Urinary Incontinence, Urogenital Pain, Faecal Incontinence

Successful management and treatment of pelvic floor disorders must always begin with a comprehensive medical-urogynecological assessment. An essential part of this process is the testing of pelvic musculature. Static and dynamic appraisal of muscles at rest, muscle recruitment, strength, endurance, stability, recovery and co-ordination becomes an integral part of assessment and treatment planning.

Patient-specific treatment can only be prescribed on the basis of a comprehensive pelvic floor assessment. Electromyography is extensively used in diagnosing and treating neuromuscular disorders. It consists of special instruments to measure the electrical activity of skeletal muscles at work or at rest. Instrumentation includes highly sensitive surface sensors and computerised analysis of muscle electrical signal. It greatly contributes to the scientific study of muscle function.

'Electromyography in the 1990's ... joins electrocardiography (EKG) and electroencephalography (EEG) as a non invasive, measurable, reliable and repeatable state of the art technology for the assessment of the internal milieu '.7

Electromyographic biofeedback has many important applications, one of which is the rehabilitation of pelvic floor musculature. From the treatment perspective electromyographic biofeedback assists the patient to develop a conscious awareness and good control of physiological processes such as muscle relaxation and contraction in the course of pelvic rehabilitation.

Multi-channel computerised electromyography provides an important technical link in the assessment and treatment of pelvic floor dysfunction. Surface EMG sensors assist with the monitoring of external/skeletal muscles while technologically advanced vaginal and anal plug sensors provide exceptionally accurate readings of specific striated pelvic muscle groups thus enabling the assessment of intra-abdominal pressure and pressure transmission ratios.

TYPICAL NON-MORBID EMG OF PELVIC FLOOR RESPONSE
1. Low resting baseline with good muscle stability.
2. Good recruitment with clear demarcation between rest and contraction.
3. Strong contraction with no fatigue.
4. Abrupt fall from contraction to resting baseline.
5. Low resting baseline with good muscle stability post contraction.

Protocols supported by computer software provide scope for comprehensive analysis of pelvic muscle fibre function. The levator ani muscle is composed of a mixture of two types of muscle fibres :

* Tonic - Slow-twitch fibres (aerobic-oxidative), type I, functionally adapted to maintain muscle tone and provide long-term support .

* Phasic - Fast-twitch fibres (anaerobic-glycolytic), type II, responsible for rapid forceful contractions and are activated as a short - term response to sudden increases of intra-abdominal pressure .

* 'Scientific literature reports of histochemical studies have shown that approximately 70% of fibres within the periurethral levator ani are type I and 30% are type II(8).

Computerised electromyographic assessment provides a total Power Spectral Analysis of muscle fibres and provides an accurate evaluation of neuromotor control.

TREATMENT RECOMMENDATIONS
Studies have shown that a majority of patients with pelvic floor disorders cannot correctly contract their pelvic floor muscles in response to verbal instruction and a large percentage even exercise in a way that could promote incontinence(9,10). Biofeedback assisted muscle rehabilitation enables the practitioner and patient to progress more reliably and efficiently through clinic and home based treatment, identifying correct muscles and procedures, maximizing learning and therefore obtaining a significant therapeutic gain.

The US Department of Health in its Clinical Practice Guidelines(11) reports that:

'Studies in the various applications of biofeedback combined with behavioural treatment report a range of 54-95% improvement in incontinence across different patient groups...'

The guidelines for clinical practice recommend that:

'Biofeedback in conjunction with other behavioural treatment techniques can be useful in the reduction of symptoms associated with urinary incontinence.'

'...that behavioural techniques such as bladder retraining and pelvic muscle exercises are effective, low-risk interventions that can reduce incontinence significantly in varied populations.'

and therefore concludes:

'...that surgery, except for very specific cases, should be considered only after behavioural and pharmacological interventions have been tried.'

URINARY INCONTINENCE
The success of EMG biofeedback in the treatment of urinary incontinence is widely documented and highly recommended to the practitioner and the patient. Biofeedback greatly improves patient care and training by 'providing a graphic representation of physiological data and by facilitating awareness and a faster development of self-regulation'(12).

EMG biofeedback is associated with a high level of patient acceptance and compliance.

PELVIC EMG ACTIVITY FOR URINARY INCONTINENCE
1. Overly relaxed musculature.
2. Slow muscle recruitment.
3. Weak Contraction.
4. Slow muscle recovery.
5. Relaxed muscle tone.

Practitioners conclude that:

'Based on our own experience in pelvic-floor rehabilitation, we suggest that this conservative treatment be offered to any incontinent patient before surgery. Patients who fail to achieve satisfactory results with this therapy should be referred for surgery…'

'Applied biofeedback offers a valuable alternative to patients presenting with urinary incontinence during physical activities and must be considered as first-line therapy… Female athletes who practice a sport with high-risk factors to the pelvic floor or women after childbirth who desire to keep in shape must be aware of such therapy.'(13)

UROGENITAL PAIN

Research into the diagnosis and treatment of vulval pain, in particular vestibulitis, vulvodynia and pudendal neurolgia, has identified unique electromyographic characteristics of pelvic floor muscles associated with these conditions. The characteristic pattern consists of elevated and unstable resting baseline, poor muscle recruitment, spasm on sustained contraction, fatigue, poor recovery and an elevated post contraction baseline(14).

Vulval pain, most often reported by patients as vulval burning, appears to be mediated by sensory and motor nerve fibres of the pudendal nerve of S3 and S4 origin. It is thought that sensitisation of these nerve endings produces superficial vulvar and vestibular irritability which destabilises and fatigues the pelvic muscles giving rise to a peculiar electromyographic pattern.

PELVIC EMG ACTIVITY IN TYPICAL VULVAR VESTIBULITIS
(initial evaluation)
1. Elevated and unstable resting baseline.
2. Poor recruitment.
3. Spasm on sustained contraction and fatigue.
4. Poor recovery.
5. Post contraction baseline remains elevated with high amplitude and instability.

'Eighty eight percent (88%) of patients with a clinical diagnosis of vestibulitis satisfy at least three or more of these abnormal electromyographic criteria.'(15)

Treatment of vulval pain through pelvic floor excercises assisted by electromyographic biofeedback has been shown to be highly effective. By strengthening the levator ani muscle there is not only improved contraction strength, but also increased muscle stability, less fatigue and a corresponding fall in resting tension. This appears to be associated with and indicative of a less active pudental nerve which leads to a reduction of pain.

'A biofeedback-assisted exercise program which stabilises pelvic floor muscles is shown to significantly reduce and in some cases eliminate symptoms of vulvar vestibulitis syndrome.'(16)

EMG biofeedback is the most successful treatment reported to date.

FAECAL INCONTINENCE

In relation to faecal incontinence, biofeedback therapy was found to be more effective when compared with medical treatment alone.

'Medical treatment of faecal incontinence is disappointing, as are various surgical procedures. Biofeedback is a specific form of behaviour modification, which aims to control bodily function. It is a treatment of choice for incontinence when anal sphincter function is altered… In our experience biofeedback was an effective procedure for treatment of incontinence.'(17)

Research and practice highlights the advantages and value of conservative therapy in the treatment to pelvic floor dysfunction. Urinary incontinence, urogenital pain and faecal incontinence are some of the more common dysfunctions successfully treated. Computerised electromyographic biofeedback is a neuromuscular assessment and treatment modality highly recommended by practitioners and well accepted by patients with a high level of compliance and good treatment outcome.

REFERENCES

1. DeLacey JOL & Richardson AC. Anatomy of genital support. In Benson JT (ed) Female pelvic floor disorders: Investigations and Management, New York, WW Norton.19-26, 1992.

2. Bourcier AP, Juras JC. Non surgical therapy for stress incontinence. Urologic Clinics of North America. 22 (3), 613-627, 1995.

3. Nygaard IE, Thompson FL, Suengalis SH & Albright JP. Urinary incontinence in elite nulliparous athletes. Obstetrics Gynecology. 84, 183-l 87, 1994.

4. Norton PA, MacDonald LD, Sedgwick PM & Stanton St. Distress and delay associated with urinary incontinence, frequency and urgency in women. British Medical Journal. 297,1187-l189,1988.

5. Wyman JF. The psychiatric and emotional impact of female pelvic floor dysfunction. Current Opinion in Obstetrics and Gynecology. 6, 336-339, 1994.

6. Kegel AH. Stress incontinence of urine in women: Physiologic treatment. Journal of the International College of Surgeons, 25(4),487-499,1956.

7. Sella GE. Muscles in motion: S-EMG analysis of the range of motion of the human body. (auth) Martins Ferry, Ohio, 1993.

8. Bourcier AP, Juras JC. Non surgical therapy for stress incontinence. Urologic Clinics of North America. 22 (3), 613-627, 1995.

9. Bo K, Oseid S, Kuarstein B I et al. Knowledge about and ability to correct pelvic floor muscle exercises in women with urinary stress incontinence. Neurourology and Urodynamics, 7, 261-265, 1988.

10. Bump R, Hurt WG, Fantl J A et al. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. American Journal of Obstetrics and Gynecology, 165 (2), 322-329,1991.

11. Urinary Incontinence Guideline Panel. Urinary Incontinence in Adults: Clinical Practice Guideline. AHCPR Publication Nu. 920038. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of health and Human Services, March 1992.

12. Bourcier AP, Juras JC. Non surgical therapy for stress incontinence. Urologic Clinics of North America 22(3),613-627,1995.

13. Bourcier AP, Juras JC. Non surgical therapy for stress incontinence. Urologic Clinics of North America. 22(3),613-627,1995.

14. White G, Jantos M, Glazer HI. Towards establishing the diagnosis of vulvar vestibulitis, In press, 1995.

15. Jantos M, White G and Glazer HI. Electromyographic studies of vulvar vestibulitis & vulvodynia. Proceeding of the 13th International Congress of the International Society for the Study of Vulvovaginal disease, 15-l9 September 1995, Buenos Aires, Argentina, 1995.

16. Glazer HI, Rodke G, Swencionis G, Hertz R & Young AW. The treatment of vulvar vestibulitis syndrome by electromyographic biofeedback of pelvic floor masculature. Journal of Reproductive Medicine. 40 (4), 283-290, 1995.

17. Guillemot F, Bouche B, Gower-Roussean C, et al. Biofeedback for the treatment of faecal incontinence. Diseases of the Colon and Rectum. 38, 393-397, 1995.