Pelvic Floor Stimulation and Overactive Bladder
Overactive bladder is a huge health problem in the United States. Beyond the vast numbers of people who suffer from this condition, over 33 million, it poses a tremendous burden on our already stressed health care system, as it is estimated that costs for this entity exceed $12 billion per year.** Traditional treatments for overactive bladder include behavioral modification, which involves teaching patients about the ideal times, types and amounts of fluids that they should ingest. With some minor modifications, many patients will see improvement in their symptoms with minor change.Oral medications are also available to treat the symptoms. There are numerous pills, which fall within the category of anti-cholinergic medications** that treat overactive bladder. In addition, several gels and patches containing the same type of medication are available.** But more recently, a new category of medication known as a beta-3 adrenergic agonist (Myrebetriq) has become available that is also effective for the treatment of overactive bladder.**** What about non-prescription options?**
Pelvic floor stimulation is another treatment that is available for the treatment of overactive bladder. It is believed that normal childbirth with vaginal delivery, can lead to damage to the muscles of the pelvic floor that are responsible for the continence mechanism. It is believed that the normal aging process also helps to contribute to the damage.
There is mounting evidence in the literature that electrical stimulation and neuromodulation of the pelvic floor muscles can positively alter one’s voiding pattern. Various techniques exist for pelvic floor stimulation. Percutaneous tibial nerve stimulation (PTNS) is one means used to treat overactive bladder. This technique involves the placement of a very fine needle near the back of the ankle, and an electrode on the leg as well. It is then hooked up to a generator that sends an electrical stimulus to the sacral nerve plexus via the tibial nerve. The treatment consists of week 30 minute sessions for 12 weeks followed by monthly maintenance treatments. When effective, overactive bladder symptoms can be controlled without the use of medications.
An implantable device known as Interstim is also available for the treatment of overactive bladder. This device consists of electrodes that are easily placed into the sacral portion of the spinal cord and then to an implantable generator. The device modulates the sacral nerves with mild electrical pulses so that the bladder can once again function properly. Prior to implanting the device, the patient goes through an evaluation that includes temporary electrodes that will help predict if the patient will benefit from the permanent implant.
Supporting ResearchA recent study from Cairo (Abdelbary AM, et al) reported on the combining of local vaginal estrogens with pelvic floor electrical stimulation using intravaginal probes. These researchers report that the use of estrogen enhances the results of electrical stimulation and delays its recurrence. Although promising, the results seen in this study were not durable and deteriorated over 6 months.** This leads to the question of whether the use of maintenance therapy with either stimulation, vaginal estrogens, or perhaps both will lead to long-term success.The lack of estrogen in post-menopausal women has long been known to be a contributing factor to overall pelvic health. Estrogens are commonly used pre-operatively in patients who are undergoing anti-incontinence procedures. Use of the hormone in this setting has been shown to increase the vascularity and the health of the surrounding tissues. Surgeons who still use pelvic mesh for the repair of pelvic prolapse advocate their use peri-operatively, and many claim that this helps to significantly decrease complication rates. I advocate the use of vaginal estrogens in elderly women who suffer from recurring urinary tract infections, and in many, this treatment alone is enough to stop them from getting these infections.Pelvic floor stimulation via a variety of techniques has been shown to be effective for many patients suffering from overactive bladder. Some of the techniques such as Interstim are fairly invasive, and not intended as a first line of therapy.** However when other treatments fail, it should be considered. Additionally there are some patients who may not respond to pelvic stimulation alone. These patients may require a combination therapy with the addition of an oral agent or gel, and they can obtain a normal voiding pattern.
Jay Motola, MD, is a board-certified urologist and attending physician, Department of Urology, Mount Sinai West, and Assistant Professor of Urology, Icahn School of Medicine at Mount Sinai. Dr. Motola is a summa cum laude, Phi Beta Kappa graduate of Boston University, and earned his medical degree at the State University of New York at Stony Brook.