1. 電刺激在尿失禁治療中之技巧及 運用 陳怡靜 中山醫學大學 物理治療學系 講師 中山醫學大學附設醫院 物理治療師

2. Types of Incontinence Stress incontinenceStress incontinence Urge incontinenceUrge incontinence Mixed incontinenceMixed incontinence Reflex incontinenceReflex incontinence Overflow incontinenceOverflow incontinence

3. Treatment for Urinary Incontinence Federal Agency for Health Care Policy and Research (AHCPR), 1996 Behavioral treatmentBehavioral treatment Pharmacologic treatmentPharmacologic treatment Surgical treatmentSurgical treatment

4. Behavioral Therapy Bladder retrainingBladder retraining Pelvic muscle rehabilitation – PMEs, PMEs and bladder inhibition augmented by biofeedback therapy, PMEs augmented with vaginal weight training, and pelvic floor electrical stimulationPelvic muscle rehabilitation – PMEs, PMEs and bladder inhibition augmented by biofeedback therapy, PMEs augmented with vaginal weight training, and pelvic floor electrical stimulation

5. Different frequencies of stimulation are advocated for the activation of these different nerve fibres the pudendal efferents (alpha-motor axons) produces a contraction of the levator ani the pudendal afferent (medium-size myelinated) will active the inhibit premature, unwanted bladder contractions the pudendal afferent (medium-size myelinated) will active the inhibit premature, unwanted bladder contractions

6. Physiological Effects Improvement of reinnervation of partly denervated PFMs by encouraging axonal sprouting.Improvement of reinnervation of partly denervated PFMs by encouraging axonal sprouting. Muscle strength is increased in a similar manner to voluntary exercise.Muscle strength is increased in a similar manner to voluntary exercise. Electrically elicited contractions can target and train type 2 (fast-twitch) fibers effectively.Electrically elicited contractions can target and train type 2 (fast-twitch) fibers effectively.

7. Mechanism of Action: Electrical stimulation activates a reflex with the pudendal nerve afferent limb and with the following central actions: Activation of sympathetic inhibitory fibers ( hypogastric inhibitory fibers) to pelvic ganglia and the detrusor Activation of sympathetic inhibitory fibers ( hypogastric inhibitory fibers) to pelvic ganglia and the detrusor Central inhibition of the pelvic motor outflow to the bladder Central inhibition of the pelvic motor outflow to the bladder

8. Electrical Stimulation Increase awareness of the PFMIncrease awareness of the PFM Teach effective PFM exerciseTeach effective PFM exercise Increase peri-urethral pressureIncrease peri-urethral pressure Inhibit detrusor contractionInhibit detrusor contraction

9. Electrical Parameters Frequency:Frequency: --10 Hz or less in the treatment of bladder instability. --10 Hz or less in the treatment of bladder instability. --10-50 Hz in treatment of weakened pelvic floor muscle. --10-50 Hz in treatment of weakened pelvic floor muscle.

10. Electrical Parameters Intensity: maximal tolerated levelIntensity: maximal tolerated level

11. Pulse width (pulse duration): 0.2- 0.5ms Pulse width (pulse duration): 0.2- 0.5ms Electrical Parameters

12. On/off ratio (duty cycle): 1:1 or 1:2On/off ratio (duty cycle): 1:1 or 1:2

13. Electrical stimulation delivery system Nonimplanted delivery system: Nonimplanted delivery system: vaginal, anal, surface electrode

14. Electrical stimulation delivery system

18. Transcutaneous Electrical Stimulation

19. Percutaneous Tibial Nerve Stimulation

20. Transvaginal electrical stimulation for female urinary incontinence A prospective, double-blind, randomized clinical trialA prospective, double-blind, randomized clinical trial 49% of women with detrusor instability who used an active electrical device were cured ( stable on provocative cyctometry).49% of women with detrusor instability who used an active electrical device were cured ( stable on provocative cyctometry). no statistically significant change in the percentage with detrusor instability in the sham device group (control group).no statistically significant change in the percentage with detrusor instability in the sham device group (control group). Brubaker L et al: Am J Obstet Gynecol 1997; 177(3): 536-540

21. Intravaginal stimulation randomized trial Electrical stimulation is safe and at least as effective as anticholinergic therapy in the treatment of urge urinary incontinence.Electrical stimulation is safe and at least as effective as anticholinergic therapy in the treatment of urge urinary incontinence. Smith JJ: J Urol 1996; 155:127-130 no significant differences between daily and every-other-day users.no significant differences between daily and every-other-day users. Siegel SW et al: Urology 1997; 50:934-940.

22. Pelvic floor electrical stimulation for the treatment of urge and mixed urinary incontinence on women The greatest improvement in the first 6 weeksThe greatest improvement in the first 6 weeks Twenty weeks of pelvic floor electrical stimulation therapy is effectiveTwenty weeks of pelvic floor electrical stimulation therapy is effective

23. Adverse Effects Transrectal stimulation Abdominal crampsAbdominal cramps DiarrhoeaDiarrhoea Anal painAnal pain Anal bleedingAnal bleeding Intravaginal stimulation Vaginal irritationVaginal irritation PainPain bleedingbleeding

24. Contraindications Implanted pacemakerImplanted pacemaker PregnancyPregnancy Malignant tumourMalignant tumour Atrophic vaginitis, vaginal infectionAtrophic vaginitis, vaginal infection Recent or recurrent haemorrhage/ haematomaRecent or recurrent haemorrhage/ haematoma

25. Patients-Oriented Approach Overactive bladder bladder Functionallimitation Weak pelvic floor muscle Payne C.K. Urology, 2000; 55 (Suppl 5): 3-6

26. patients clinic Urodynamicevaluation SUI DI MI PFME PFME functional abdominal/ PFM use (PBBS) functional abdominal/ PFM use (PBBS) PFME PFME bladder re-training bladder re-training ES ES urge control technique urge control technique GSI +DI GSI +DI Physiotherapy

27. Pelvic Floor Re-education Pelvic Floor Assessment 0 1 2 3 4 5 Biofeedback Electrical stimulation Grade 3 Biofeedback Pelvic floor exercise

28. The following considerations should be made before using electrical stimulation with the individual patient Dose the patient need electrical stimulation?Dose the patient need electrical stimulation? Which kind of electrical stimulation is preferable?Which kind of electrical stimulation is preferable? Is electrical stimulation alone sufficient for effective pelvic floor re-education?Is electrical stimulation alone sufficient for effective pelvic floor re-education?

29. Thank You for Your Attention!