Perineal electrostimulation and biofeedback

Pelvic floor or perineal stimulation is a popular method for treating incontinence.

Pelvic floor electrostimulation successfully restores continence, especially in female patients.
 Pelvic floor electrostimulation is normally applied using vaginal electrodes (probes), characterised by at least two electrodes, often in the form of rings. The aim is to stimulate the group of perineal muscles, especially the pubo-coccygeal and pubo-rectal muscles.

Stress incontinence,

which is frequently due to sphincter deficiency. Symptoms include leaking of urine, caused by a strain (such as coughing, rising from a chair, etc), in absence of detrusor activity. Stress incontinence is usually treated with relatively high frequency electrical pulses (from 35 to 100 pulses per sec. (p.p.s.) depending on patients and therapist preference), this exercises the phasic components of the muscle fibres which provide strong but short contractions.

The treatment should be performed for about 20 minutes daily starting with relatively short work periods and gradually building up endurance by increasing the contraction time as the muscles strengthen. Pulse widths may be selected between 100 to 400 microseconds, depending on the patient.

Urge incontinence,

caused by detrusor instability. Here the most appropriate frequency is between 5 and 10 Hz, with a pulse-width of between 250 and 400 microseconds. The treatment is best performed on a daily basis for the first week, then 2 to 3 sessions per week for the next 3 or 4 weeks. The therapy may be conducted at home.

Mixed Incontinence,

accounts for about 40% of all cases of incontinence and is characterised by episodes of incontinence when straining, along with or alternating with episodes of incontinence due to detrusor instability causing urgency.

Depending on the predominance of the first or the second kind of incontinence, one can decide to use a relatively high frequency (e.g.. 75 Hz) for greater effect on the muscle tone or lower frequencies to give greatest effect on detrusor inhibition. Urge incontinence usually responds more quickly than stress so this is usually treated first. Alternatively two treatments per day, one for urge and the other for stress may be carried out.

Effects of perineal electrostimulation

There are many effects, observed by different experimenters, of perineal stimulation.

Reinforcing effect on the pelvic floor – Electrostimulation causes a slight increase in muscle activity. When the manual muscle functionality test (PC-Test) gives a value of 1 or 2 (1=contraction just perceptible), (2=weak contraction) endovaginal electrostimulation has been revealed to be particularly effective, allowing a quick recovery of at least 2 points. The effectiveness of electrostimulation makes use of the motor excitement action, which causes an increase in muscle tone and the vascular action on local circulation. The two actions are obviously linked, but are separate.

Effect on the pressure of urethral closure – Significant increases in urethral closure pressure have been observed by certain experimenters (Dr. PIGNE’ – BOURCIER).

Effect on vesical tone – A clear improvement in vesical compliance accompanied by a considerable reduction in the non-inhibited contractions of the detrusor and an improvement in cystomanometric ability have been noted.

Perineal Biofeedback

Perineal Biofeedback (BF) is an active therapeutic technique consisting in the fine and real-time graphical visualisation (and/or audible emission) of voluntary muscle contractions/relaxation by the patient.
The therapeutic aim is the improvement of voluntary control of the perineal muscles. The patient is visually (visual feedback) and acoustically (audible feedback) made aware of the contraction level of its perineal muscles (pubococcygeus and puborectalis), acquired by means of a vaginal probe including a couple of conductive electrodes (EMG-BF) or acquired by means of a silicone balloon integrated in a special vaginal probe.

The conscious appraisal of the performed work determines the effectiveness of the BF treatment. The EMG (electromyographic) biofeedback exploits the small signal generated by the perineal muscles provided on the probe electrodes. In addition to the

two electrodes on the probe (active electrodes), it is necessary to apply a third electrode (indifferent electrode) in correspondence with a bony prominence (eg iliac crest). Since the surface EMG (sEMG) taken at the vaginal or anal mucosal level is very small (of the order of micro-volts), this indifferent electrode is indispensable to suppress environmental electrical interferences.

The electromyographic biofeedback, can be implemented, as well as on the perineal muscles, by vaginal or anal probe, on any external muscle.
In this case, instead of the probe, two adhesive electrodes are required to be applied to the skin, spaced 3 cm. each other along the muscle to be treated. It is always necessary a third indifferent electrode to be applied on a bony prominence.

We can identify 3 pathological situations each corresponding to a biofeedback techniques: Recruiting BF, Training BF, Relaxing BF.

Perineal biofeedback is not an alternative treatment to perineal electrostimulation, but a complementary treatment, indicated when the patient, while managing to weakly contract the perineal muscles, is unable to sufficiently control them in cases of sudden increases of abdominal pressure (coughing or sudden efforts).

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