60% of patients to contract the pelvic floor muscles separately, especially since these muscles are anatomically hidden. Instead of activating the pelvic floor muscles, patients usually contract the antagonist muscles, namely, the abdominal, gluteal and hip muscles, thereby increasing the intra-abdominal pressure even more. It is evident that such exercises are not only ineffective, but may also exacerbate urinary incontinence. 

The goal of training different pelvic muscle groups separately can be achieved more effectively using the biofeedback method with the assistance of the Callibri BeFit PRO device, as the patient receives visual information, which allows her to ensure the correct performance of the exercises.

The clinical rationale for this method is twofold. First, there is continuous interaction between the patient and physician, and second, the tone of the pelvic floor muscles is quantitatively assessed during the exercises using special intracavitary electrodes and sensors that generate an electromyogram of these muscles.

Thus far, Callibri BeFit PRO, a modern computer-based biofeedback system for pelvic floor muscle training, has had an excellent track record among similar products on the Russian market. 

OPERATING PRINCIPLE OF BIOFEEDBACK SYSTEM

1. Special vaginal or rectal sensors record changes in the tone of the working pelvic floor muscles and transform them into electromyographic (EMG) signals.
2. The EMG signals are amplified and displayed on a screen as graphical images.
3. At the same time, Callibri’s miniature sensors simultaneously record contractions of the abdominal and gluteal muscles and send the signal to a PC program. 
4. Thus, the patient and medical specialist can verify whether the exercises are performed correctly. 

The duration of a daily session varies from 15 to 20 minutes. The course of treatment consists of approximately 15 sessions. When necessary, the clinical effect can be reinforced by repeating biofeedback therapy 2–3 times per year.

The effectiveness of the biofeedback method has been demonstrated in multiple clinical trials.

An extensive analysis of clinical trials indicates that systematic biofeedback training of the pelvic floor muscles performed under the supervision of medical staff resulted in recovery for 20% and improvement for 47% (p = 0.01) of women with different types of urinary incontinence compared with patients who did not receive treatment.

Analysis of published data identified the following indications for biofeedback therapy in urogynecology:

• stress urinary incontinence of low severity;
• stress urinary incontinence of any severity if surgical intervention is not feasible due to a co-occurring extragenital pathology;
• overactive bladder with or without urge urinary incontinence;
• mixed urinary incontinence;
• pelvic relaxation or pelvic floor dysfunction;
• sexual dysfunction in women (less intense orgasms, anorgasmia, vaginismus);
• prevention of postpartum urinary incontinence following childbirth complications or injuries.

CONTRAINDICATIONS

1. This type of therapy does not have absolute contraindications. 
2. Relative contraindications include two groups of causes that are generally classified as either a physical or psychological inability of the patient to perform the task:

• disorders that make it essentially impossible to achieve a positive result due to anatomical changes of the pelvic organs, such as malignant tumors or pronounced infravesical obstruction; 
• local acute infectious or inflammatory diseases that preclude the use of rectal or vaginal sensors, such as vaginitis or vulvovaginitis; 
• severe decompensated comorbidities (unstable angina, previous myocardial infarction, severe disturbance of cerebral blood flow, thyrotoxicosis), hyperthermia-related infections or injuries;
• age younger than 4–5 years, when the patient is unable to understand the task at hand due to underdeveloped cognitive abilities;
• old age accompanied by the loss of mental capacity; 
• psychiatric disorders; 
• lack of motivation or dependency status of the patient unwilling to participate in treatment.

CONCLUSION

1. The biofeedback method is widely used for all types of urinary incontinence as either stand-alone therapy for SUI and pelvic floor dysfunction or in combination with pharmacological treatment for UUI. 
2. This type of therapy has the advantage of being nosotropic. The biofeedback effect comprises, on the one hand, the possibility of increasing the activity and contractility of the external urethral sphincter and the achievement of its muscular hypertrophy with targeted and deliberate training, and, on the other hand, improved blood circulation and trophic processes in the lesser pelvis, as demonstrated by results of three-dimensional ultrasonography. Moreover, voluntary contractions of the external anal and urethral sphincters result in reflexive inhibition of detrusor contractile activity, forming the so-called anal and urethral detrusor reflexes. This explains the high effectiveness of biofeedback therapy for patients with urge urinary incontinence. 
3. Other important advantages of the biofeedback method are:

• minimal invasiveness and absence of pain;
• absence of side effects;
• opportunity to combine it with any other treatment method (except for electrostimulation);
• ability to use any other treatment method in the future.

Referenced literature:

1. Ivanovskij, Yu.V., Smirnov, M.A. Morfo-funkcional'nye obosnovanija primenenija metoda biologicheskoj obratnoj svjazi v urologii i proktologii [Morphofunctional validation of using biofeedback in urology and proctology]. Biologicheskaja obratnaja svjaz’ [Biofeedback]. 2000; 2: 2-9. [in Russian]
2. Smirnov, M.A., Parshina T.V. Primenenie metoda biologicheskoj obratnoj svjazi – put' k uspehu v reabilitacii pacientov s nederzhaniem mochi [Application of the biofeedback method — a path to success in rehabilitation of patients with urinary incontinence]. Biologicheskaja obratnaja svjaz’ [Biofeedback]. 2000; 2: 10–17. [in Russian]