Electrical stimulation of the pelvic floor muscles in stress urinary incontinence

According to the International Continence Society (ICS), urinary incontinence is any uncontrolled leakage of urine through the urethra. It is caused by neurological, structural, or hormonal disorders. Urinary incontinence significantly reduces quality of life, leading to withdrawal from family and social life.

Who suffers from urinary incontinence?

Urinary incontinence affects both women and men, but women are twice as likely to suffer from it. Symptoms are most severe in women of menopausal age and later, while the first symptoms often appear in younger people around the age of 30.

Is urinary incontinence a global problem of the 21st century?

According to the WHO, urinary incontinence is one of the most significant global health problems of the 21st century. Numerous studies suggest that approximately 200 million people in developed countries may suffer from urinary incontinence. Data from various studies indicate that approximately 10-25% of women over the age of 30 experience urinary incontinence. This problem occurs periodically or constantly. In women over 50, urinary incontinence affects one-third of the sample.

According to research from the National Health Fund, reimbursement for surgical treatment in 2015 amounted to approximately PLN 60 million, almost 100% more than in 2014.

The above data illustrates the scale of the problem of loss of urinary control.

Who is at risk of urinary incontinence?

There are factors that can predispose to the development of urinary incontinence, and they are categorized by their nature. It is important to note that these factors can interact, and when present simultaneously, they increase the risk.

The first group includes factors:

• genetic,
• environmental,
• lifestyle
  

The next division includes:

• predisposing factors: genetic, racial, neurological, anatomical, and cultural factors
• triggering factors: previous childbirth, muscle and/or nerve damage, radiation, and gynecological surgery (e.g., hysterectomy).
• decompensatory factors: physical activity level, BMI (above normal, obesity), diet, lung disease, obesity, and medication-induced urinary dysfunction
• promoting factors: age, dementia, mental retardation, and comorbidities.

What is the diagnosis of urinary incontinence?

Differential diagnosis is crucial because it allows for determining the type and severity of the disorder. Collaboration between a gynecologist and a urologist is crucial. Diagnostic workup should include: history, gynecological examination, urine laboratory tests, functional tests, voiding diary

Types of Urinary Incontinence
According to the ICS, there are five types of urinary incontinence:

• Stress Urinary Incontinence (SUI)
• Urge Urinary Incontinence (URI)
• Overflow Urinary Incontinence
• Extrasphincteric Urinary Incontinence
• Mixed, reflex urinary incontinence, nocturia, and continuous urinary incontinence

Stress Urinary Incontinence

Stress urinary incontinence (SUI) occurs when, during an increase in intra-abdominal pressure, involuntary leakage of urine occurs without a sense of urgency. Physiological increases in intra-abdominal pressure can occur during activities such as sneezing, coughing, or physical exertion. The frequency of urination remains unchanged.

Causes of Stress Urinary Incontinence

The cause of stress urinary incontinence is decreased muscle tone in the perineum, pelvic floor, and fascia, as well as loosening of the connective tissue. In stress urinary incontinence, impulse conduction through the pudendal nerves to the striated urethral sphincter is impaired. Prolonged impulse conduction time through the pudendal nerve – above 2.4 ms – increases the risk of stress urinary incontinence by 97%.

Degrees of Stress Urinary Incontinence

Stress urinary incontinence can be divided into the following degrees:

• Degree I – involuntary leakage of urine occurs only with a significant and sudden increase in intra-abdominal pressure.
• Degree II – involuntary leakage of urine occurs with a moderate increase in intra-abdominal pressure, such as with jumping, light exertion, or climbing stairs.
• Degree III – involuntary leakage of urine occurs while lying down, walking, or standing.

How to treat stress urinary incontinence?

Surgical Treatment of Urinary Incontinence

Surgical treatment of urinary incontinence can include a number of different surgical procedures that may be used if conservative therapy—physiotherapy and pharmacology—is ineffective. It's important to remember that surgical procedures can be very effective in treating urinary incontinence, but there is always a risk of complications. Therefore, it's important to consult a specialist before deciding on surgical treatment for urinary incontinence.

Conservative Treatment

This is the safest and most affordable form of treatment for this condition. It includes:

• pharmacological therapy
• physiotherapy
• behavioral therapy

Pharmacological treatment for urinary incontinence

Pharmacological treatment involves the use of estrogens in women with urinary incontinence caused by menopause. It is used before surgical treatment for SUI in women with urogenital atrophy. Estrogens are used to increase tissue turgor around the vaginal vestibule.

Pelvic Floor Muscle Physiotherapy

Physiotherapy includes pelvic floor muscle training (PFMT), which aims to increase muscle fiber volume. This method involves systematically consciously tensing and then relaxing the pelvic muscles according to a plan developed by a physiotherapist, which helps normalize muscle strength.

Electrical Stimulation in the Treatment of Urinary Incontinence

Neuromuscular Electrical Stimulation (EMS) is a painless procedure that involves stimulating muscles using electrical impulses. During therapy, motor muscles or nerves are stimulated. These procedures are a good option when, for example, nerve-to-muscle connections have been severed or weakened, and the natural nervous system mechanism triggered by consciousness is unable to induce contraction. Electrical stimulation causes contraction of the external urethral sphincter, which in turn tightens the urethral muscle, increases intraurethral pressure, and contracts the levator ani muscles. This contributes to the elevation of the bladder neck and thus lengthens the proximal segment of the urethra. This strengthens weakened pelvic floor muscles.

This passive method has been known since 1963. It uses pulsed current at a frequency of 20-100 Hz (most often 50 Hz) to induce a tetanic contraction of the pelvic floor muscles lasting 1-5 seconds. The procedure takes 20-30 minutes. Treatments are typically performed twice a week, and the duration of treatment ranges from 6 weeks to 6 months.

During electrostimulation, a vaginal electrode is inserted into the vagina and the pudendal nerve is stimulated using alternating current to rebuild the muscles.

Patients can also perform pelvic floor muscle stimulation at home after receiving training from a physiotherapist, using electrostimulators. For pelvic floor muscle stimulation, special vaginal (for vaginal electrostimulation) or rectal (for anal stimulation) probes are available. Adhesive electrodes can also be applied to the skin near the muscle to be rehabilitated.

Kegel Muscle Stimulator and Various Types of Probes

Contraindications to Kegel Muscle Stimulation

• Pacemaker
• Cardiac arrhythmia
• Pregnancy
• Inflammation of the reproductive or urinary tract
• Vaginal infection
• Residual urine exceeding 100 ml
• Menstruation
• Static disorders - limit the effects of electrostimulation
• Peripheral denervation
• Neoplastic process in the area to be stimulated
  
• Mental retardation

Side effects of short-term stimulation (twice a week for several weeks or months):

• Discomfort
• Irritation and pain at the electrode insertion site
• Less commonly, vaginal or urinary tract infections
• Presence of foul-smelling discharge
  
• Increased bowel movements.

Symptoms are usually mild and subside within a few days of completing UI therapy.

Before beginning pelvic floor muscle stimulation treatments with an electrostimulator, it is recommended to consult a specialist.

Effects of Pelvic Floor Muscle Electrostimulation

The purpose of electrostimulation in UI therapy is to restore the function of the Kegel muscles. Data indicate that the effectiveness of electrostimulation is estimated at 30-50%, depending on the individual case.

It is important to perform electrostimulation under the supervision of a specialist or physiotherapist, who will help select the appropriate intensity of the electrical impulses and monitor treatment progress. Electrostimulation can be an effective form of therapy for people suffering from stress urinary incontinence, but other therapeutic methods, such as pelvic floor muscle exercises or biofeedback, are also recommended for optimal results.

Research indicates that electrostimulation is an effective physiotherapy method not only for SUI, but also for urge urinary incontinence and mixed forms. After appropriate treatment qualification by a specialist and in combination with other methods, it can be helpful as a first-line treatment or as a precursor to/adjunctive treatment to surgery.