Medical Policies - Mental Health


Biofeedback as a Treatment of Urinary Incontinence

Number:PSY301.016

Effective Date:06-15-2018

Coverage:

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Biofeedback is considered experimental, investigational and/or unproven as a treatment of urinary incontinence.

Description:

Urinary Incontinence is a common condition defined as an involuntary leakage of urine. Women are twice as likely to be affected as men, and prevalence increases with age. The severity of incontinence affects quality of life and treatment decisions. The types of urinary incontinence include stress, urge, overflow, functional, and postprostatectomy incontinence. Nonsurgical treatment options may include pharmacologic treatment, pelvic muscle exercises, bladder training exercises, electrical stimulation, and neuromodulation.

Biofeedback is a technique intended to teach patients self-regulation of certain physiologic processes not normally considered to be under voluntary control. The technique involves the feedback of a variety of types of information not commonly available to the patient, followed by a concerted effort on the part of the patient to use this feedback to help alter the physiologic process in some specific way. Biofeedback has been proposed as a treatment for a variety of diseases and disorders, including anxiety, headaches, hypertension, movement disorders, incontinence, pain, asthma, Raynaud’s disease, and insomnia. Biofeedback training is done either in individual or group sessions and as a single therapy or in combination with other therapies designed to teach relaxation. A typical program consists of 10 to 20 training sessions of 30 minutes each. Training sessions are performed in a quiet, non-arousing environment. Subjects are instructed to use mental techniques to affect the physiologic variable monitored, and feedback is provided for successful alteration of the physiologic parameter. This feedback may be in the form of signals, such as lights or tone, verbal praise, or other auditory or visual stimuli.

Biofeedback, in conjunction with pelvic floor muscle training, is a possible treatment modality for stress, urge, mixed, and overflow urinary incontinence because it may enhance awareness of body functions and the learning of exercises to train pelvic muscles. There are several proposed methods of biofeedback that may be employed for the treatment of urinary incontinence, including vaginal cones or weights, perineometers, and electromyographic (EMG) systems with vaginal and rectal sensors.

The various forms of biofeedback mainly differ in the nature of the disease or disorder under treatment, the biologic variable that the subject attempts to control, and the information that is fed back to the subject. Biofeedback techniques include peripheral skin temperature feedback, blood-volume-pulse feedback (vasoconstriction and dilation), vasoconstriction training (temporalis artery), and EMG biofeedback; these may be used alone or in conjunction with other therapies (e.g., relaxation, behavioral management, medication).

Regulatory Status

A variety of biofeedback devices have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. The FDA defines a biofeedback device as “an instrument that provides a visual or auditory signal corresponding to the status of one or more of a patient's physiological parameters (e.g., brain alpha wave activity, muscle activity, skin temperature, etc.) so that the patient can control voluntarily these physiological parameters.” FDA product code: KPI.

Rationale:

Several methodologic difficulties arise in assessing biofeedback. (1) For example, most interventions that include biofeedback are multimodal and include relaxation and behavioral instruction, which may have effects separate from those due to biofeedback. While studies may report a beneficial effect of multimodality treatment, without appropriate control conditions, it is impossible to isolate the specific contribution of biofeedback to the overall treatment effect. For example, relaxation, attention, or suggestion may account for successful results that have been attributed to biofeedback. These effects are nonspecific therapeutic factors, some of which can be considered placebo effects. To demonstrate efficacy of biofeedback for treating incontinence, studies are needed to isolate the effect of biofeedback and demonstrate an improvement in health outcomes compared with other interventions (e.g., relaxation or behavioral therapy alone). In addition, although studies in the 1990s found that feedback on physiologic processes provided patients with an enhanced ability to control these processes, evidence is needed on the relation between a patient’s ability to exert control over the targeted physiologic process and any health benefits of the intervention. The latter finding underscores the importance of seeking controlled studies showing whether use of biofeedback improves disease-related health outcomes, as opposed to physiologic, intermediate outcomes.

Women with Urinary Incontinence

A number of randomized controlled trials (RCTs) addressing biofeedback for urinary incontinence have been published, and there are several systematic reviews of RCTs.

Systematic Reviews

Most recently, in 2016, Moroni et al. published a systematic review of 37 randomized controlled trials (RCTs) on conservative treatment of stress urinary incontinence in women. (2) Five trials were identified that compared pelvic floor muscle training (PFMT) plus biofeedback with biofeedback alone; the studies included a total of 250 women. A pooled analysis of 4 studies found significantly more urine loss as measured by a posttreatment pad test with PFMT alone than with PFMT plus biofeedback (mean difference [MD], 0.90; 95% confidence interval [CI], 0.71 to 1.10). Reviewers noted that the difference between groups was likely not clinically significant because there was only about a 1-gram difference. Moreover, the finding was largely due to the effect of 1 study. Results on other outcomes (e.g., quality of life, number of incontinence episodes) could not be pooled due to imprecision of the estimates.

In 2012, an Agency for Healthcare Research and Quality comparative effectiveness review identified 6 RCTs (total N=542 patients) comparing PFMT plus biofeedback with PFMT alone. (3) A meta-analysis of these studies did not find a statistically significant difference between interventions in continence rates. When findings were pooled, the relative risk (RR) was 1.27 (95% CI, 0.88 to 1.85). The absolute risk difference was 0.08 (95% CI, -0.03 to 0.19).

A 2011 Cochrane systematic review of RCTs included studies on feedback or biofeedback in conjunction with PFMT for treating urinary incontinence in women. (4) Feedback was defined as verbal feedback by a clinician, whereas biofeedback involved use of an instrument or device. After examining 36 full-text articles, 24 trials met reviewers’ eligibility criteria, and 17 contributed data to the analysis of at least 1 primary outcome measure. Sixteen of the 24 trials compared PFMT plus biofeedback with PFMT alone; 9 of them included the same PFMT programs in both groups. The primary outcomes of the review were quality of life and improvement or cure. Nine trials used one of several validated quality-of-life instruments; however, only 4 of these reported data in a form amenable to meta-analysis. Thus, quality-of-life results were not pooled. Data were pooled for the other primary outcome (improvement or cure), but there were a sufficient number of studies only for the comparison between PFMT with and without biofeedback. In a pooled analysis of 7 studies, there was a significant reduction in the proportion of women reporting “no improvement or cure” when biofeedback was added to muscle exercise (RR=0.75; 95% CI, 0.66 to 0.86). Reviewers noted that there may have been other differences between groups, such as more frequent contact with a health care professional or a greater number of treatment sessions, which might partially explain the difference between the improvement or cure rates in women who did or did not receive biofeedback. Moreover, when only the outcome “no cure” was examined, there was no significant difference between groups that did and did not receive biofeedback (5 studies; RR=0.92; 95% CI, 0.81 to 1.05). Among secondary outcomes, a pooled analysis of 7 trials did not find a significant difference in leakage episodes in a 24-hour period after treatment (MD = -0.01; 95% CI, -0.21 to 0.01).

For the outcomes frequency and nocturia, data could not be combined but reviewers reported that the pattern was one of no difference between groups.

As noted in the description of the Cochrane review, studies evaluating biofeedback for treating urinary incontinence in women have used various combinations of interventions and a variety of comparator interventions. Selected larger RCTs that compared PFMT with and without biofeedback (i.e., attempted to isolate the effect of biofeedback) and that were published as full articles are described next.

Randomized Controlled Trials

Burgio et al. (2002) reported on findings of an RCT with 222 women who had urge or mixed incontinence. (5) Interventions in this 3-armed trial were as follows: 1) 74 patients who received behavioral training along with digital palpation instruction (no biofeedback) and 4 office visits in 8 weeks; 2) 73 patients who received biofeedback-assisted behavioral training and 4 office visits in 8 weeks; and 3) 75 patients who were given a self-help book with no office visits (control condition). Behavioral training in the 2 intervention groups included teaching pelvic floor exercises as well as skills and strategies for reducing incontinence. Patients in all groups kept bladder diaries through the 8-week treatment period. In an intention-to-treat analysis, the mean reduction in incontinence episodes was 69.4% in the behavioral training plus verbal feedback group, 63.1% in the behavioral training plus biofeedback group, and 58.6% in the control group. The 3 groups did not differ significantly from one another (p=0.23). In addition, quality-of-life outcomes were similar in the 3 groups.

In 2006, Williams et al. published a United Kingdom (U.K.) study that included 238 women who had failed a primary behavioral therapy (e.g., advice on fluid intake, bladder reeducation, weight loss) for 3 months. (6) They were randomized to intensive PFMT (n=79), PFMT using vaginal cones (n=80), or continued behavioral therapy (n=79) for 3 months. Patients in all 3 groups were seen in the clinic every other week for 8 weeks and at 12 weeks. At 12 weeks, all 3 groups had moderate reductions in incontinence episodes and some improvement in voiding frequency; there were no statistically significant differences in outcomes among the 3 groups. For example, mean reduction in incontinence episodes over 24 hours was -1.03 in the PFMT group, -0.28 in the vaginal cone group, and -0.59 in the control group (p=0.2).

Several other RCTs comparing the efficacy of PFMT alone with PFMT with biofeedback were published in 2012 and 2013. (7, 8) They tended not to find statistically significant differences in outcomes between interventions; however, sample sizes were small (i.e., <25 per group) and thus the studies may have been underpowered.

Section Summary: Women with Urinary Incontinence

Numerous RCTs have evaluated biofeedback as a treatment of urinary incontinence in women and there have been several systematic reviews. The methodology of the studies varied, and many did not isolate the potential contribution of biofeedback. A comparative effectiveness review did not find a statistically significant difference in continence rates when patients received PFMT with or without biofeedback. Other systematic reviews evaluating biofeedback and/or verbal feedback as part of treatment for urinary incontinence found improvement in some outcomes (e.g., improvement or cure, urine volume) but not others (e.g., cure, leakage episodes). There is a lack of consistent evidence from well-designed trials to suggest that biofeedback is an effective treatment of urinary incontinence.

Men with Prostatectomy-Related Urinary Incontinence

Several RCTs evaluating biofeedback to treat prostatectomy-related urinary incontinence have been published. In addition, there have been several systematic reviews of these RCTs.

Post-Prostatectomy Urinary Incontinence

Systematic Reviews

In 2015, a Cochrane review assessed conservative treatments for post-prostatectomy urinary incontinence. (9) Reviewers included a comparison of PFMT (with or without biofeedback) and sham or no treatment. They did not evaluate the potential added value of biofeedback (i.e., by comparing PFMT with biofeedback and PFMT without biofeedback).

In 2016, Hsu et al. published a systematic review of PFMT with biofeedback in men who had radical prostatectomy. (10) Thirteen trials met reviewers’ inclusion criteria. However, on closer inspection, not all trials included a biofeedback intervention, and other trials did not compare PFMT alone to PFMT plus biofeedback. Thus, conclusions about the added efficacy of biofeedback cannot be determined from the results of this meta-analysis.

Previously, in 2007, MacDonald et al. published a systematic review of PFMT to improve urinary incontinence after radical prostatectomy. (11) Reviewers identified 3 studies (281 men) that compared biofeedback and PFMT with muscle training alone (written/verbal instructions provided). Study findings were not pooled; none of the individual trials included in the review found a statistically significant difference in outcomes between groups.

Randomized Controlled Trials

In 2011, Goode et al. reported on a RCT evaluating biofeedback and PFMT in 208 men with urinary incontinence persisting at least 1 year after radical prostatectomy. (12) Men with pre-prostatectomy incontinence were excluded. Participants were randomized to 1 of 3 groups: 8 weeks of behavioral therapy (PFMT and bladder control exercises; n=70), behavioral therapy plus biofeedback and electric stimulation (n=70), and a delayed-treatment control group (n=68). The biofeedback and electric stimulation intervention, called “behavior-plus,” consisted of in-office electric stimulation with biofeedback using an anal probe and daily home pelvic floor electrical stimulation. After 8 weeks, patients in the 2 active treatment groups were given instructions for a maintenance program of pelvic floor exercises and fluid control and were assessed at 6 and 12 months. The primary efficacy outcome was reduction in the number of incontinent episodes at 8 weeks, as measured by a 7-day bladder diary. A total of 176 (85%) of 208 randomized men completed the 8 weeks of treatment. In an intention-to-treat analysis of the primary outcome, the mean reduction in incontinent episodes was 55% (28-13 episodes/week) in the behavioral therapy group, 51% (26-12 episodes/week) in the behavior-plus group, and 24% (25-20 episodes/week) in the control group. The overall difference between groups was statistically significant (p=0.001), but the behavior plus intervention did not result in a significantly better outcome than behavioral therapy alone. Findings were similar on other outcomes. For example, at the end of 8 weeks, there was a significantly higher rate of complete continence in the active treatment groups (11/70 [16%] in the behavior group, 12/70 [17%] in the behavior-plus group) than the control group (4/68 [6%]), but the group receiving biofeedback and electrical stimulation did not have a significantly higher continence rate than the group receiving behavioral therapy alone.

Planned Radical Prostatectomy

A few trials have evaluated the use of pre- or perioperative biofeedback for patients undergoing radical prostatectomy for prevention of postoperative urinary incontinence.

In 2012, Tienforti et al. in Italy reported on a RCT comparing biofeedback (sessions before and after surgery) in combination pelvic floor muscle exercises with a control intervention PFMT alone in patients undergoing radical prostatectomy. (13) The trial enrolled 34 patients, 32 of whom (16 in each group) were available for the final 6-month analysis. By 6 months, 10 (62.5%) of 16 patients in the treatment group and 1 (6.3%) of 16 patients in the control group were continent (p=0.002). The mean number of incontinence episodes per week was also significantly lower in the intervention group (2.7) than in the control group (13.1) at 6 months (p=0.005).

A 2003 randomized trial by Wille et al. randomized 139 men prior to radical prostatectomy to 1 of 3 groups. (14) Group 1 received verbal and written instructions about PFMT from a physical therapist. Group 2 received PFMT instruction and instruction on using an electrical stimulation device. Group 3 received the previous 2 intervention components and training on using biofeedback with the electrical stimulation device. Patients had regular contact with a health care provider for the first 5 weeks after surgery. In the immediate postsurgical period, 20.5% in group 1, 22.9% in group 2, and 20.7% in group 3 were continent (p=0.815). After 6 and 12 months, continence rates remained similar among the groups. Twelve-month continence rates were 88% in group 1, 81% in group 2, and 88.6% in group 3 (p=0.524).

In 2000, Bales et al. randomized 100 men scheduled to undergo radical prostatectomy to PFMT plus biofeedback intervention (n=50) or to a control group (n=50) that received written and brief verbal instructions performing PFMT. (15) The intervention consisted of a single session with a trained nurse 2 to 4 weeks before surgery. Three men dropped out of the PFMT plus intervention group. At 6 months after surgery, the incidence of urinary incontinence was 94% (44/47) in the PFMT plus biofeedback group and 96% (948/40) in the control group. The difference between groups was not statistically significant.

Section Summary: Men with Prostatectomy-Related Urinary Incontinence

RCTs have evaluated the efficacy of biofeedback with PFMT for prevention and/or treatment of prostatectomy-related urinary incontinence compared to PFMT without biofeedback. These trials had mixed findings, but did not consistently report significantly improved outcomes when biofeedback was added to the intervention. The timing and delivery of the intervention were not well-defined. Systematic reviews have not pooled study findings.

Children with Dysfunctional Elimination Syndrome

In 2010, Palmer published an article with an overview of bladder control and pediatric voiding dysfunction. The author addresses biofeedback and concludes that biofeedback has been shown to be very effective in children to correct incontinence secondary to dysfunctional voiding, as well as in treating giggle incontinence and to help resolve vesicoureteral reflux. (23)

In 2008, Kaye and Palmer published an article evaluating the efficacy of biofeedback with and without animation in treating dysfunctional voiding and urinary symptoms. The comparison reported included 120 girls with urinary complaints and exhibited dysfunctional voiding on electromyography uroflow. The authors noted their comparison included the last 60 cases of biofeedback using electromyography tracing alone (non-animated) were compared with the first 60 cases using the Urostym Pediflow program (animated). The evaluation of the 2 groups included improvement in post-void residual volume after treatment, and time to resolution of symptoms and dysfunctional voiding. Results reported included the following: Dysfunctional voiding resolved in 95% of patients in both groups. Post-void residual reduction was similar, namely from 35% to 9% of pre-void volume in the nonanimated group, and from 28% to 8% in the animated group. Children in the animated biofeedback group achieved success in significantly fewer sessions (3.6) than those undergoing nonanimated biofeedback (7.6, t test p <0.05). The authors concluded that in spite of their proved experience with nonanimated biofeedback systems and inexperience with an animated system, animated biofeedback systems yielded similar results in a significantly shorter time. Animated and nonanimated biofeedback is efficacious in the treatment of dysfunctional voiding and its symptoms. (24)

In 2011, a published article from Kajbafzadeh et al. assessed the efficacy of animated biofeedback in children with dysfunctional elimination syndrome. Eighty children were randomly assigned to two groups to undergo either conservative therapy or animated biofeedback. Group A had 40 patients and were treated with animated biofeedback along with pelvic floor muscles exercises and behavioral modification (hydration, high fiber diet, scheduled voiding). Group B had 40 patients and were treated with behavioral modification only. Results reported by the authors included animated biofeedback therapy was more efficient than nonbiofeedback management with regards to objective and subjective voiding problems and bowel dysfunction (p<0.05). The following conclusions were indicated by the authors animated biofeedback effectively treats bowel and voiding dysfunction in children with dysfunctional voiding. (25)

Desantis et al. conducted a literature search to analyze if biofeedback was an effective method to treat children less than 18 years of age for dysfunctional elimination syndrome. The authors noted articles were retrieved for data abstraction and quality assessment. Primary outcomes were urinary tract infections (UTIs) and daytime incontinence. Twenty-seven studies were evaluated (1 random controlled trial [RCT], and 26 case-series). The authors results indicated the pooled estimate showed 83% (95% CI: 79%-86%) and 80% (95% CI: 76%-85%) improvement in UTI and daytime incontinence respectively. Although not statistically significant, the RCT favored biofeedback over standard therapy. The authors of the article indicated in their conclusions that biofeedback is an effective, non-invasive method of treating dysfunctional elimination syndrome, and approximately 80% of children benefited from this treatment. Also noted in the conclusion was, most reports were of low level of evidence and studies of more solid design such as RCT should be conducted. (26)

Section Summary: Children with Dysfunctional Elimination Syndrome

Although the results reported in these studies are encouraging, they involve small numbers of patients and only one study was an RCT. Therefore, the evidence at this time is insufficient to consider coverage of biofeedback for urinary incontinence in children.

Practice Guidelines and Position Statements

American Urological Association et al.

In their 2014 guidelines on diagnosis and treatment of overactive bladder (OAB), the American Urological Association and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction did not make specific recommendations on biofeedback. (16) The guidelines included the statement: “Clinicians should offer behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, fluid management) as first line therapy to all patients with OAB”.

American College of Physicians

In 2014, the American College of Physicians (ACP) published clinical practice guidelines on nonsurgical management of urinary incontinence in women. (17) The guidelines were based on literature published through December 2013. ACP concluded that low-quality evidence showed pelvic floor muscle training (PFMT) with biofeedback using a vaginal electromyography probe increased continent compared to no active treatment and that high-quality evidence showed this combination of treatments improved urinary incontinence symptoms compared to no active treatment. The guidelines did not compare PFMT alone and PFMT plus biofeedback.

National Institute for Health and Clinical Excellence

In 2015, the National Institute for Health and Clinical Excellence updated its 2006 guidance on the management of urinary incontinence in women. (18) Recommendations on biofeedback included: “do not use perineometry or pelvic floor electromyography as biofeedback as a routine part of pelvic floor muscle training” and “electrical stimulation and/or biofeedback should be considered in women who cannot actively contract pelvic floor muscles in order to aid motivation and adherence to therapy”.

Canadian Urological Association

In 2012, the Canadian Urological Association issued guidelines on treatment of adult urinary incontinence. (19) The guidelines made the following conclusions on the use of biofeedback:

Post-prostatectomy incontinence: “Preoperative biofeedback-assisted behavioural training can shorten the time to regain continence postoperatively and reduce the prevalence of severe incontinence 6 months after the procedure (level of evidence 2, grade B)…. Postoperative … biofeedback does not appear to improve continence outcomes compared with PFMT (level of evidence 2, grade B).

Stress incontinence: “The benefit of biofeedback is unknown (grade B).”

National Institutes of Health

In 2007, the National Institutes of Health convened a consensus development conference on prevention of fecal and urinary incontinence; it subsequently released a statement addressing PFMT and biofeedback (20):

“Pelvic floor muscle training and biofeedback are effective in preventing and reversing some pregnancy-related fecal and urinary incontinence for the first year after delivery. There is insufficient research on the sustained long-term benefits of pelvic floor muscle training or biofeedback on preventing fecal or urinary incontinence.”

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

90875, 90876, 90901, 90911

HCPCS Codes

E0746

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does have a national Medicare coverage position.

A national coverage position for Medicare may have been changed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Biofeedback. TEC Assessments. Chicago, Illinois: 1995; Volume 10:Tab 25.

2. Moroni RM, Magnani PS, Haddad JM, et al. Conservative treatment of stress urinary incontinence: a systematic review with meta-analysis of randomized controlled trials. Rev Bras Ginecol Obstet. Feb 2016; 38(2):97-111. PMID 26883864

3. Shamliyan T, Wyman J, Kane RL, et al. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness. Comparative Effectiveness Review No. 36 (AHRQ Pub. No. 11(12)- EHC074-1). Rockville (MD): Agency for Healthcare Research and Quality; 2012.

4. Herderschee R, Hay-Smith EJ, Herbison GP, et al. Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev. 2011(7):CD009252. PMID 21735442

5. Burgio KL, Goode PS, Locher JL, et al. Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial. JAMA. Nov 13 2002; 288(18):2293-2299. PMID 12425706

6. Williams KS, Assassa RP, Gillies CL, et al. A randomized controlled trial of the effectiveness of pelvic floor therapies for urodynamic stress and mixed incontinence. BJU Int. Nov 2006; 98(5):1043-1050. PMID 17034605

7. Hirakawa T, Suzuki S, Kato K, et al. Randomized controlled trial of pelvic floor muscle training with or without biofeedback for urinary incontinence. Int Urogynecol J. Aug 2013; 24(8):1347-1354. PMID 23306768

8. Pereira VS, de Melo MV, Correia GN, et al. Vaginal cone for postmenopausal women with stress urinary incontinence: randomized, controlled trial. Climacteric. Feb 2012; 15(1):45-51. PMID 22066898

9. Anderson CA, Omar MI, Campbell SE, et al. Conservative management for postprostatectomy urinary incontinence. Cochrane Database Syst Rev. 2015; 1:CD001843. PMID 25602133

10. Hsu LF, Liao YM, Lai FC, et al. Beneficial effects of biofeedback-assisted pelvic floor muscle training in patients with urinary incontinence after radical prostatectomy: A systematic review and metaanalysis. Int J Nurs Stud. Aug 2016; 60:99-111. PMID 27297372

11. MacDonald R, Fink HA, Huckabay C, et al. Pelvic floor muscle training to improve urinary incontinence after radical prostatectomy: a systematic review of effectiveness. BJU Int. Jul 2007; 100(1):76-81. PMID 17433028

12. Goode PS, Burgio KL, Johnson TM, 2nd, et al. Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent postprostatectomy incontinence: a randomized controlled trial. JAMA. Jan 12 2011; 305(2):151-159. PMID 21224456

13. Tienforti D, Sacco E, Marangi F, et al. Efficacy of an assisted low-intensity programme of perioperative pelvic floor muscle training in improving the recovery of continence after radical prostatectomy: a randomized controlled trial. BJU Int. Oct 2012; 110(7):1004-1010. PMID 22332815

14. Wille S, Sobottka A, Heidenreich A, et al. Pelvic floor exercises, electrical stimulation and biofeedback after radical prostatectomy: results of a prospective randomized trial. J Urol. Aug 2003; 170(2 Pt 1):490-493. PMID 12853806

15. Bales GT, Gerber GS, Minor TX, et al. Effect of preoperative biofeedback/pelvic floor training on continence in men undergoing radical prostatectomy. Urology. Oct 1 2000; 56(4):627-630. PMID 11018619

16. American Urological Association. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline. Available at <https://www.auanet.org> (accessed November, 2016).

17. Qaseem A, Dallas P, Forciea MA, et al. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. Sep 16 2014; 161(6):429-440. PMID 25222388

18. National Institute for Health and Clinical Excellence (NICE). Urinary incontinence in women: management [CG171]. 2015; Available at <https://www.nice.org.uk> (accessed December 16, 2016).

19. Canadian Urological Association. Guidelines for adult urinary incontinence collaborative consensus document. 2012; Available at < www.ncbi.nlm.nih.gov> (accessed November, 2016).

20. Shamilyan T, Wyman J, Bliss DZ, et al. Prevention of urinary and fecal incontinence in adults. Evidence Reports/Technology Assessments No. 161 (AHRQ Publication No. 08-E003). Rockville (MD) Agency for Healthcare Research and Quality; 2007.

21. Centers for Medicare and Medicaid Services. National coverage decision for biofeedback therapy for the treatment of urinary incontinence (Publication No. 100-3, Section 30.1.1). 2001; Available at <http://www.cms.gov> (accessed November, 2016).

22. Biofeedback as a Treatment of Urinary Incontinence in Adults. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2017 January) Medicine 2.01.27.

23. Palmer LS. Biofeedback in the management of urinary continence in children. Curr Urol Rep. 2010 Mar; 11(2): 122-7. PMID 20425100

24. Kaye JD, and Palmer LS. Animated biofeedback yields more rapid results than nonanimated biofeedback in the treatment of dysfunctional voiding in girls. J Urol. 2008 Jul; 180(1):300-5. PMID 18499170

25. Kajbafzadeh AM, Sharifi-Rad, et al. Animated biofeedback; an ideal treatment for children with dysfunctional elimination syndrome. J Urol. 2011 Dec; 186(6): 2379-84. PMID 22019033

26. Desantis DJ, Leonard MP, Preston MA, et al. Effectiveness of biofeedback for dysfunctional elimination syndrome in pediatrics: a systematic review. J Pediatr Urol 2011 Jun; 7(3): 342-8. PMID 21527216

Policy History:

DateReason
6/15/2018 Reviewed. No changes.
6/1/2017 Document updated with literature review. Coverage unchanged.
12/1/2016 Reviewed. No changes.
10/1/2015 Document updated with literature review. Coverage unchanged.
12/1/2014 Reviewed. No changes.
2/1/2013 New medical document. Biofeedback is considered experimental, investigational and unproven as a treatment of urinary incontinence. Coverage is unchanged. (This topic was previously addressed on PSY301.007 Biofeedback and Neurofeedback.)

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