title: Brain Mechanisms Underlying Urge Incontinence and its Response to Pelvic Floor Muscle Training.
abstract: OBJECTIVE
  Urge urinary incontinence is a major problem, especially in the elderly, and to our knowledge the underlying mechanisms of disease and therapy are unknown. We used biofeedback assisted pelvic floor muscle training and functional brain imaging (functional magnetic resonance imaging) to investigate cerebral mechanisms, aiming to improve the understanding of brain-bladder control and therapy.
  
  
  METHODS
  Before receiving biofeedback assisted pelvic floor muscle training functionally intact, older community dwelling women with urge urinary incontinence as well as normal controls underwent comprehensive clinical and bladder diary evaluation, urodynamic testing and brain functional magnetic resonance imaging. Evaluation was repeated after pelvic floor muscle training in those with urge urinary incontinence. Functional magnetic resonance imaging was done to determine the brain reaction to rapid bladder filling with urgency.
  
  
  RESULTS
  Of 65 subjects with urge urinary incontinence 28 responded to biofeedback assisted pelvic floor muscle training with 50% or greater improvement of urge urinary incontinence frequency on diary. However, responders and nonresponders displayed 2 patterns of brain reaction. In pattern 1 in responders before pelvic floor muscle training the dorsal anterior cingulate cortex and the adjacent supplementary motor area were activated as well as the insula. After the training dorsal anterior cingulate cortex/supplementary motor area activation diminished and there was a trend toward medial prefrontal cortex deactivation. In pattern 2 in nonresponders before pelvic floor muscle training the medial prefrontal cortex was deactivated, which changed little after the training.
  
  
  CONCLUSIONS
  In older women with urge urinary incontinence there appears to be 2 patterns of brain reaction to bladder filling and they seem to predict the response and nonresponse to biofeedback assisted pelvic floor muscle training. Moreover, decreased cingulate activation appears to be a consequence of the improvement in urge urinary incontinence induced by training while prefrontal deactivation may be a mechanism contributing to the success of training. In nonresponders the latter mechanism is unavailable, which may explain why another form of therapy is required.
authors.affiliation: Department of Medicine (Geriatrics), University of Pittsburgh, Pittsburgh, Pennsylvania. Electronic address: Bdc29@pitt.edu.
authors.forename: Derek
authors.initials: D
authors.lastname: Griffiths
authors.affiliation: Department of Medicine (Geriatrics), University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Becky
authors.initials: B
authors.lastname: Clarkson
authors.affiliation: Department of Medicine (Geriatrics), University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Stasa D
authors.initials: SD
authors.lastname: Tadic
authors.affiliation: Department of Medicine (Geriatrics), University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Neil M
authors.initials: NM
authors.lastname: Resnick
mesh_terms: D000368:Aged; D001676:Biofeedback, Psychology; D001921:Brain / Q000502:physiology*; D005081:Exercise Therapy; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D017773:Pelvic Floor; D053202:Urinary Incontinence, Urge / Q000628:therapy*
keywords: biofeedback; brain; magnetic resonance imaging; overactive; psychology; urge; urinary bladder; urinary incontinence
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