Voiding Disorders Research Articles

Psychosomatic urology: how to treat chronic urological diseases

In specialist urology clinics, 50 - 70 % of patients have chronic urological diseases such as recurrent urinary tract infections, a somatoform overactive bladder, adult and infantile enuresis, a chronic pelvic pain syndrome, and the psychosomatic form of post-prostatectomy incontinence. The 12-month prevalence of psychological disorders in the general adult population is 28 % 1. As many as 20 % of children and adolescents are found to have psychological abnormalities 2. These are frequently accompanied by somatoform symptoms, often consisting of a psychosomatic voiding disorder with a consecutive complex pelvic floor dysfunction 3 4 5 6. Most patients report a long history of suffering as both the functional nature and the psychosocial stress causing and perpetuating the discomfort have remained unrecognised. Therefore, most patients have undergone various treatment attempts that were not indicated and thus unsuccessful and maybe even associated with complications. This tends to further increase the somatisation and the symptoms.To treat the root cause, it is necessary to eliminate the underlying psychosomatic voiding disorder and pelvic floor dysfunction. This requires a multimodal treatment approach such as PELVICFIT®, which combines a body-oriented training based on progressive muscle relaxation, training of body perception, and medical psychotherapy. This is crucial because patients must learn how to (re)gain control of the external urethral sphincter, achieve a physiological voiding behaviour, and reduce psychosocial stress in order to successfully treat the chronified symptoms 7 8 9.

Toilet training and parental help-seeking behavior toward elimination disorders: Our experience in a semi-urban setting

Introduction: Elimination disorders consist of enuresis and encopresis. When a child fails to successfully achieve toilet training by the age of five and has repeated voiding of urine on the bed or clothing at least twice per week for at least 3 consecutive months it is called enuresis; while bowel continence if not achieved by age 4 years, is encopresis. This study seeks to determine parental/caregiver concerns and help-seeking behaviors toward elimination disorders. Materials and Methods: This study was cross-sectional and was conducted over a 3-month period from January 2017 to March 2017. Convenience sampling method was adopted, and pretested researchers-administered questionnaires were used. Results: Two hundred individuals were recruited consisting of 104 (52%) males and 96 (48%) females with a male-to-female ratio of 1.1:1. About 194 (97%) of the respondents were aware of elimination disorders, 62 (31.0%) of them reported elimination disorder occurred in their wards, only 24.2% of the caregivers had sought for medical treatment for elimination disorder. Majority of the caregivers did not know the cause of elimination disorder, but 2% of them believed evil spirits were responsible for elimination disorders. Enuresis was the most commonly reported elimination disorder and most occurred at night (80.6%), and none had isolated encopresis. Ethnicity and educational qualification of respondents had no relationship with their help-seeking behavior toward elimination disorder ([Fishers' exact test = 11.337, P = 0.023] and [Fishers' exact test = 8.074, P = 0.089]). Conclusion: Elimination disorders were prevalent; however, few caregivers seek for medical help/treatment, and their help-seeking behavior was not influenced by their ethnicity or educational qualification.

Reliability and Validity of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version, DSM-5 November 2016-Turkish Adaptation (K-SADS-PL-DSM-5-T)

The aim of this study was to evaluate the reliability and validity of the Schedule for Affective Disorders and Schizophrenia for School-Age ChildrenPresent and Lifetime Version, DSM-5 November 2016 -Turkish Adaptation (K-SADS-PL-DSM-5-T). METHOD: A total of 150 children and adolescents between 6 and 17 years of age were assessed with K-SADS-PL-DSM-5-T. The degree of agreement between the DSM-5 criteria diagnoses and the K-SADS-PL-DSM-5-T diagnoses were considered as the measure of consensus validity. In addition, concurrent validity was examined by analyzing the correlation between the diagnoses on K-SADS-PL-DSM-5-T and relevant scales. Interrater reliabilities were assessed on randomly selected 20 participants. Likewise, randomly selected 20 other participants were interviewed with K-SADS-PL-DSM-5-T three weeks after the first interview to evaluate test-retest reliability. RESULTS: The consistency of diagnoses was almost perfect for eating disorders, selective mutism and autism spectrum disorder (κ=0.92-1.0), substantial for elimination disorders, obsessive-compulsive disorder, oppositional defiant disorder, generalized anxiety disorder, social anxiety disorder, depressive disorders, disruptive mood dysregulation disorder and attention deficit hyperactivity disorder (κ=0.67-0.80). Interrater reliability was perfect for selective mutism (κ=1.0), substantial for oppositional defiant disorder, disruptive mood dysregulation disorder, attention deficit hyperactivity disorder, depressive disorders and social anxiety disorder (κ=0.63-0.73). Test-retest reliability was almost perfect for autism spectrum disorder (κ=0.82), substantial for attention deficit hyperactivity disorder, oppositional defiant disorder, disruptive mood dysregulation disorder, depressive disorders and generalized anxiety disorder (κ=0.62-0.78). CONCLUSION: The results of this study show that the K-SADS-PL-DSM-5-T is an effective instrument for diagnosing major childhood psychiatric disorders including selective mutism, disruptive mood dysregulation disorder and autism spectrum disorder which have recently been added to the schedule.

Psychiatric morbidity among school students

Background: Psychiatric morbidity represents most important problem among all children including school going children worldwide, prevalence of psychiatric disorders among children has been reported to be 14-20% across various studies Child and adolescent population are susceptible for psychiatric morbidity; we plan to evaluate the prevalence of psychiatric morbidity among school going students of class 8 and 9.Methods: It was a cross sectional observational study. Study was conducted in two steps, firstly screening was done with GHQ-12 along with socio-demographic data sheets, on second step students scoring above GHQ cutoff score were interviewed by consultant psychiatrist and diagnosis was made as per ICD 10 DCR.Results: A total of 128 students, consisting of 73 male and 55 females (57% and 43% respectively) with mean age of 13.02±0.58 years participated. With GHQ screening 38 students scored above the cut-off marks and finally 6 children were diagnosed as generalized anxiety disorder, 6 as Depression, 1 as elimination disorder (nocturnal enuresis), 3 as separation anxiety, 4 cases of OCD, and 2 cases of Panic disorder totaling to 21 (16.41%) students.Conclusions: This study finds a prevalence of 16.41% of the psychiatric morbidity among school students.

Trastornos de la eliminación urinaria en el paciente mayor

Urinary elimination disorders, essentially represented by the onset of lower urinary tract symptoms (LUTS), comprise one of the most relevant medical/surgical problems in the elderly patient, and have a negative effect on quality of life and considerable impact on different areas. However, many patients are not diagnosed because they do not seek medical advice for their problem, considering it a trivial disorder, inherently associated with ageing and for which there is no effective treatment. Due to the above, the singularity of the elderly patient must be referred to within their clinical, social and health context, since this is an age group that often presents with latent clinical symptoms, atypical disease presentations, polymedication and a significant comorbidity load. Only thus will it be possible to appropriately establish the limit between their clinical-pathological characteristics and the condition of biological ageing.

Further Evidence of Morbidity and Dysfunction Associated With Subsyndromal ADHD in Clinically Referred Children.

While the diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) have evolved over the years, some children with impairing ADHD symptoms fail to meet the full diagnostic threshold for the disorder. The main aim of this study was to evaluate the morbidity and dysfunction of subsyndromal ADHD in the clinical setting. Subthreshold and full ADHD subjects were derived from consecutive referrals (n = 2,947) to a pediatric psychopharmacology program at a major academic center. Subjects were diagnosed with subthreshold ADHD if they met at least 1 of the following criteria: (1) their age at onset for ADHD was ≥ 7 years; (2) they had ≥ 5 but < 8 ADHD symptoms using the DSM-III-R or ≥ 4 but < 6 ADHD inattentive or hyperactive/impulsive symptoms using the DSM-IV. Healthy controls were derived from 2 identically designed longitudinal case-control studies of youth with and without ADHD. Psychiatric assessments relied on clinical structured interviews and measures of psychopathology, social functioning, cognitive ability, and academic achievement. Of the 1,931 children diagnosed with ADHD, 140 (7%) were diagnosed with subthreshold ADHD. 48% of subthreshold ADHD subjects had an age at onset ≥ 7 years, and 73% had insufficient symptoms. Reanalysis of findings using DSM-5 criteria showed that only 21% of our subthreshold ADHD subjects would have met DSM-5 criteria based on age at onset of < 12 years, while 79% would have maintained their subthreshold diagnoses. Subjects with subthreshold ADHD differed from controls in the mean number of comorbid disorders; rates of mood, anxiety, and elimination disorders (all P < .001) and substance use disorders (P < .05); scores on all Child Behavior Checklist clinical and social functioning scales; scores on 7 of the 10 Social Adjustment Inventory for Children and Adolescents scales; rates of requiring extra help in school and being placed in a special class; and scores on 4 of the 5 Wechsler Intelligence Scale for Children-Revised Version subscales (excluding Digit Span) as well as in Freedom from Distractibility Index score (P < .001). Subthreshold and full ADHD subjects had similarly elevated Global Assessment of Functioning scores versus controls (P < .001), but subjects with subthreshold ADHD had fewer perinatal complications and better family functioning scores and were more likely to be female and older and to come from families of higher socioeconomic status than subjects with full ADHD. Clinically referred children failing to meet full-threshold diagnosis for ADHD due to either insufficient symptoms or later age at onset have patterns of clinical features highly similar to those with the full syndrome. These results extend to previously reported findings in nonreferred samples documenting the high morbidity and disability associated with subthreshold ADHD.

Особенности симптомов нижних мочевыводящих путей у мужчин Московского региона. Результаты эпидемиологического исследования

Voiding disorders in men are manifested by various symptoms associated with impairment of the urinary flow along the urinary tract and worsening of the urinary bladder storage function. There is a considerable lack of data on the prevalence of LUTS, their severity, and correlation with data from objective studies in men in the Russian Federation in general and in the Moscow region in particular. A prospective multicenter epidemiological study "Specific Features of Lower Urinary Tract Symptoms in Men Living in the Moscow Region" was conducted based on data acquired from April 1 to May 31, 2017 by an anonymous survey of 525 men (mean age 64.2+/-9.93 years old), residing in Moscow and presenting with complaints of urination disorders. The respondents answered questions of a specially developed 140-item questionnaire. All demographic and medical information was taken into account, including concomitant diseases and ongoing therapy. The patients filled out the IIEF, I-PSS, QoL, and AMS (Aging Male Screening) questionnaires. Analysis the I-PSS scores showed that symptoms of the emptying phase predominated over the symptoms of the filling phase in all age groups. The most frequent complaints were "frequent urination" and "weak urine stream". Forty and 30% of respondents had moderate and severe LUTS, respectively. The remaining 30% of men had mild LUTS. Prostate volume was significantly greater than that reported in similar studies conducted in Asia, Europe and North America (mean 55.27 cm3). The level of total prostate-specific antigen (PSA) was known in 98.8% of patients over the age of 50 and averaged 3.87+/-4.41 ng/ml. The mean age at the first testing for total PSA in Moscow is 56.7+/-9.0 years. This study is the first epidemiological study of this scale and focus. Its findings can be used to compose a "portrait" of a standard patient and identify patterns that limit the extrapolation of international epidemiological studies to the population of Russian patients. It seems necessary to develop an updated LUTS management strategy, taking into account the identified national characteristics.

Associated Factors of Primary Enuresis Among Children and Adolescents in Amhara Region, Northwest, Ethiopia, 2016

Introduction: Primary enuresis is the most common elimination disorder in children and adolescents aged 5-17 years worldwide. It often results in psychological, social, and financial problems. This disorder is understudied in less affluent countries. Objective : This study was done to assess the prevalence and associated factors of primary enuresis in children and adolescents in Bahir-Dar Town, Ethiopia. Materials and Methods : This cross-sectional community-based study was conducted in children and adolescents from May to July 2016. A total of 1547 subjects were selected using a multistage sampling technique. Data were collected using DSM-5 criteria and the Strengths and Difficulties Questionnaire (SDQ). Results: A total of 1520 participants were involved in the study with a response rate of 98.25%. The prevalence of primary enuresis was 8.6%. Age range 5-8 years [AOR=10.35, 95% CI (3.468, 30.875)], deep sleep [AOR=2.18, 95% CI (1.192, 3.983)], and conduct problems [AOR=5.98, 95% CI (3.341, 10.694)] were significantly associated with primary enuresis. Conclusions: Factors that affect primary enuresis are young age, deep sleep, snoring during sleep, sleeping more than two hours a day, and conduct problems. Therefore, special attention should be given to children and adolescents about primary enuresis prevention. Keywords : Primary enuresis; Child; Adolescent

Identification of risk for neonatal haemolysis.

To identify neonates at risk of haemolytic hyperbilirubinaemia through near-concurrent measurements of total serum/plasma bilirubin (TB) or transcutaneous bilirubin (TcB) and end-tidal breath carbon monoxide (CO), corrected for ambient CO (ETCOc), an index of bilirubin production and haemolysis. Paired TB/TcB (mg/dL) and ETCOc (ppm) measurements were obtained in newborns (n = 283) at 20 to <60 hours of age in five nurseries. TB/TcB values were assigned TB/TcB percentile risk values using the Bhutani hour-specific nomogram. In infants having two serial TB/TcB measurements (n = 76), TB rate of rise (ROR, mg/dL/h) was calculated. For the entire cohort (n = 283), 67.1% and 32.9% had TB/TcB<75th and ≥75th percentile, respectively. TB/TcB (5.79 ± 1.84 vs 9.14 ± 2.25 mg/dL) and ETCOc (1.61 ± 0.45 vs 2.02 ± 1.35 ppm, p = 0.0002) were different between the groups. About 36.6% of infants with TB/TcB ≥75th percentile had ETCOc ≥ 2.0 ppm. In the subcohort of infants with serial TB/TcB measurements (n = 76), 44.7% and 55.3% had TB/TcB<75th and ≥75th percentile, respectively. TB/TcB (5.28 ± 1.97 vs 9.53 ± 2.78 mg/dL), ETCOc (1.72 ± 0.48 vs 2.38 ± 1.89 ppm, p = 0.05) and TB ROR (0.011 ± 0.440 vs 0.172 ± 0.471 mg/dL/h) were different between the groups. The combined use of TB/TcB percentile risk assessments and ETCOc measurements can identify infants with haemolytic hyperbilirubinaemia. The addition of TB ROR can identify those infants with elimination disorders.

Familial reactive perforating collagenosis in two siblings

Reactive perforating collagenosis (RPC) is a rare form of transepithelial elimination disorder, in which genetically altered collagen is extruded through the epidermis. Of the acquired and inherited form, the latter is extremely rare. Here, we present two cases of inherited form of RPC in siblings aged 4 and 7 years presented with a history of itchy raised lesions of 9 months and 3 years duration, respectively. Dermatological examination revealed multiple papules with a central keratotic plug distributed mainly over face and extensors of upper and lower extremities. Koebnerization was present. Skin biopsy revealed perforating collagen bundles in the upper dermis and epidermis.

Immigration-related mental health disorders in refugees 5-18 years old living in Turkey.

PurposeThis study assessed early-onset psychiatric disorders and factors related to these disorders in a group of refugee children after immigration due to war.Materials and methodsThis study was conducted between January 2016 and June 2016. Clinical interviews were conducted with 89 children and their families, and were performed by native speakers of Arabic and Persian who had been primarily educated in these languages and were living in Turkey. A strengths and difficulties questionnaire (SDQ) that had Arabic and Persian validity and reliability was applied to both children and their families. Independent variables for cases with and without a psychiatric disorder were analyzed using the χ2 test for categorical variables, Student’s t-test for those that were normally distributed, and Mann–Whitney U-test for data that were not normally distributed. Data that showed significant differences between groups who had a psychiatric disorder and on common effects in emerging psychiatric disorders were analyzed through binary logistic regression analysis.ResultsA total of 89 children and adolescents were interviewed within the scope of the study. The mean age of cases was 9.96±3.98 years, and 56.2% (n=50) were girls, while 43.8% (n=39) were boys. Among these children, 47 (52.8%) had come from Syria, 27 (30.3%) from Iraq, 14 (15.7%) from Afghanistan, and 1 (1.1%) from Iran. A psychiatric disorder was found in 44 (49.4%) of the children. A total of 26 children were diagnosed with anxiety disorders, 12 with depressive disorders, 8 with trauma and related disorders, 5 with elimination disorders, 4 with attention deficit/hyperactivity disorder, and 3 with intellectual disabilities. It was determined that seeing a dead or injured person during war/emigration and the father’s unemployment increased the risk of psychopathology. The OR was 7.077 (95% CI 1.722–29.087) for having seen a dead or injured individual and 4.51 (95% GA 1.668–12.199) for father’s employment status.ConclusionWithin the context of war and emigration, these children try to cope with the negative circumstances they experience prior to migration, as well as the despair they see their parents experience.

De l’urologie pédiatrique à l’urologie adulte, quelle prise en charge de l’adolescent ? État des lieux d’une consultation de transition en urologie

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The Developmental Difficulties for Children With Cloacal Malformation and Their Families

Cloacal malformation(CM) is a congenital disorder in which the urinary, genital, and digestive tracts drain through a common orifice. Treatment starts in infancy and involves repeated surgical repair, but improving quality of life continues to be problematic after surgery due to complications such as elimination disorders. To elucidate the issues encountered by patients with CM and their families in daily life, and the actual developmental difficulties faced by these patients. Semi-structured interviews were held with the participants. The participants were 3 females with CM, and 5 parents with children who had received the same diagnosis. All parents had received an explanation of the treatments performed when their child was an infant, but that they had not received a detailed explanation of CM itself. To prepare for entering their child into nursery school, parents approached the nursery school suggesting that they would look after their child at home during episodes of incontinence. During childhood, patients were not told the proper name for their condition even after they entered high school. Patients said that although their situation caused psychological distress, they were eager to learn the name of their condition. The patient in her 20s remembered wanting to die on a daily basis during adolescence. The parents were concerned about how and whether to discuss sex education with their children and some parents avoided talking to their child about sex altogether. Patients noted worry about matters such as relationships with partners, a lack of people whom they could approach for advice, and their prospects for future pregnancies.

Urothelial Tight Junction Barrier Dysfunction Sensitizes Bladder Afferents.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic voiding disorder that presents with pain in the urinary bladder and surrounding pelvic region. A growing body of evidence suggests that an increase in the permeability of the urothelium, the epithelial barrier that lines the interior of the bladder, contributes to the symptoms of IC/BPS. To examine the consequence of increased urothelial permeability on pelvic pain and afferent excitability, we overexpressed in the urothelium claudin 2 (Cldn2), a tight junction (TJ)-associated protein whose message is significantly upregulated in biopsies of IC/BPS patients. Consistent with the presence of bladder-derived pain, rats overexpressing Cldn2 showed hypersensitivity to von Frey filaments applied to the pelvic region. Overexpression of Cldn2 increased the expression of c-Fos and promoted the activation of ERK1/2 in spinal cord segments receiving bladder input, which we conceive is the result of noxious stimulation of afferent pathways. To determine whether the mechanical allodynia observed in rats with reduced urothelial barrier function results from altered afferent activity, we examined the firing of acutely isolated bladder sensory neurons. In patch-clamp recordings, about 30% of the bladder sensory neurons from rats transduced with Cldn2, but not controls transduced with GFP, displayed spontaneous activity. Furthermore, bladder sensory neurons with tetrodotoxin-sensitive (TTX-S) action potentials from rats transduced with Cldn2 showed hyperexcitability in response to suprathreshold electrical stimulation. These findings suggest that as a result of a leaky urothelium, the diffusion of urinary solutes through the urothelial barrier sensitizes bladders afferents, promoting voiding at low filling volumes and pain.

Residual Urine Measurement in Children with Voiding Disorders: Comparison between Ultrasonographic Bladder Scanning and Catheterization

Residual Urine Measurement in Children with Voiding Disorders: Comparison between Ultrasonographic Bladder Scanning and Catheterization

Dysfunctional Voiding in Pediatrics: A Review of Pathophysiology and Current Treatment Modalities.

In Dysfunctional Voiding (DV), the external urethral sphincter or pelvic diaphragm (consisting of striated muscle) contracts during voiding, contrary to normal physiological mechanism. In Flowmetry plus pelvic Electromyography (EMG), the perineal surface electrodes will show a persistent activity during voiding. The cause is believed to be the persistence of an immature bladder control. The overall prevalence of DV is estimated between 7 and 11% of girls of school age. Symptoms of DV comprise a range of symptoms, deriving from outlet obstruction, incomplete voiding and elevated Post Micturition Residual (PMR): from daytime urine leaks, nocturnal enuresis, Urinary Tract Infections (UTI), or Vesicoureteral reflux (VUR), to the final decompensation of upper urinary tract in extreme cases. The literature reflects a high prevalence of constipation among these patients: between 33 and 56% of dysfunctional voiders are constipated. Initially, therapy of functional voiding disorders such as DV, comprises a series of fundamental principles called Urotherapy or voiding re-education. Currently, Urinary animated Biofeedback (Bfb) is the treatment modality of choice. This therapy discloses patients their own physiological and muscular mechanisms. Majority of the studies on Bfb efficacy reflect an improvement/ cure rate of around 70-80%. Initial flowmetric improvement followed by symptom relief or clinical improvement as the Bfb sessions continue, is likely to occur. It has been observed that there are two variables associated with clinical success of Bfb in DV syndrome: the absence of PMR at the end of treatment and an adequate or even aggressive constipation management.

Evidence-Based Psychosocial Treatments for Pediatric Elimination Disorders

Pediatric elimination disorders are common in childhood, yet psychosocial correlates are generally unclear. Given the physiological concomitants of both enuresis and encopresis, and the fact that many children with elimination disorders are initially brought to their primary care physician for treatment, medical evaluation and management are crucial and may serve as the first-line treatment approach. Scientific investigation on psychological and behavioral interventions has progressed over the past couple of decades, resulting in the identification of effective treatments for enuresis and encopresis. However, the body of literature has inherent challenges, particularly given the multicomponent nature of many of the treatment packages. This review identified 25 intervention studies—18 for nocturnal enuresis and 7 for encopresis—over the past 15 years and classified them according to the guidelines set forth by the Task Force on the Promotion and Dissemination of Psychological Procedures. For nocturnal enuresis, the urine alarm and dry-bed training were identified as well-established treatments, Full Spectrum Home Therapy was probably efficacious, lifting was possibly efficacious, and hypnotherapy and retention control training were classified as treatments of questionable efficacy. For encopresis, only two probably efficacious treatments were identified: biofeedback and enhanced toilet training (ETT). Best practice recommendations and suggestions for future research are provided to address existing limitations, including heterogeneity and the multicomponent nature of many of the interventions for pediatric elimination disorders.

Voiding disorders in children

Voiding disorders in children are common. They are manifested by dysfunction in phase of filling and/or emptying the bladder and by bowel motility disorders. Functional voiding disorders are associated with recurrent urinary tract infections, vesicoureteral reflux, reflux nephropathy and constipation. According to the International Children's Continence Society the main clinical symptoms and causes of urinary incontinence in children are nocturnal enuresis and different forms of dysfunction of the lower urinary tract: overactive bladder, dysfunctional voiding or underactive bladder.

Urethral Syndrome and Urethral Pain: Do we Treat People or Diagnoses?

The urethral syndrome with urethral pain and bladder voiding disorders is a diagnosis of exclusion. Possible aetiologies are diverse and include organic, functional and inflammatory pathologies of the urethra. Infections, inflammation of the paraurethral glands, spasms of the sphincter muscle and/or of the pelvic floor muscles, oestrogen deficiency, trauma, neuropathies, hypersensitivity and psychosomatic issues have been investigated as possible causes.Patients with urethral syndrome must be viewed, evaluated and treated holistically. They need a lot of time and attention during their evaluation and treatment. It is now well known that psychosocial aspects are involved in the development of many somatic conditions and may have a crucial impact on the course of a disease. This needs to be taken into consideration during the treatment process.

Biofeedback for Pelvic Muscle Dysfunction

Biofeedback for pelvic floor muscle dysfunction provides a practical and effective intervention for elimination disorders. Dysfunction in the pelvic floor muscles can affect bladder and bowel function and can cause pelvic pain. According to the National Association of Continence, there are 25 million Americans affected by bladder or bowel incontinence. Surface electromyographic (sEMG) sensors monitor the electrical activity of the pelvic floor muscles. Additional muscle co-contractions of the obturator internus, hip adductors, and transverse abdominis can facilitate improvements in symptoms affected by pelvic floor dysfunction. Pelvic floor therapy incorporates urge reduction techniques and functional control strategies. Dietary and lifestyle recommendations are also provided. The Biofeedback Certification International Alliance (BCIA) is the primary certifying body in the fields of biofeedback and neurofeedback. BCIA has a Blueprint of Knowledge specific for certification in pelvic muscle dysfunction biofeedback (PMDB). The Blueprint outlines the fundamental science, history, and theory of sEMG biofeedback as used for elimination disorders and chronic pelvic pain. You can find more information on PMDB at www.bcia.org.