INTRA VAGINAL ELECTRICAL STIMULATION

Urinary incontinence can be a significant physical, social and psychological problem for many women. Fortunately, there are a number of conservative treatment options, which are effective, in the management of these problems.

The process of urination and its control depend on an intact neuromuscular system. The bladder is made up of smooth muscle - the detrusor muscle, while the urethra has smooth muscles with a band of striated muscle. Both the somatic and autonomic nervous systems provide innervation to these muscles. The bladder muscle must contract while the urethral sphincter relaxes during urination. It works best when the two are coordinated. The pelvic floor musculature consists of striated muscle fibres innervated by the pudendal nerve. By supporting the bladder and helping to lengthen the urethra, the pelvic floor muscles assist the passage of urine and its control.

Electrical stimulation is a modality that physiotherapists use to treat a variety of conditions. Electrical stimulation is used to restore normal physiological reflex mechanisms in abnormal nervous systems and muscles, as well as to strengthen striated muscles. Using Electro therapy, we try to stimulate the fibres of the pelvic (S2-S4), hypogastric (T10-L2), and pudendal nerves. It is believed that electrical stimulation can inhibit detrusor activity by activating inhibitory nerve fibres in the sympathetic hypogastric nerve, and inhibiting parasympathetic excitatory nerves in the pelvic nerve. It is also used to stimulate and strengthen the striated muscles of the pelvic floor via the pudendal nerve.

Routinely used machines are the interferential electrical stimulation machine and intra-vaginal stimulation machines. The Empi Intravaginal Stimulation Unit is a unit providing neuromuscular stimulation that can be used at home by the patient. The unit consists of a compact battery operated stimulator has two independent channels. One channel operates at 125 Hz to promote bladder inhibition; the other operates at 50 Hz to stimulate muscle contraction. Both channels can be used separately, or together. The electrode is a soft, silicone rubber cylinder about the size of a tampon. The electrode can be easily inserted and the patient learns how to take proper care of it. The therapist adjusts the settings on the stimulator and then the patient is taught how to control the intensity. The intensity should be high enough to cause a muscle contraction but within the patient's comfort limits.

Many of the patients with incontinence have weakened musculature contributing to their urinary incontinence. Their symptoms often improve when they follow their prescribed exercise program and have adequate strength. Electrical stimulation is indicated when they have strength less than ‘fair’ as measured during a manual muscle test. It may also be indicated to provide sensory stimulation for patients with urge incontinence.

 

CASE STUDY

Mrs N is a 64-year-old female who has complained of urinary incontinence for ‘many’ years. She came to the clinic for consultation. On initial assessment, she reported that she ‘wet her pants’ with coughing, sneezing, laughing, walking and jumping. She also complained of urgency and stated "she must find a toilet immediately". She stated her frequency of urination was about once per hour during the day and only once during t he night. Her input per day was 6 – 8 glasses of water. Bowel function was normal.

Mrs. N has seven children, all delivered via normal vaginal delivery. Her past medical history includes pelvic floor repair in 1974, Hysterectomy & bilateral salpingo-oopherectomy in 1992 and high blood pressure. Present medications include Premarin, Tenormin and Persantin. She reported that incontinence worsened after the hysterectomy.

On her first visit to the incontinence clinic she demonstrated a weak pelvic floor contraction. Her pelvic floor muscle strength was given a grade of 2/5 (based on Kendall’s scale for manual muscle testing) and she was able to hold each contraction for about two seconds. She was started on a pelvic floor exercise regime in a gravity-eliminated position, a bladder re-training program and to keep a bladder diary.

She was seen on a regular basis until May 1994 when EMPI system was introduced as a treatment progression. Her pelvic floor muscle strength was t hen graded as 3/5(fair) and she still complained of symptoms of SI with coughing and walking. The frequency of her visits to the toilet has also decreased.

Electrical stimulation was initiated using the intravaginal electrode. The system was set off "low" (maximum – 60 milliamps) for 15 minutes with five seconds on the ten seconds off. The intensity was increased until a visible contraction was noted. She was also instructed to contract her pelvic floor when she feels the "tingling sensation". The patient demonstrated ability to use the machine independently and she was to use it twice daily for 15 minutes each time. She was reviewed within a few days to check that she was able to use the machine independently and perform the correct exercises.

Mrs. N was on electrical stimulation plus pelvic floor exercise regime for five months. She was consistent with the regime expect for a month where she was ill, followed by a holiday abroad. During the five months, she reviewed at least once a month to check the use of the machine and to progress the treatment regime when necessary.

After 6 months she reported that she could finally feel a "good" pelvic floor contraction. Her symptoms have also improved – she leaks urine only when she coughs or sneezes when her bladder is full. Furthermore, her frequency to visits to the toilet has also decreased to six times per day and once at night. On assessment, manual muscle test revealed a grade 4/5 with the ability to hold t he contraction for 10 seconds. She was also able to elicit "quick flicks" but cannot do so with power or speed. She also reported that she feels much better about herself as she is able to regain control of her bladder.

The patient cited in the case study above has responded well to electrical stimulation although progress has been slow. Many of the patients using the EMPI System respond quickly and see results in 6 – 8 weeks. Presently, the machine is being used on women with severe incontinence and extremely weak pelvic floor muscle (0 – 2/5 strength). Electrical stimulation is an option for treatment in women who demonstrate urinary incontinence especially when traditional pelvic floor exercises have been unsuccessful. A physiotherapist to determine the appropriate settings and discontinue its use when progression is noted should evaluate candidates for therapy.