Electrical Stimulation In Incontinence

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(2000) Pelvic floor electrical stimulation in the treatment of adult urinary incontinence. Tecnologica. MAP. Suppl 15-17.

Abelli L., Ferri G.L., Astolfi M., Conte B., Geppetti P., Parlani M., Dahl D., Polak J.M., and Maggi C.A. (1991) Acrylamide-induced visceral neuropathy: evidence for the involvement of capsaicin-sensitive nerves of the rat urinary bladder. Neuroscience 41, 311-321.
Abstract: The mechanisms underlying the severe urinary retention induced by acrylamide intoxication were studied in detail in the rat. Subcutaneous treatment with acrylamide monomer (50 mg/kg daily for 10 days) almost completely impaired the micturition reflex, resulting in urinary retention. In fact, the ability to eliminate an oral water load was virtually abolished, while bladder filling with saline (transvesical cystometrogram) failed to activate reflex micturition. Instead, a picture of overflow incontinence resulted in urethane-anaesthetized rats, which was not reversed by intravenous administration of 4- aminopyridine. The nerve-mediated contractile response to field stimulation (0.1-20 Hz, 0.5 ms, 60 V) of the isolated bladder was unaffected, thus suggesting the integrity of bladder efferent innervation, and no evidence was found from in vitro experiments that the myogenic contractility of the bladder was depressed by acrylamide treatment. Conversely, the sensory nerve-mediated response to capsaicin was abolished and sensory nerve fibres of the bladder were selectively depleted of their content of substan

Aitchison M., Fisher B.M., Carter K., McKee R., MacCuish A.C., and Finlay I.G. (1991) Impaired anal sensation and early diabetic faecal incontinence. Diabet. Med. 8, 960-963.
Abstract: Faecal incontinence develops in up to 20% of diabetic patients. To try to determine the relative contributions of sensory and motor neuropathy in this troublesome complication, anorectal function was examined in 10 male diabetic patients with early faecal incontinence (mucus leakage or faecal staining without the need to wear a pad), 10 asymptomatic male diabetic patients, and 10 normal control subjects. Motor function was tested using anal manometry to determine the resting and maximum squeeze pressure, and the functional anal canal length. No significant differences were found between the groups. Sensory function was tested by measuring the mucosal sensitivity to electrical stimulation, and the response to inflation of a balloon in the rectum. In the mid-anal canal position the symptomatic patients had a significantly higher sensory threshold at 6.6 +/- 2.8 mA compared with 3.0 +/- 1.2 mA in the normal control subjects (p less than 0.002), and in the high anal zone symptomatic patients had a significantly elevated sensory threshold at 9.1 +/- 2.0 mA compared with 4.6 +/- 1.6 mA in asymptomatic patients and 3.6 +/- 1.3 mA in the normal control subjects (both p less than 0.001). There were no significant differences in the first sensation of fullness, maximum tolerated volume or percentage fall from resting pressure between the groups on inflation of the balloon. Elevation of the sensory threshold in the upper anal canal is an early abnormality in the development of diabetic faecal incontinence

Alexander S. and Rowan D. (1966) Closure of the urinary sphincter mechanism in anaesthetized dogs by means of electrical stimulation of the perineal muscles. Br. J. Surg. 53, 1053-1056.

Alexander S. (1976) A critical look at incontinence radio-implants. Urol. Int. 31, 129-133.
Abstract: Indwelling electrical stimulation of the pelvic floor by a radio- implant benefits some cases of problem or recurrent urinary incontinence. It is not possible to predict success or failure with a given patient. The only worthwhile criterion for selection is the presence of contraction of pelvic floor musculature in response to voluntary effort or trial electrical stimulation. The results are not simply explained by postulating electrically induced closure of the urethra. There may be conscious enhancement of the urinary sphincter mechanism. Re-education of voluntary sphincter muscles by electrophysiotherapy may occur. Reflex inhibition of the detrusor may occur. The surgery involved in inserting an implant restores continence in some patients

Andersson K.E., Andersson P.O., Fovaeus M., Hedlund H., Malmgren A., and Sjogren C. (1988) Effects of pinacidil on bladder muscle. Drugs 36 Suppl 7, 41-49.
Abstract: Infravesical outflow obstruction and bladder hypertrophy are often associated with bladder hyperactivity causing frequency, urge and urinary incontinence. This hyperactivity may be due to a supersensitivity to depolarising stimuli. Drugs that inhibit smooth muscle activity by opening K+ channels, resulting in hyperpolarisation, would therefore seem to be an attractive therapeutic principle. Pinacidil is an effective vasodilator classified as a K+ channel opener. The drug has been shown to effectively depress spontaneous contractile activity, the contractions induced by low (less than 40 mmol/L) concentrations of K+, carbachol and by electrical stimulation of nerves in isolated normal human bladder tissue and also in normal and hypertrophied rat bladder. The effect was more pronounced in hypertrophied detrusor. Pinacidil in concentrations inhibiting muscle activity also increased the efflux of 86Rb in bladder tissue. In vivo pinacidil suppressed spontaneous contractile activity in rats with infravesical bladder obstruction and detrusor hypertrophy. The findings make K+ channel openers an interesting, potentially useful therapeutic principle in hyperactivity associated with bladder hypertrophy

Appell R.A. (1998) Electrical stimulation for the treatment of urinary incontinence. Urology 51, 24-26.
Abstract: OBJECTIVES: To describe the rationale for the use of electrical stimulation (ES) for the treatment of urinary incontinence, and to summarize the results of clinical studies assessing these techniques. METHODS: The effect of ES on the lower urinary tract (LUT) is explained, and the literature on clinical application of this technique is reviewed. RESULTS: The use of ES is aimed at altering LUT function by stimulation of the sacral autonomic or somatic nerves. Two types of ES have been used: chronic stimulation and acute maximal functional electrostimulation. The frequency used depends on the clinical diagnosis. In patients with stress incontinence, uncontrolled studies suggest that high frequency and high amperage are required to obtain a 50% success rate, although success does not necessarily equate with cure. The only placebo-controlled trial in this population found that 62% of patients experienced significant improvement on provocative pad test determinations, but only 20% were dry. Researchers agree that low frequency and moderate amperage are required in patients with detrusor instability. The reported effectiveness of ES in this population has ranged widely, from 45% to 91%, but all studies agree that approximately one-third of patients will obtain a good long-term results. A review of multiple studies found that 20% of patients were reported as dry and 37% were significantly improved with functional ES. CONCLUSIONS: Although nearly all studies of ES have been uncontrolled, a substantial body of "soft" data attests to the efficacy and safety of this technique

Aristizabal Agudelo J.M., Salinas C.J., Fuertes M.E., Virseda C.M., Salman M.S., Bravo de Rueda A.C., and Resel E.L. (1996) [Urodynamic results of the treatment of urinary incontinence with peripheral electric stimulation]. Arch. Esp. Urol. 49, 836-842.
Abstract: OBJECTIVES: To evaluate the urodynamic results achieved by electrostimulation in patients with different types of urinary incontinence. METHODS: 37 patients (32 females and 5 males) with urinary incontinence were treated with peripheral electrical stimulation. The urodynamic diagnosis were: detrusor instability (24.3%), stress urinary incontinence (24.3%), mixed urinary incontinence (48.6%), and bladder hyper-reflexia (2.7%). Rectal and vaginal electrodes were utilized. The therapeutic frequencies were 10 Hz, 20 Hz and 50 Hz. RESULTS: Detrusor instability disappeared in the cases treated with the 10 Hz frequency (79%) and in one case treated with the 50 Hz frequency. A significantly increased bladder capacity and decreased first micturition sensation were observed in this patient group. All patients with stress urinary incontinence were treated with high frequency (50 Hz), which achieved positive results in 44%. In the group of patients with mixed urinary incontinence. 45% remained unchanged. Treatment failed to achieve satisfactory results in the single case of detrusor hyperreflexia in this series. CONCLUSION: Peripheral electrical stimulation is a valid alternative in the treatment of male and female incontinence. Satisfactory results were achieved with the 10 Hz frequency in 89% of the patients with bladder instability and with the 50 Hz frequency in 44% of the patients with stress urinary incontinence

Baeten C.G., Konsten J., Heineman E., and Soeters P.B. (1994) Dynamic graciloplasty for anal atresia. J. Pediatr. Surg. 29, 922-924.
Abstract: The aim of this study was to assess whether an electrically stimulated graciloplasty (dynamic graciloplasty) can achieve continence in nine patients with anal atresia (median age, 28 years; range, 18 to 40). As the first procedure, a gracilis muscle was transposed. Six weeks later, intramuscular electrodes were implanted and connected to a pulse generator. Eventually, the muscle was gradually trained, by electrical stimulation, to achieve fecal continence. Continence was obtained in five patients (55%). Manometry demonstrated an increase in mean anal pressure, from 36 mm Hg (without stimulation) to 52 mm Hg (with stimulation), after 8 weeks (mean increase, 16 mm Hg, [95% confidence interval, 8, 24 mm Hg; n = 9; P < .01). Failures resulted from a noncontracting distal part of the gracilis muscle (in three patients) and a nondistending rectum (in one patient). We conclude that dynamic graciloplasty can achieve continence in a substantial number of patients with thus-far untreatable incontinence after surgical correction for anal atresia

Balcom A.H., Wiatrak M., Biefeld T., Rauen K., and Langenstroer P. (1997) Initial experience with home therapeutic electrical stimulation for continence in the myelomeningocele population. J. Urol. 158, 1272-1276.
Abstract: PURPOSE: In an attempt to enhance bladder and bowel continence 29 patients underwent long duration, low intensity transcutaneous therapeutic electrical stimulation. This technology has previously been shown to be effective for inducing regenerative hypertrophy of disuse atrophied skeletal muscle, and it has been associated with improved continence in the myelomeningocele population. Our objectives were to enhance urinary and fecal continence, and evaluate the mechanisms by which therapeutic electrical stimulation influences continence. MATERIALS AND METHODS: A total of 29 children with lumbar or sacral myelomeningocele underwent therapeutic electrical stimulation at home during sleep using a commercially available stimulator with a safety sensing circuit and 2 sets of electrodes placed on the skin at bedtime. Left and right side electrode placement was alternated on 6 of 7 consecutive nights. In 9 boys and 2 girls with more than 9 months of followup initial and subsequent cystometrography, urethral pressure profile, electromyography, voiding cystourethrography and renal ultrasound studies were evaluated. RESULTS: In the 11 children there was no radiographic evidence of urinary tract or musculoskeletal deterioration during treatment. Mean actual bladder capacity increased from 133 to 196 ml. (p < 0.05). Mean bladder capacity, as a percent of maximum predicted bladder capacity for a normal age matched child without myelomeningocele, also significantly increased from 59 before to 76% after 9 months of therapeutic electrical stimulation (p < 0.05). No significant change was noted in urethral pressure profile. A subjective improvement in the sensation of pelvic fullness was also observed. CONCLUSIONS: When administered at home by parents while the child sleeps, therapeutic electrical stimulation is safe for bladder and bowel continence in the myelomeningocele population. It seems to increase significantly bladder capacity, does not appear to change urethral pressure profile and results in a subjectively improved sensation of pelvic fullness, enhancing urinary and fecal continence. The most beneficial effect of therapeutic electrical stimulation seems to be on the bladder wall and less so on the striated pelvic floor musculature with subjective enhancement of pelvic fullness also contributing positively

Bardoel J.W., Stadelmann W.K., Perez-Abadia G.A., Galandiuk S., Zonnevijlle E.D., Maldonado C., Stremel R.W., Tobin G.R., Kon M., and Barker J.H. (2001) Dynamic rectus abdominis muscle sphincter for stoma continence: an acute functional study in a dog model. Plast. Reconstr. Surg. 107, 478-484.
Abstract: Fecal stomal incontinence is a problem that continues to defy surgical treatment. Previous attempts to create continent stomas using dynamic myoplasty have had limited success due to denervation atrophy of the muscle flap used in the creation of the sphincter and because of muscle fatigue resulting from continuous electrical stimulation. To address the problem of denervation atrophy, a stomal sphincter was designed using the most caudal segment of the rectus abdominis muscle, preserving its intercostal innervation as well as its vascular supply. The purpose of the present study was to determine whether this rectus abdominis muscle island flap sphincter design could maintain stomal continence acutely. In this experiment, six dogs were used to create eight rectus abdominis island flap stoma sphincters around a segment of distal ileum. Initially, the intraluminal stomal pressures generated by the sphincter using different stimulation frequencies were determined. The ability of this stomal sphincter to generate continence at different intraluminal bowel pressures was then assessed. In all cases, the rectus abdominis muscle sphincter generated peak pressures well above those needed to maintain stomal continence (60 mmHg). In addition, each sphincter was able to maintain stomal continence at all intraluminal bowel pressures tested

Bauchet L., Segnarbieux F., Martinazzo G., Frerebeau P., and Ohanna F. (2001) [Neurosurgical treatment of hyperactive bladder in spinal cord injury patients]. Neurochirurgie 47, 13-24.
Abstract: OBJECTIVES: We report long-term results of posterior sacral root rhizotomies in combination with Finetech-Brindley anterior sacral root stimulators implanted intradurally in 20 spinal cord injury patients. MATERIAL: and methods: The 14 female and 6 male patients included 14 paraplegics and 6 tetraplegics. All of them initially presented hyperactive bladder, detrusor-sphincter dyssynergia, recurrent urinary tract infection and performed (self) intermittent catheterization. Prior to implantation, an intrathecal test using bupivacaine was performed to confirm the compliances of the bladder. The main indication for implantation was persistent urinary incontinence refractory to medical therapy. RESULTS: After implantation the mean follow-up was 4,5 years. In all, 18 patients used the stimulator alone for bladder emptying and 18 patients were completely continent. The mean bladder capacity increased from 190 ml preoperatively to 460 ml after the operation. The mean residual urinary volume was reduced from 90 ml to 25 ml. No changes were noted by renal isotopic scanning in upper urinary tracts of patients. In 1 patient, a second extradural implant was performed. DISCUSSION: This article also include an overview of a) the different available sites where application of electrical stimulation results in a detrusor contraction, b) the benefits and disadvantages of the sacral posterior rhizotomy, c) selective stimulation techniques that allow selective detrusor activation by sacral root stimulation. CONCLUSION: Sacral anterior root stimulation combined with sacral posterior rhizotomy is a valuable method to restore bladder functions in spinal cord injured patients suffering from hyperactive bladder refractory to medical therapy

Beckman N.J. (1995) An overview of urinary incontinence in adults: assessments and behavioral interventions. Clin. Nurse Spec. 9, 241-7, 274.
Abstract: Urinary incontinence affects millions of Americans. Often the goal of treatment is to improve the condition, prevent complications and provide comfort. Behavioral interventions can improve the condition in 54-75% of patients with urge and/or stress incontinence and can cure 12- 16% of patients. Advanced practice nurses (APNs) are in a unique position of both providing direct care to patients who experience these problems and educating other nurses about signs, symptoms and appropriate nursing interventions for urinary incontinence. The scope of the problem, costs of urinary incontinence and potential cost savings with treatment are discussed in this article. Acute and chronic urinary incontinence and the necessary assessments to be performed by the APN are reviewed. Bladder training, habit training, prompted voiding and pelvic muscle exercises are the behavioral interventions used with urinary incontinence. Adjunct therapy, including biofeedback, vaginal cones and electrical stimulation, also is discussed

Benson J.T. (2000) Sacral nerve stimulation results may be improved by electrodiagnostic techniques. Int. Urogynecol. J. Pelvic. Floor. Dysfunct. 11, 352-357.
Abstract: Sacral nerve electrical stimulation (sacral neuromodulation) therapy for patients with refractory urge incontinence, frequency and urgency, and non-obstructive retention yields an effective 75%-80% success rate. Electrodes are surgically implanted if initial percutaneous stimulation testing has a successful clinical response. Unfortunately, up to 50% of patients are denied surgical implantation because of an unsuccessful response to the test stimulation. In this descriptive study, adding electrodiagnostic monitoring to the currently used biological monitoring techniques was associated with a reduction in the number of tested patients denied implantation to 20%. These findings suggest that the incorporation of electrodiagnostic techniques may improve the clinical efficacy of sacral stimulation therapy. Randomized prospective testing of this hypothesis is suggested

Berghmans L.C., Hendriks H.J., Bo K., Hay-Smith E.J., de Bie R.A., and van Waalwijk van Doorn ES (1998) Conservative treatment of stress urinary incontinence in women: a systematic review of randomized clinical trials. Br. J. Urol. 82, 181-191.
Abstract: OBJECTIVE: To assess the efficacy of physical therapies for first-line use in the treatment and prevention of stress urinary incontinence (SUI) in women, using a systematic review of randomized clinical trials (RCTs). MATERIALS AND METHODS: A computer-aided and manual search for published RCTs investigating treatment and prevention of SUI using physical therapies, e.g. pelvic floor muscle (PFM) exercises, with or without other treatment modalities, were carried out. The methodological quality of the included trials was assessed using criteria based on generally accepted principles of interventional research. RESULTS: Twenty-four RCTs (22 treatment and two prevention) were identified; the methodological quality of the studies included was moderate and 11 RCTs were of sufficient quality to be included in further analysis. Based on levels-of-evidence criteria, there is strong evidence to suggest that PFM exercises are effective in reducing the symptoms of SUI. There is limited evidence for the efficacy of high- intensity vs a low-intensity regimen of PFM exercises. Despite significant effects of biofeedback after testing as an adjunct to PFM exercises, there is no evidence that PFM exercises with biofeedback are more effective than PFM exercises alone. There is little consistency (of stimulation types and parameters) in the studies of electrical stimulation, but when the results are combined there is strong evidence to suggest that electrostimulation is superior to sham electrostimulation, and limited evidence that there is no difference between electrostimulation and other physical therapies. In the prevention of SUI the efficacy of PFM exercises, with or without other adjuncts, is uncertain

Berghmans L.C., Hendriks H.J., de Bie R.A., van Waalwijk van Doorn ES, Bo K., and van Kerrebroeck P.E. (2000) Conservative treatment of urge urinary incontinence in women: a systematic review of randomized clinical trials. BJU. Int. 85, 254-263.
Abstract: OBJECTIVE: To assess the efficacy of physical therapies for first-line use in the treatment of urge urinary incontinence (UUI) in women, using a systematic review of randomized clinical trials (RCTs). MATERIALS AND METHODS: A computer-aided and manual search was carried out for RCTs published between 1980 and 1999 investigating the treatment of UUI defined by the keywords 'physical therapies', e.g. bladder (re)training (including 'behavioural' treatment), pelvic floor muscle (PFM) exercises, with or without biofeedback and/or electrical stimulation. The methodological quality of the included trials was assessed using methodological criteria, based on generally accepted principles of interventional research. RESULTS: Fifteen RCTs were identified; the methodological quality of the studies was moderate, with a median (range) score of 6 (3-8.5) (maximum possible 10). Eight RCTs were considered of sufficient quality, i.e. an internal validity score of >/= 5.5 points on a scale of 0-10, and were included in a further analysis. Based on levels-of-evidence criteria, there is weak evidence to suggest that bladder (re)training is more effective than no treatment (controls), and that bladder (re)training is better than drug therapy. Stimulation types and parameters in the studies of electrical stimulation were heterogeneous. There is insufficient evidence that electrical stimulation is more effective than sham electrical simulation. To date there are too few studies to evaluate effects of PFM exercise with or without biofeedback, and of toilet training for women with UUI. CONCLUSION: Although almost all studies included reported positive results in favour of physical therapies for the treatment of UUI, more research of high methodological quality is required to evaluate the effects of each method in the range of physical therapies

Bielefeldt K., Enck P., and Erckenbrecht J.F. (1990) Sensory and motor function in the maintenance of anal continence. Dis. Colon Rectum 33, 674-678.
Abstract: Anorectal function was prospectively evaluated in 43 consecutive patients with fecal incontinence and in 19 healthy volunteers using manometry and electrical stimulation of the anoderm. Both anorectal motor and sensory function was impaired in incontinent patients as compared with healthy controls. Further statistical analysis identified four subgroups of patients showing different pathomechanisms of fecal incontinence: severe combined anorectal motor and sensory dysfunction, isolated anal sphincter dysfunction, isolated anorectal sensory dysfunction, and combined dysfunction of the internal anal sphincter and impaired anorectal sensitivity. These data support the hypothesis that sensory function of both the rectum and the anal canal is an important and independent factor in the preservation of continence

Bladou F., Houvenaeghel G., Delpero J.R., Monges G., Serment G., and Guerinel G. (1996) Construction of a urinary sphincter by means of an electrically stimulated striated muscle: experimental procedure and urodynamic results on canine model. Int. Surg. 81, 94-98.
Abstract: A canine model of urinary neosphincter using electrically stimulated autologous striated muscle is described. The superior belly of canine sartorius was activated by a pacemaker with an intermittent low frequency stimulation (0.5-1 pulse per sec) during 7 weeks. Then, the muscle graft was passed around the urethra and sutured back on to itself to form a neosphincter. The surgical procedure was easy to perform and with no complication. Urethral pressure profile was performed initially (T0), and when the muscle was in peri-urethral position, before (T1) and during electrical stimulation (T2). The continence parameter readings (maximal urethral closure pressure MUP, functional length FL, continence zone CZ, and continence area CA) increased from T0 to T1, and from T1 to T2. We noted: 1) 28%, 38%, 52%, and 86% increases for the MUP, FL, CZ, and CA respectively from T0 to T1, 2) 10%, 41%, 30%, and 43% increases for MUP, FL, CZ, and CA respectively from T1 to T2. Chronic low frequency stimulation could transform a skeletal fast-twitch type 2 muscle into a slow-twitch fatigue-resistant type 1 muscle. In this study, morphological changes of the stimulated muscle were noted, whereas phenotype was unchanged. This dynamic autologous neosphincter may be a new alternative to the artificial urinary sphincter prosthesis with fewer complications. Further studies are ongoing to evaluate the efficacy of such a neosphincter as continent system for bladder substitution after pelvic exenteration for pelvic cancers

Bo K. and Maanum M. (1996) Does vaginal electrical stimulation cause pelvic floor muscle contraction? A pilot study. Scand. J. Urol. Nephrol. Suppl 179, 39-45.
Abstract: The purpose of the present study was to evaluate whether vaginal electrical stimulation using Conmax and Medicon MS-105 causes pelvic floor muscle contraction. In addition, pain and discomfort described by the participants were registered. Nine women, mean age 37.7 years (range 24-54) participated in the study; five healthy physio-therapists and four patients with diagnosed genuine stress incontinence. All the participants used Conmax and Medicon MS-105 with 10, 20 and 50 Hz in random order. The women increased the current step by step to tolerance level. Two physiotherapists were observing the perineum and notified whether a correct contraction was occurring. The participants reported whether there was a correct contraction of the pelvic floor and described pain and discomfort, classified according to McGill Pain Questionnaire. The results demonstrated that a correct contraction was reported and observed in only one of nine women. Electrical stimulation with all frequencies caused pain and discomfort in all women

Bo K. and Talseth T. (1997) Change in urethral pressure during voluntary pelvic floor muscle contraction and vaginal electrical stimulation. Int. Urogynecol. J. Pelvic. Floor. Dysfunct. 8, 3-6.
Abstract: The purpose of the study was to compare the effect of voluntary pelvic floor muscle (FFM) contraction and vaginal electrical stimulation on urethral pressure. Twelve women with genuine stress incontinence, mean age 49.4 years (range 33-66) participated in the study. The urethral and bladder pressures were recorded simultaneously through a double- lumen 8 Ch catheter. The patients first performed three voluntary PFM contractions. Then two electrical stimulators, Conmax and Medicon MS 105, 50 Hz, were used in random order. A visual analog scale was used to measure pain and discomfort. Pain was reported to mean 6.8, SEM 0.64 (range 0.7-9.9) and mean 6.1, SEM 0.81 (range 0-9.1) with Conmax and Medicon MS 105, respectively. The mean paired difference in favor of voluntary contraction with Conmax was -8.0, SD 6.7, P = 0.0067, and with Medicon MS 105 it was -12.2, SD 5.9, P = 0.0022. The results demonstrated that voluntary PFM contraction increased urethral pressure significantly more than did vaginal electrical stimulation

Bo K. (1998) Effect of electrical stimulation on stress and urge urinary incontinence. Clinical outcome and practical recommendations based on randomized controlled trials. Acta Obstet. Gynecol. Scand. Suppl 168, 3-11.
Abstract: BACKGROUND: The aim of the present study was to review the literature on randomized controlled trials of electrical stimulation to treat urge and stress urinary incontinence. METHODS: Studies were compiled from Medline from 1980 till 1996 and manual searches of relevant journals. Randomized controlled studies full length published in English, German and Scandinavian languages were included. RESULTS: Nine studies evaluating the effect of electrical stimulation on stress urinary incontinence and one study evaluating the effect of urge incontinence were found. Only three studies had a sufficient sample size to enable conclusion on stress urinary incontinence. Two demonstrated negative, and one positive effect (20%) cure and 46% improved measured by pad test). The study on urge incontinence demonstrated that there was no difference in effect after electrical stimulation or anticholinergic drugs. CONCLUSION: The results of randomized controlled trials evaluating the effect of electrical stimulation to treat stress and urge urinary incontinence are conflicting. There is a need for more randomized controlled trials with sufficient sample sizes, use of sensitive, reproducible and valid outcome measures, and optimal stimulation parameters. Based on the present knowledge pelvic floor muscle exercise should be the first choice of treatment for stress urinary incontinence

Bo K., Talseth T., and Holme I. (1999) Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 318, 487-493.
Abstract: OBJECTIVE: To compare the effect of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment for genuine stress incontinence. DESIGN: Stratified, single blind, randomised controlled trial. SETTING: Multicentre. PARTICIPANTS: 107 women with clinically and urodynamically proved genuine stress incontinence. Mean (range) age was 49.5 (24-70) years, and mean (range) duration of symptoms 10.8 (1- 45) years. INTERVENTIONS: Pelvic floor exercise (n=25) comprised 8-12 contractions 3 times a day and exercise in groups with skilled physical therapists once a week. The electrical stimulation group (n=25) used vaginal intermittent stimulation with the MS 106 Twin at 50 Hz 30 minutes a day. The vaginal cones group (n=27) used cones for 20 minutes a day. The untreated control group (n=30) was offered the use of a continence guard. Muscle strength was measured by vaginal squeeze pressure once a month. MAIN OUTCOME MEASURES: Pad test with standardised bladder volume, and self report of severity. RESULTS: Improvement in muscle strength was significantly greater (P=0.03) after pelvic floor exercises (11.0 cm H2O (95% confidence interval 7.7 to 14.3) before v 19.2 cm H2O (15.3 to 23.1) after) than either electrical stimulation (14.8 cm H2O (10. 9 to 18.7) v 18.6 cm H2O (13.3 to 23.9)) or vaginal cones (11.8 cm H2O (8.5 to 15.1) v 15.4 cm H2O (11.1 to 19.7)). Reduction in leakage on pad test was greater in the exercise group (-30.2 g; -43. 3 to 16.9) than in the electrical stimulation group (-7.4 g; -20.9 to 6.1) and the vaginal cones group (-14.7 g; - 27.6 to -1.8). On completion of the trial one participant in the control group, 14 in the pelvic floor exercise group, three in the electrical stimulation group, and two in the vaginal cones group no longer considered themselves as having a problem. Conclusion: Training of the pelvic floor muscles is superior to electrical stimulation and vaginal cones in the treatment of genuine stress incontinence

Bo K. (2000) [Pelvic floor muscle exercise and urinary incontinence--train yourself continent!]. Tidsskr. Nor Laegeforen. 120, 3583-3589.
Abstract: BACKGROUND: Urinary incontinence is a major female health problem with prevalence rates varying between 8% and 52%. Urinary incontinence can be treated with surgery, medication, and several forms of pelvic floor muscle training. The aim of this review article is to evaluate the evidence from randomized controlled trials of pelvic floor muscle training in the treatment of urinary incontinence. MATERIAL AND METHODS: Computerised search in Medline and Sport and manual search in former published systematic reviews were undertaken. Only published articles of randomized controlled trials were included. RESULTS: Several randomized controlled trials have demonstrated that pelvic floor muscle training is more effective than no treatment and electrical stimulation in the treatment of stress incontinence. Adding biofeedback to the training has so far showed no additional effect. There is a lack of published studies on the effect of pelvic floor muscle training in urge incontinence and in men. INTERPRETATION: Female stress urinary incontinence can be effectively treated by pelvic floor muscle exercise; this is suggested as the first choice of treatment. There is a need for randomized controlled trials to evaluate the effect of pelvic floor muscle exercise in prevention of urinary incontinence

Bo K. and Berghmans L.C. (2000) Nonpharmacologic treatments for overactive bladder-pelvic floor exercises. Urology 55, 7-11.
Abstract: The theory behind the use of physical therapies (electrical stimulation or pelvic floor muscle [PFM] training with or without biofeedback) for overactive bladder is to (1) inhibit detrusor muscle contraction by voluntary contraction of the PFMs at the same time as the urge to void; and (2) prevent sudden falls in urethral pressure by a change in PFM morphology, position, and neuromuscular function. Few trials have evaluated the effect of PFM training on symptoms of overactive bladder. Most studies are flawed because they include several diagnoses and treatment modalities in the same intervention. Because of the lack of evidence, no firm conclusion can be drawn on the effect of PFM exercise on overactive bladder. There are some initially promising results, but there is still a need for high-quality, randomized controlled trials on the effect of PFM training on the inhibition of detrusor contraction in human beings. The efficacy of PFM training in combination with other treatments, such as pharmacotherapy, also requires investigation

Boccon-Gibod L. (1980) [Urinary incontinence following prostatectomy: hopes and disappointments. 42 cases (author's transl)]. Nouv. Presse Med. 9, 2339-2342.
Abstract: Between 0,5 and 1% of prostatectomies are complicated by urinary incontinence due to the destruction of both proximal and distal urethral sphincters. Any incontinence persisting more than 12 months after surgery should be considered as permanent. Among all treatments proposed (medical treatment, electrical stimulation of the perineum, various plastic operations and prostheses with varied and numerous materials), only inflatable prostheses seem to give "better than nothing results. The best treatment of post-operative incontinence, however, is preventive: extreme care should be exercised during the enucleation or trans-urethral resection of the adenoma

Bock J.U. and Jongen J. (1996) [Diagnostic and therapeutic procedures in fecal incontinence in general practice of the surgically educated proctologist]. Zentralbl. Chir 121, 659-664.
Abstract: Age related, about 10% of the general population suffer from faecal incontinence. In a surgical, proctological office diagnosis is possible with carefully taken history, physical examination, digital examination of the anorectum, rigid rectosigmoidoscopy, and anoscopy. Together with special examinations (endoanal ultrasound, electromyography, pudendal nerve terminal motor latency [PNTML], anorectal manometry, defaecography, transit time of the colon) the plan for medical and surgical treatment can be made. The basic medical conservative therapy consists of regulating the form of stool (high fibre diet and/or loperamid), training of the sphincter and pelvic muscles electrical stimulation or biofeedback training. Outpatient surgery is possible for small prolapsing tumors of the lower rectum or anal canal, hemorrhoids grade 2 or segmental anal prolapse. Inpatient surgery is needed for any form of reconstruction of the sphincter or the sensitive area of the anal canal,

Borrelli M., Alves P.R., Gama A.H., and Goes G.M. (1977) Urinary incontinence: two cases of electronic stimulation after failing the Leadbetter technique. Urol. Int. 32, 260-264.
Abstract: Two cases of urinary incontinence treated by electrical stimulation after failing the Leadbetter technique are presented. Both were first seen bearing imperforated anus. They suffered several operations for correcting this pathology and further attempting to relieve complete urinary incontinence. After a trial with intrarectal stimulation one of them received an implant. The other continued to use the anal plug. In both cases the result has been satisfactory. Cine radiological documentation of the sphincteric action of the stimulated muscles was performed

Bosch J.L. and Groen J. (1995) Sacral (S3) segmental nerve stimulation as a treatment for urge incontinence in patients with detrusor instability: results of chronic electrical stimulation using an implantable neural prosthesis. J. Urol. 154, 504-507.
Abstract: PURPOSE: We studied the effects of sacral (S3) nerve stimulation in patients with urge incontinence due to detrusor instability. MATERIALS AND METHODS: A permanent S3 foramen electrode was implanted in 18 patients (average age 46 years) who had shown a good response during temporary stimulation via a percutaneously placed wire electrode. Average followup was 29 months. RESULTS: The average voiding frequency and pad use per 24 hours decreased significantly. Improvement in several urodynamic parameters was noted. The correlation between symptomatic and urodynamic improvement was incomplete. CONCLUSIONS: Neuromodulation appears to be a valuable treatment option in these patients

Bosch J.L. and Groen J. (2000) Sacral nerve neuromodulation in the treatment of patients with refractory motor urge incontinence: long-term results of a prospective longitudinal study. J. Urol. 163, 1219-1222.
Abstract: PURPOSE: Conservative treatment rarely results in a durable cure of patients with urge incontinence and bladder overactivity. Instrumental and surgical procedures often have significant side effects and less than optimal results. We developed a technique of sacral nerve neuromodulation using chronic unilateral electrical stimulation of the S3 sacral nerve to inhibit the micturition reflex to provide effective nondestructive alternative therapy for patients whose condition is refractory to conservative treatment. MATERIALS AND METHODS: Of 85 patients 45 who responded to a test with a temporary electrode underwent implantation of a permanent S3 sacral nerve electrode coupled to a pulse generator. Treatment results were evaluated by urodynamic studies and voiding/incontinence diaries documenting pad use, incontinence episodes, voiding frequency and voided volume. Partial success and cure were defined as 50% to 90% and more than 90% improvement, respectively, in pad use and/or incontinence episodes. RESULTS: Of 45 patients 18 (40%) were cured at an average followup of 47.1 months and 9 (20%) achieved partial success. Median number of pads used and median number of incontinence episodes daily had decreased from 5.4 to 1.2 (p = 0.0001) and 7.1 to 1.3 (p = 0.0001), respectively, 6 months after implantation. Subsequently these results remained almost constant for 5 years. Bladder overactivity disappeared in 19 of the 44 patients (43%). The repeat intervention rate was 37.7% and there was no permanent injury or nerve damage. CONCLUSIONS: Sacral nerve neuromodulation is safe, effective and durable in patients with urge incontinence refractory to conservative treatment

Bouamrirene D., Micallef J.P., Rouanet P., and Bacou F. (2000) Electrical stimulation-induced changes in double-wrapped muscles for dynamic graciloplasty. Arch. Surg. 135, 1161-1167.
Abstract: HYPOTHESIS: Treatment of fecal incontinence has been greatly improved by electrical stimulation of gracilis muscle transposed around the anal canal. Various configurations of the muscle have been used: single alpha, gamma, epsilon muscle loops, split sling, or double wrap. We report herein experimental data on muscle transformation and damage induced by the latter surgical approach. DESIGN, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This study was conducted on 4 groups of New Zealand white rabbits. Group 1 had unstimulated transposed gracilis muscles. Group 2 had left transposed gracilis muscles stimulated only. Group 3 had both right and left transposed gracilis muscles stimulated. Group 4 were the controls (not operated on). Muscle properties were studied by electrophysiological,immunohistochemical,and biochemical techniques. RESULTS: Transformation from fast-contractile glycolytic muscle fibers into fast-intermediate to slow-contractile oxidative muscle fiber types induced a fatigue resistance of the transposed muscle that has undergone long-term stimulation and muscle alterations characterized by fiber atrophy and fibrosis. CONCLUSIONS: Whatever technique of dynamic graciloplasty is used, muscle degeneration associated with mobilization might result primarily from the surgical dissection, whereby collateral blood supply to the gracilis is interrupted and exacerbated by long-term stimulation

Bourcier A.P. and Juras J.C. (1995) Nonsurgical therapy for stress incontinence. Urol. Clin. North Am. 22, 613-627.
Abstract: This article discusses the therapies that have been developed for the treatment of stress incontinence due to female pelvic-floor dysfunction. A combination of pelvic muscle exercises, biofeedback, behavioral modification, and electrical stimulation are all treatment options that do not involve surgery. When physiotherapy proves successful, and surgery is avoided, it is necessary for the patient to be put on a maintenance program to avoid relapse. The authors also discuss the link between urinary stress incontinence and women involved in sports

Bratt H., Salvesen K.A., Eriksen B.C., and Kulseng-Hanssen S. (1998) Long-term effects ten years after maximal electrostimulation of the pelvic floor in women with unstable detrusor and urge incontinence. Acta Obstet. Gynecol. Scand. Suppl 168, 22-24.
Abstract: OBJECTIVE: The purpose was to study any long-term therapeutic effects of maximal electrical stimulation in female urge incontinence. METHODS: A postal questionnaire containing six questions about urinary incontinence was distributed to 30 women who had been treated with maximal stimulation because of unstable detrusor and urge incontinence 9-13 years earlier. The response rate was 90% (27 women). The mean age at follow-up was 62 years. RESULTS: Twenty-one (78%) women reported symptoms of urge incontinence. Among them, 13 had this problem daily, whereas eight only had problems weekly or even more seldom. Nineteen (70%) women reported symptoms of stress incontinence. Twenty-one women would have recommended maximal stimulation to a friend today. CONCLUSION: After approximately ten years most of the women had symptoms of urge incontinence. This was, however, a minor problem among a third of them. A majority of the women were satisfied with maximal stimulation as a treatment modality. The treatment had not prevented a later occurrence of stress incontinence

Brehmer M. and Nilsson B.Y. (2000) Elevation of sensory thresholds in the prostatic urethra after microwave thermotherapy. BJU. Int. 86, 427-431.
Abstract: OBJECTIVES: To determine whether transurethral microwave thermotherapy (TUMT) affects the sensory threshold in the posterior urethra and whether such an effect influences urinary storage symptoms. PATIENTS AND METHODS: The sensory threshold was measured before and at 3 and 12 weeks after TUMT in 13 men with minor obstructive symptoms caused by benign prostatic hyperplasia. Sensations were evoked by electrical stimulation at different frequencies, using a bipolar ring-electrode mounted on a urethral catheter. Changes in sensory thresholds were evaluated in the patients both as a group and individually. The patients were interviewed about their symptoms at each measurement. RESULTS: After TUMT, 12 patients were satisfied and reported decreased irritative symptoms, primarily less frequent nocturnal micturition; two patients were cured of urgency incontinence. In 11 of the satisfied patients, and the unsuccessful patient, decreased urge accompanied increased sensory thresholds. Thresholds elevated by >/= 30% were correlated with decreased irritative symptoms. CONCLUSIONS: TUMT decreases sensitivity in the posterior urethra, which may alleviate storage symptoms

Brown C. (1998) Pelvic floor rehabilitation: conservative treatment for incontinence. Ostomy. Wound. Manage. 44, 72-76.
Abstract: Pelvic floor rehabilitation is used to treat stress urinary incontinence, urge, and fecal incontinence as well as other pelvic floor musculature disorders. When treating patients, it is important to thoroughly assess the pelvic floor. In addition to evaluating the urinary system, sexual and bowel functions must also be considered. Treatment plans should be devised on an individual basis according to the evaluation findings. Rehabilitation goals should be established. The patient must understand the function of her urinary system and the role she must play in its control. Muscle retraining is achieved through a personalized exercise program. This program may be augmented by manual techniques, biofeedback or electrical stimulation. While the Agency for Health Care Policy and Research (AHCPR) does endorse the use of behavioral modalities in treating urinary incontinence, the use of bladder retraining and pelvic floor rehabilitation is not always recommended when indicated, nor accessible for all patients who require it. More research is needed, in addition to ongoing public and professional education on behavioral interventions in order to underline the advantages of this form of treatment for incontinence

Brubaker L., Benson J.T., Bent A., Clark A., and Shott S. (1997) Transvaginal electrical stimulation for female urinary incontinence. Am. J. Obstet. Gynecol. 177, 536-540.
Abstract: OBJECTIVE: Our purpose was to determine the objective and subjective efficacy of transvaginal electrical stimulation for treatment of common forms of urinary incontinence in women. STUDY DESIGN: A prospective, double-blind, randomized clinical trial included 121 women with either urinary incontinence caused by detrusor instability or genuine stress incontinence, or both (mixed incontinence). Participants used the assigned device for 8 weeks. Identical preintervention and postintervention assessment included multichannel urodynamic testing, quality-of-life scale, and urinary diaries. RESULTS: A total of 121 women completed this study at four North American urogynecology centers. Detrusor instability was cured (stable on provocative cystometry) in 49% of women with detrusor instability who used an active electrical device (p = 0.0004, McNemar's test), whereas there was no statistically significant change in the percentage with detrusor instability in the sham device group. There was no statistically significant difference between the preintervention and postintervention rates of genuine stress incontinence for either the active device group or the sham device group. CONCLUSION: This form of transvaginal electrical stimulation may be effective for treatment of detrusor overactivity, with or without genuine stress incontinence

Brubaker L. (2000) Electrical stimulation in overactive bladder. Urology 55, 17-23.
Abstract: Electrical stimulation is an effective and well-tolerated treatment for overactive bladder. Initial work in animals indicated the potential of this treatment, and early clinical experience in Europe further supported its likely efficacy. Although the mechanism of action of electrical stimulation remains unproven in humans, it is believed to be a neuromodulating therapy which affects the neural signaling that controls continence. There is also strong evidence that electrical stimulation affects striated muscle. The therapy can cause hypertrophy of skeletal muscle fibers, possibly by the recruitment of faster- conducting motor units, which would not normally be recruited during voluntary efforts. In addition, electrical stimulation can alter the expression of myosin isoforms, favoring a conversion to type I muscle. Despite our incomplete understanding of the mechanism of action of electrical stimulation, clinical devices have been developed quickly. Case series have been reported throughout Europe. These were followed by controlled clinical trials in the United States. There is good evidence that the use of vaginal electrical stimulators can reduce the occurrence of symptoms of overactive bladder in about half of the patients treated. Multiple uses of nonimplanted stimulation, including thigh stimulation, anal stimulation, and direct pelvic muscle stimulation, have been reported. In these trials, it is common for objective findings to be poorly correlated with subjective reports of improvements or cure. Patients frequently report that the urge-to-leak time improves, but this is difficult to measure objectively. The use of nonimplanted devices is effective and well tolerated, and should precede the use of implanted devices. A direct comparison with other effective methods of treatment for overactive bladder is warranted

Caldwell K.P. (1968) The use of electrical stimulation in urinary retention and incontinence. Proc. R. Soc. Med. 61, 703.

Caldwell K.P., Cook P.J., Flack F.C., and James E.D. (1968) Urethral pressure recordings in male incontinents under electrical stimulation. Invest Urol. 5, 572-579.

Caldwell K.P. (1974) Proceedings: Electrical stimulation. Urol. Int. 29, 225.

Caputo R.M., Benson J.T., and McClellan E. (1993) Intravaginal maximal electrical stimulation in the treatment of urinary incontinence.  J. Reprod. Med. 38, 667-671.
Abstract: Urinary incontinence imposes a large economic burden, estimated at $10 billion per year. As the cost of health care continues to rise, conservative therapeutic measures are becoming more attractive. Anecdotal reports suggest that electrical stimulation may be up to 87% effective in the treatment of urinary incontinence. Investigators use different stimulation devices and protocols and make a comparison of results difficult. The true efficacy of electrical stimulation for the treatment of urinary incontinence is unknown since there have been no controlled clinical trials. Within our referral-based urogynecology practice, we employ intermittent, intravaginal maximal electrical stimulation in conjunction with bladder drills and pelvic floor exercises. Over a one-year period we treated 76 women with urinary incontinence: 19 with stress incontinence (SUI), 30 with detrusor instability (DI) and 27 with mixed incontinence (MI). After six weeks, our overall objective improvement rate was 76%; 89% of patients with SUI, 73% with DI and 70% with MI met the criteria for improvement. Long- term follow-up averaged 6 months, with a range of 2-12. Of patients who showed an initial objective improvement, 87% maintained that improvement. Intravaginal electrical stimulation may be effective therapy for urinary incontinence. Controlled clinical trials are needed to determine its efficacy and standardize stimulation protocols before its widespread use

Chancellor M.B., Hong R.D., Rivas D.A., Watanabe T., Crewalk J.A., and Bourgeois I. (1997) Gracilis urethromyoplasty--an autologous urinary sphincter for neurologically impaired patients with stress incontinence. Spinal Cord. 35, 546-549.
Abstract: PURPOSE: To investigate the effect of a neurovascularly intact gracilis muscle urethral wrap, to be used to restore urinary continence as a transposed urinary sphincter graft, in patients with neurogenic lower urinary tract dysfunction. METHODS: Five neurologically impaired men with a denervated and damaged urinary sphincter mechanisms were treated. The etiology of sphincteric insufficiency included sphincter denervation in three patients, external sphincterotomy in one, and urethral trauma due to a chronic indwelling catheter in one. All patients underwent gracilis urethromyoplasty sphincter reconstruction. Two patients also underwent concomitant ileocystoplasty and one patient ileocystostomy because of poor bladder compliance and a bladder capacity of < 200 ml. RESULTS: The gracilis urethromyoplasty functioned as a new autologous sphincter with follow-ups ranging from 6-35 months. The surgery was successful in four patients. Three of the four patients were managed with intermittent catheterization, and one managed by ileocystostomy. The fifth patient continued to require an indwelling urethral catheter. CONCLUSION: Gracilis urethromyoplasty achieves compression of the urethra using a neurovascularly intact muscle graft. The functional urethral closure, obtained from the gracilis muscle wrap, assures dryness, and permits intermittent self-catheterization. It also avoids the risks of infection, erosion, or malfunction associated with the artificial urinary sphincter. The potential exists for electrical stimulation of this muscle graft to allow volitional control of the neo-sphincter mechanism, and voluntary voiding

Chancellor M.B., Heesakkers J.P., and Janknegt R.A. (1997) Gracilis muscle transposition with electrical stimulation for sphincteric incontinence: a new approach. World J. Urol. 15, 320-328.
Abstract: Neurovascularly intact gracilis-muscle transposition to the proximal urethra is an exciting new technique for sphincteric incontinence. The functional urethral closure of gracilis myoplasty assures dryness, permits intermittent self-catheterization when necessary, and avoids the risks of erosion associated with the artificial urinary sphincter. Electrical stimulation of the transposed muscle (dynamic urethral myoplasty) using intramuscular electrodes and a subcutaneously placed pulse generator can alter the molecular physiology of the gracilis muscle from that of predominantly fast-twitch to that of slow-twitch fibers that are fatigue-resistant and more suitable for long-term sphincter function

Collins C.D., Brown B.H., and Duthie H.L. (1968) A basis for electrical stimulation for anal continence. Scand. J. Gastroenterol. 3, 395-400.

Collins C.D., Brown B.H., and Duthie H.L. (1969) An assessment of intraluminal electrical stimulation for anal incontinence. Br. J. Surg. 56, 542-546.

Collins C.D. (1972) Urethral incontinence in women. Observations on the effect of electrical stimulation. Proc. R. Soc. Med.  65, 832-833.

Collins C.D. (1974) Proceedings: Intermittent electrical stimulation. Urol. Int. 29, 221.

Creasey G.H., Kilgore K.L., Brown-Triolo D.L., Dahlberg J.E., Peckham P.H., and Keith M.W. (2000) Reduction of costs of disability using neuroprostheses. Assist. Technol. 12, 67-75.
Abstract: The lifetime costs associated with spinal cord injury are substantial. Assistive technology that reduces complications, increases independence, or decreases the need for attendant services can provide economic as well as medical or functional benefit. This study describes two approaches for estimating the economic consequences of implanted neuroprostheses utilizing functional electrical stimulation. Life care plan analysis was used to estimate the costs of bladder and bowel care with and without a device restoring bladder and bowel function and to compare these with the costs of implementing the device. For a neuroprosthesis restoring hand grasp, the costs of implementation were compared to the potential savings in attendant care costs that could be achieved by the use of the device. The results indicate that the costs of implementing the bladder and bowel system would be recovered in 5 years, primarily from reduced costs of supplies, medications, and procedures. The costs of the hand grasp neuroprosthesis would be recovered over the lifetime of the user if attendant time was reduced only 2 hours per day and in a shorter time if attendant care was further reduced. Neither analysis includes valuation of the quality of life, which is further enhanced by the neuroprostheses through restoration of greater independence and dignity. Our results demonstrate that implantable neuroprosthetic systems provide good health care value in addition to improved independence for the disabled individual

Dahms S.E. and Tanagho E.A. (1998) The impact of sacral root anatomy on selective electrical stimulation for bladder evacuation. World J. Urol. 16, 322-328.
Abstract: Although different structures have been studied with electrostimulation to elicit bladder evacuation, only the sacral root remains feasible for clinical application at present. However, the resultant concomitant contractions of the bladder and sphincteric muscles have been the principal problem over the last few decades. Attempts to identify fibers within the sacral ventral root that innervate the detrusor predominantly have been made by microsurgery alone or in combination with advanced electrical blocking techniques. This article evaluates our past and present efforts to achieve voiding in light of the mixed nature of sacral root anatomy

Davila G.W. (1994) Urinary incontinence in women. How to help patients regain bladder control. Postgrad. Med. 96, 103-110.
Abstract: Urinary incontinence can have devastating effects on a woman's social life and physical activities. Simple diagnostic tools, including the Q- tip test and cystometry, can help identify the cause. Many causes are reversible, and an appropriate treatment regimen can bring improvement in or completely restore bladder control. Management options that may help patients avoid surgical intervention include bladder drills, pelvic floor muscle exercises, and functional electrical stimulation. Additional nonsurgical approaches are currently under investigation and should result in more options for treating urinary incontinence in women

Deen K.I., Premaratna R., Fonseka M.M., and De Silva H.J. (1998) The recto-anal inhibitory reflex: abnormal response in diabetics suggests an intrinsic neuroenteropathy. J. Gastroenterol. Hepatol. 13, 1107-1110.
Abstract: As electrical stimulation of the rectum has been shown to result in reflex internal sphincter inhibition mediated by intrinsic nerves, we aimed to evaluate the integrity of these nerves in the rectum of diabetic patients. Anal canal pressure, recto-anal inhibitory reflex (RAIR) and continence were evaluated in 30 diabetic patients (male:female 13:17, median age 57 years, range 37-70) and these data were compared with similar data obtained from 22 age- and sex-matched healthy controls (male:female 9:13, median age 51 years, range 19-65 years). Median duration of diabetes was 8 years (range 3-30). Twelve (40%) of the 30 diabetics had impaired continence for gas (n = 12) and liquid faeces (n = 3). None of the controls had incontinence. Median maximum resting anal canal pressure (MRP) was: patients 30 mmHg (range 20-75 mmHg) versus controls 40 mmHg (range 20-105 mmHg, P = 0.61). Median maximum squeeze pressure (MSP) was 65 mmHg (range 30-150 mmHg) in patients versus 84mmHg (range 35-230 mm Hg) in controls (P = 0.59). Median threshold rectal mucosal electrosensation (RMES-T) was 27mA (5- 40 mA) in patients versus 13 mA (5-28 mA) in controls (P = 0.03). Maximum tolerable rectal mucosal electrosensation was 40 mA (20-60) in patients versus 20 mA (10-30), in controls (P = 0.042, all comparisons using the Wilcoxon rank test). Recto-anal inhibitory reflex was present in eight, abnormal in five (one incontinent) and absent in 17 (11 incontinent) diabetics, while it was present in 18 and abnormal in four controls (test of proportion, P = 0.031). Blood glucose in diabetics on the day of the procedure was 98 mg/dL (70-165 mg/dL). Rectal mucosal electrosensitivity and RAIR were impaired in significantly more patients with diabetes than controls, implying impairment of intrinsic neuronal function. The recto-anal inhibitory reflex was either impaired or absent in all diabetic patients with incontinence

Dijkema H.E., Weil E.H., Mijs P.T., and Janknegt R.A. (1993) Neuromodulation of sacral nerves for incontinence and voiding dysfunctions. Clinical results and complications. Eur. Urol. 24, 72-76.
Abstract: Neuromodulation of sacral nerves is a new form of treatment for patients with refractory voiding dysfunctions such as incontinence, retention and chronic pelvic pain. Electrical stimulation of S3 activates the pelvic floor and modulates innervation of the bladder, sphincter and pelvic floor, restoring the balance and coordination in sacral reflexes. 19 of 23 patients with an implanted neuroprosthesis for neuromodulation have a more than 50% improvement in their main symptoms after a median follow-up of 12 months. In urge-incontinent patients the number of leakings decreased from 7.4 to 1.5/day, and the functional capacity increased from 135 to 227 ml

Donnelly V.S., O'Herlihy C., Campbell D.M., and O'Connell P.R. (1998) Postpartum fecal incontinence is more common in women with irritable bowel syndrome. Dis. Colon Rectum 41, 586-589.
Abstract: PURPOSE: Anal sphincter damage can occur during vaginal delivery and may lead to impairment of fecal continence. The aim of this study was to determine the influence of irritable bowel syndrome on symptoms of fecal incontinence following first vaginal delivery. METHODS: A prospective, observational study was performed before delivery, six weeks, and six months following delivery in primiparous women. A bowel function questionnaire was completed, and anal vector manometry, mucosal electrosensitivity, pudendal nerve terminal motor latency, and anal endosonography were performed. A total of 208 women were assessed before and after delivery, and 104 primigravid women were studied after delivery only. A total of 34 of 312 (11 percent) had an existing diagnosis of irritable bowel syndrome. RESULTS: The prevalence of abnormal manometry or endosonography was similar in women with and without irritable bowel syndrome. However, six weeks after delivery, women with irritable bowel syndrome had a higher incidence of defecatory urgency (64 percent) and loss of control of flatus (35 percent) compared with those without (urgency, 10 percent, P < 0.001; flatus, 13 percent, P = 0.007). The incidence of frank fecal incontinence was similar in the two groups. Women with IBS had increased mucosal sensitivity to electrical stimulation of the upper anal canal both before and after delivery. CONCLUSION: Women with IBS are more likely to experience subjective alteration of fecal continence postpartum compared with the healthy primigravid population, but they are not at increased risk of anal sphincter injury

Dorey G. (2000) Male patients with lower urinary tract symptoms. 2: Treatment. Br. J. Nurs. 9, 553-558.
Abstract: The first part of this article (Dorey, 2000) described the subjective and objective assessment of men with lower urinary tract symptoms (LUTS). This article will examine treatment protocols for stress incontinence, urge incontinence, post-prostatectomy incontinence, post- micturition dribble, overflow incontinence, reflex incontinence and functional incontinence. Pelvic floor muscle exercises, biofeedback, electrical stimulation, urge suppression techniques, and fluid intake are discussed. It is concluded that men with LUTS can benefit from conservative treatment

Dudognon P., Salle J.Y., Munoz M., Guinvarc'h S., Bouru M., and Labrousse C. (1995) [Rehabilitation of female urinary incontinence]. Rev. Prat. 45, 322-327.
Abstract: Perineal rehabilitation is an appropriate alternative to surgery in the treatment of urinary female incontinence. The most important factors influencing the success of this technique is the ability of the patient to identify correctly the muscles of the pelvic floor, to strengthen this muscles using exercises, electrical stimulation and biofeedback, to contract voluntarily the pelvic floor musculature during stress or sensation of voiding for having a preventive effect on loss of urine, and also to change, if necessary, the micturitional and drinking customs. Some conditions are required to complete a good result: strong motivation of the woman, ability of the physiotherapist or the midwife, quality of care and follow-up of the physician who must clearly know the place of this conservative treatment in selected patients, particularly in moderate stress incontinence, without important prolapse, urge incontinence, pregnancy and post-partum, two conditions in which this technique must have a preventive and curative efficiency

Dumoulin C., Seaborne D.E., Quirion-DeGirardi C., and Sullivan S.J. (1995) Pelvic-floor rehabilitation, Part 1: Comparison of two surface electrode placements during stimulation of the pelvic-floor musculature in women who are continent using bipolar interferential currents. Phys. Ther. 75, 1067-1074.
Abstract: BACKGROUND AND PURPOSE: Electrical stimulation of the pelvic floor is used as an adjunct in the conservative treatment of urinary incontinence. No consensus exists, however, regarding electrode placements for optimal stimulation of the pelvic-floor musculature. The purpose of this study was to compare two different bipolar electrode placements, one suggested by Laycock and Green (L2) the other by Dumoulin (D2), during electrical stimulation with interferential currents of the pelvic-floor musculature in continent women, using a two-group crossover design. SUBJECTS: Ten continent female volunteers, ranging in age from 20 to 39 years (mean = 27.3, SD = 5.6), were randomly assigned to one of two study groups. METHODS: Each study group received neuromuscular electrical stimulation (NMES) of the pelvic- floor musculature using both electrode placements, the order of application being reversed for each group. Force of contraction was measured as pressure (in centimeters of water [cm H2O]) exerted on a vaginal pressure probe attached to a manometer. Data were analyzed using a two-way, mixed-model analysis of variance. RESULTS: No difference in pressure was observed between the two electrode placements. Differences in current amplitude were observed, with the D2 electrode placement requiring less current amplitude to produce a maximum recorded pressure on the manometer. Subjective assessment by the subjects revealed a preference for the D2 electrode placement (7 of 10 subjects). CONCLUSION AND DISCUSSION: The lower current amplitudes required with the D2 placement to obtain recordings comparable to those obtained with the L2 technique suggest a more comfortable stimulation of the pelvic-floor muscles. The lower current amplitudes required also suggest that greater increases in pressure might be obtained with the D2 placement by increasing the current amplitude while remaining within the comfort threshold. These results will help to define treatment guidelines for a planned clinical study investigating the effects of NMES and exercise in the treatment of urinary stress incontinence in women postpartum. [Dumoulin C, Seaborne DE, Quirion-DeGirardi C, Sullivan SJ. Pelvic-floor rehabilitation, part 1: comparison of two surface electrode placements during stimulation of the pelvic-floor musculature in women who are continent using bipolar interferential currents

Duthie H.L. (1968) The use of intermittent electrical stimulation in anal incontinence. Proc. R. Soc. Med. 61, 706-707.

Eckstein H.B. (1975) Treatment of incontinence by electrical stimulation. Nurs. Times 71, 1423-1424.

Egon G., Barat M., Colombel P., Visentin C., Isambert J.L., and Guerin J. (1998) Implantation of anterior sacral root stimulators combined with posterior sacral rhizotomy in spinal injury patients. World J. Urol. 16, 342-349.
Abstract: Brindley-Finetech sacral anterior root stimulators combined with posterior sacral rhizotomy were implanted in 68 males and 28 females with spinal cord lesions. In 9 patients the electrodes were implanted extradurally in the sacrum, and in 90 patients they were implanted intradurally (3 patients had a second extradural implant after a first intradural implant). Three patients died from causes unrelated to the implant. Of the 93 surviving patients, 83 used their implants for micturition and 82 were fully continent. The mean bladder capacity increased from 206 ml preoperatively to 564 ml after the operation. Three patients had a preoperative vesicorenal reflux that disappeared after surgery. In all, 51 patients used the stimulator for defecation. Erection was possible with electrical stimulation in 46 males and was used for coitus by 17 couples. Secondary deafferentation at the level of the conus was performed four times. Three patients who had a cerebrospinal fluid leak were operated on again. Two implants had to be removed because of infection. Sacral anterior root stimulation combined with sacral deafferentation is a welcome addition to the treatment of neurogenic bladder in spinal cord injury patients

Erlandson B.E., Fall M., Carlsson C.A., and Linder L.E. (1977) Mechanisms for closure of the human urethra during intravaginal electrical stimulation. Scand. J. Urol. Nephrol. Suppl 49-54.
Abstract: The effect of intravaginal electrical stimulation (IVS) on the urethral pressure profile (UPP) before and during succinylcholine blockade or spinal anaesthesia was studied in patients with stress incontinence and in patients with clinically normal urethral function. During succinylcholine blockade, the UPP was lowered to 74% and during spinal anaesthesia to 39% of the original maximal UPP. IVS could not influence the UPP during succinylcholine blockade, while the UPP could be restored during spinal anaesthesia when the stimulation strength was increased 3 to 4 times. The following conclusions were arrived at: 1) The urethral effect of IVS is due to activation of somatic nerves and not to activation of nerves supplying smooth muscles or direct activation of striated and smooth muscles. 2) The more pronounced depression of the UPP during spinal anaesthesia compared to succinylcholine blockade should be caused by the loss of nervous activity of the smooth muscles. 3) The fact that the UPP could be restored during spinal anaesthesia indicates that activation of somatic efferents can compensate for the loss of striated and smooth muscle activity. Therefore, IVS can control incontinence in partial lower motor neuron lesions, provided a sufficient number of efferent neurons are preserved

Erlandson B.E., Fall M., and Carlsson C.A. (1977) The effect of intravaginal electrical stimulation on the feline urethra and urinary bladder. Electrical parameters. Scand. J. Urol. Nephrol. Suppl 5-18.
Abstract: Intravaginal electrical stimulation (IVS) in cats caused urethral closure and bladder inhibition. The aim was to ascertain the electrical parameters most appropriate for these effects. Minimum voltage was used as main criterion to select an effective, non-destructive stimulation when the shape, frequency and duration of the pulses were systematically varied. Urethral closure was achieved at minimum voltage (3 V) with alternating pulses at a frequency of 50 Hz and a pulse duration of 1.5 ms. Corresponding optimal parameters for bladder inhibition were: alternating pulses, 10 Hz and 1.5 ms. Minimum voltage was 1 V. Moreover, the positions of the electrodes were of significance for the responses. The clinical implications of these findings are that: 1)more differentiated treatment of incontinence could be achieved by adapting the stimulation parameters to the cause of incontinence, and 2) specific electrode positions would probably give optimal responses

Erlandson B.E., Fall M., and Sundin T. (1977) Intravaginal electrical stimulation. Clinical experiments of urethral closure. Scand. J. Urol. Nephrol. Suppl 31-39.
Abstract: The effect on the urethra of intravaginal electrical stimulation (IVS) was registered by means of urethral pressure profiles (UPP). With the object of finding the most appropriate electrical parameters and optimal electrode positions within the vagina, 24 patients with stress incontinence, 22 with urgency and 4 continent women were studied. Electrical stimulation was given via an obturator with seven electrodes, which could be connected in different combinations of pairs. In all the women, stimulation with the electrodes in specific positions effected a more marked rise in the UPPs than with the electrodes in other positions. A change in position of more than 5 to 10 mm caused a decrease in the response. It was determined that a frequency of between 20 to 50 Hz with a pulse duration of 1 to 5 ms was most effective for urethral closure

Esa A., Kiwamoto H., Sugiyama T., Park Y.C., Kaneko S., and Kurita T. (1991) Functional electrical stimulation in the management of incontinence: studies of urodynamics. Int. Urol. Nephrol. 23, 135-141.
Abstract: Intermittent functional electrical stimulation (FES) was employed for the control of incontinence. One FES session lasted for 30 minutes. It was repeated at intervals of 3 days to 1 week via an anal plug electrode. The success rate was 64% in 41 patients with pollakiuria, urgency and/or urge incontinence, and 43% in 7 patients with stress incontinence. Detrusor activity measured by cystometry did not correlate significantly with the effect on subjective symptoms and the urethral pressure did not increase. The remarkable clinical effect was observed in patients with overactive detrusor function. It seems that FES indirectly inhibits detrusor contraction by suppressing the intrasacral pathway for detrusor activity

Fall M., Erlandson B.E., Sundin T., and Waagstein F. (1977) Intravaginal electrical stimulation. Clinical experiments on bladder inhibition. Scand. J. Urol. Nephrol. Suppl 41-47.
Abstract: The effect of intravaginal electrical stimulation (IVS) on the bladder in 17 patients with motor detrusor instability was explored. Isotonic volume registrations and cystometries were used for evaluation of volume increase and inhibition of abortive detrusor contractions. With either one or the other method, bladder inhibition was found in all patients, but with both methods only in 6. During isotonic volume registration, the volume increase showed considerable variations ranging between 4 to 465%, and during cystometry between 11 to 3500%. Bladder inhibition proved to be most effective when using a frequency of 10 Hz

Fall M., Erlandson B.E., Nilson A.E., and Sundin T. (1977) Long-term intravaginal electrical stimulation in urge and stress incontinence. Scand. J. Urol. Nephrol. Suppl 55-63.
Abstract: Using a new device for intravaginal electrical stimulation (IVS), 24 women with pure stress incontinence, mixed urge and stress incontinence or urge incontinence due to detrusor instability, were treated. To minimize mechanical discomfort, the electrode carrier was made of flexible material and inflatable. Furthermore, this design facilitated fixed, constant positioning of the electrodes at individually tested sites to produce maximum response at voltage well tolerated by the patient. The stimulation frequency was adjusted to suit the cause of incontinence: 20 to 50 Hz in stress incontinence, 10 Hz detrusor instability. The electrode carrier was well accepted. Seven of the 9 patients with pure stress incontinence became continent during IVS. Three of them have so far remained continent for 2 to 8 months without IVS. The 15 patients with detrusor instability or mixed incontinence were all free from symptoms after IVS for more than 3 months. Two of them have remained cured for more than 3 months after they had stopped IVS

Fall M., Erlandson B.E., Carlsson C.A., and Sundin T. (1978) Effects of electrical intravaginal stimulation on bladder volume: an experimental and clinical study. Urol. Int. 33, 440-442.
Abstract: Clinical observations have indicated that not only stress incontinence due to defective urethral closure but also urge incontinence due to bladder hyperactivity can be successfully treated by electrical stimulation of the pelvic floor. Clinical investigations revealed that intravaginal electrical stimulation caused bladder inhibition registered as a volume increase. This inhibition was most marked at a low stimulation frequency (10 Hz). Animal experiments indicated that the bladder inhibition was achieved by autonomic spinal reflex mechanisms activated by stimulation of pudendal afferents

Fall M. (1984) Does electrostimulation cure urinary incontinence? J. Urol. 131, 664-667.
Abstract: A followup study is presented of a prospective series of women treated with an inflatable intravaginal electrode carrier and an external pulse generator. The devices were individually adjustable with respect to electrode positioning and stimulation parameters. The study included 40 women with detrusor instability and/or genuine stress incontinence. The primary results for urge symptoms were favorable. Of the patients 73 per cent were primarily free of symptoms during treatment and 45 per cent remained free of symptoms after withdrawal of treatment, including two-thirds in whom re-education persisted during the followup of 6 years. Of the patients with genuine stress incontinence 40 per cent exhibited persistent re-education. There were considerable discrepancies between symptomatic cure or improvement, and the urodynamic findings at followup. Intravaginal electrical stimulation may be regarded as the treatment of choice for urge incontinence due to detrusor instability, and in mixed stress and urge incontinence. The method also is an alternative to an operation in some women with genuine stress incontinence

Fall M., Ahlstrom K., Carlsson C.A., Ek A., Erlandson B.E., Frankenberg S., and Mattiasson A. (1986) Contelle: pelvic floor stimulator for female stress-urge incontinence. A multicenter study. Urology 27, 282-287.
Abstract: The clinical efficacy of a new device for treatment of female incontinence was studied in a multicenter trial. The device consists of an inflatable electrode carrier and an external stimulator unit. Forty women were treated: 10 had primary or recurrent genuine stress incontinence, 15 had urge incontinence due to idiopathic detrusor instability, not responding to drug treatment, and 15 had stress incontinence combined with detrusor instability. Twenty-five patients were improved by the treatment. Another 8 reported an excellent result of treatment and remained free of symptoms for more than six months after withdrawal of the treatment. The results were more favorable in patients with bladder hyperactivity than in genuine stress incontinence. The patients' general ratings of treatment efficacy correlated well with their recordings of urinary frequency and consumption of incontinence pads. The functional bladder capacity increased in improved patients, but normalization of urodynamic parameters was no prerequisite for clinical improvement. We found intravaginal electrical stimulation to be a valuable alternative to medical and surgical intervention in patients with detrusor instability

Fall M. and Lindstrom S. (1991) Electrical stimulation. A physiologic approach to the treatment of urinary incontinence. Urol. Clin. North Am. 18, 393-407.
Abstract: Appropriate management of patients with urinary incontinence requires access to a variety of methods. Electrical stimulation, although so far proportionally small in the armamentarium of methods, is founded on physiologic principles and has the advantage of being curative without significant side effects

Fall M. (1998) Advantages and pitfalls of functional electrical stimulation. Acta Obstet. Gynecol. Scand. Suppl 168, 16-21.
Abstract: Functional electrical stimulation has many theoretical advantages. In clinical practice, very favorable results have been repeatedly presented. The experience now encompasses thirty years and a very large number of incontinent patients. Although the methods are widely used, they are differently appreciated. Problems include the fact that functional electrical stimulation does not belong to the therapeutic traditions in urology and gynecology, there is a need of personal training for successful treatment and there is a lack of systematic studies on different clinical applications. Significant advantages are a rational physiological basis, applicability in a variety of lower urinary tract dysfunctions, few side effects and a potential curative effect

Flack F.C. (1968) The use of electrical stimulation in urinary retention and incontinence. Proc. R. Soc. Med. 61, 704.

Flannery J.F., Ellis F.G., and Lale P.G. (1969) Electrical stimulation of the striated urinary sphincter mechanism. Br. J. Surg. 56, 632.

Formal C.S., Cawley M.F., and Stiens S.A. (1997) Spinal cord injury rehabilitation. 3. Functional outcomes. Arch. Phys. Med. Rehabil. 78, S59-S64.
Abstract: This self-directed learning module highlights new advances in this topic area. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article contains information about mobility, ambulation, upper extremity function, bowel management, and technology to enhance function in the community. New advances covered in this section include functional electrical stimulation for enhancing mobility and upper extremity function

Fossberg E., Sorensen S., Ruutu M., Bakke A., Stien R., Henriksson L., and Kinn A.C. (1990) Maximal electrical stimulation in the treatment of unstable detrusor and urge incontinence. Eur. Urol. 18, 120-123.
Abstract: Ninety-one patients with unstable detrusor and urge incontinence were treated with maximal electrical stimulation. There were 17 dropouts. From the remaining 74 patients 51 were subjectively cured or significantly improved, this effect lasted for more than 6 weeks in 40. Objectively a significant decrease in frequency was found, also a significant increase in bladder volume. No effect on detrusor pressure at bladder contraction was noted

Geirsson G. and Fall M. (1997) Maximal functional electrical stimulation in routine practice. Neurourol. Urodyn. 16, 559-565.
Abstract: Maximal functional electrical stimulation is now an established treatment for urgency and urge incontinence. Many studies have been presented with good and consistent results. In a number of prospective studies we have previously recorded very favourable effects in stress incontinence and urge incontinence. In the present study, we have compared our previous experience with a retrospective analysis of a series of maximal functional electrical stimulation given according to a simple routine protocol and including 84 patients. The overall subjective improvement rate was 54% but the cure rate was only 5%, which is far below our experience in previous studies, as well as in others. The subjective outcome was in agreement with changes in mictrurition variables as recorded in voiding diaries. The discrepancy probably depends on a number of factors. It is suggested that the most crucial ones are patient selection, the intensity of stimulation, and the number of sessions given. It is important to realize the limitations and pitfalls of the technique when it is applied in routine practice

George B.D., Williams N.S., Patel J., Swash M., and Watkins E.S. (1993) Physiological and histochemical adaptation of the electrically stimulated gracilis muscle to neoanal sphincter function. Br. J. Surg. 80, 1342-1346.
Abstract: The physiological and histochemical characteristics of the gracilis muscle were studied in 19 patients undergoing electrically stimulated gracilis neosphincter construction. Indications for surgery were faecal incontinence (n = 11) and reconstruction following sphincter excision or congenital absence (n = 8). Transposition of the gracilis muscle around the anal canal followed by chronic low-frequency electrical stimulation was associated with a shift in the frequency-response curve and a prolongation of the time-course of individual muscle twitches suggestive of transformation to a slow-twitch fatigue-resistant type. Temporary cessation of electrical stimulation resulted in a reversal of the frequency-response changes. Muscle biopsies taken before and a median of 80 (range 49-137) days after transposition and low-frequency electrical stimulation indicated a significant increase in the proportion of type 1 fibres and a significant decrease in their diameter. These results show that the human gracilis muscle is capable of physiological and histochemical adaptation to long-term neosphincter function

Gladh G., Mattsson S., and Lindstrom S. (2001) Anogenital electrical stimulation as treatment of urge incontinence in children. BJU. Int. 87, 366-371.
Abstract: OBJECTIVES: To evaluate retrospectively the result of anogenital afferent stimulation (AGAS) in neurological healthy children with therapy-resistant urge incontinence. PATIENTS AND METHODS: The study included 48 children (24 girls and 24 boys, 5-14 years old) with a diagnosis of bladder instability verified by cystometry in all. Anogenital afferent stimulations were applied using a battery-powered dual constant-current stimulator. The children were stimulated continuously at 10 Hz for 20 min once or twice daily and if required the children and/or the parents continued to apply the treatment at home. For home stimulation a single (anal) channel stimulator was used. The patients were instructed to stimulate for 20 min at maximum intensity two to three times a week until the effects were optimal. The outcome was evaluated retrospectively by comparing voiding/incontinence diaries obtained before and at the follow-up 6-12 months after the end of treatment. RESULTS: AGAS was applied at the clinic for a median (range) of 9 (4-20) times. Thirty-one children continued with home stimulation for another 25 (5-96) sessions. At the follow-up, 18 children were cured and another seven improved, with a leakage score of less than half that before treatment. The treatment was well tolerated by most children. CONCLUSIONS: Anogenital afferent stimulation is an effective, potentially curative treatment in children with severe urge incontinence. Home stimulation is a well accepted adjuvant to treatment at the clinic and improves the outcome

Godec C., Cass A.S., and Ayala G.F. (1975) Bladder inhibition with functional electrical stimulation. Urology 6, 663-666.
Abstract: Spastic or hyperreflex bladder dysfunction can cause frequency, urgency, and incontinence. Detrusor activity was inhibited by FES (functional electrical stimulation) applied to the anal sphincter causing decreased bladder spasticity and increased bladder capacity. FES is indicated for incontinence not only because of weakness of the pelvic floor but also because of hyperreflex bladder

Godec C. and Kralj B. (1976) Selection of patients with urinary incontinence for application of functional electrical stimulation. Urol. Int. 31, 124-128.
Abstract: Contradictory data from the literature along with our own experience using functional electrical stimulation (FES) have facilitated the determination of objective criteria for the application of FES in correcting urinary incontinence. Simultaneous urodynamic, neurophysiological, and radiological examinations employed during our studies enabled us to determine changes in these parameters due to FEX. Among a large number of patients with urinary incontinence (for example: paraplegics, patients with spina bifida, stress incontinence following prostate operations, or resistant enuresis) we have determined that FES is appropriate if applied to properly selected patients. FES is indicated on the basis of the following criteria: the degree of morphological lesion of the urinary tract, the peripheral denervation of the muscles of the pelvic floor, the condition of the spinal center for miction, and, above all the quality of response to FES. FES not only activates the closing muscles of the bladder, but also inhibits the reflex contractions of the detrusor. Here, it should be noted that FES is indicated for cases of reflex incontinence. During FES of the pelvic floor muscles intravesical pressure normally diminishes and the reflex contractions of the detrusor subside. Sometimes, however, the reflex of miction occurs. In such a case, two reflex mechanisms are engaged. Their equilibrium, i.e. controlled miction, can be achieved with an afferent in flow which inhibits the reflex of miction. The use of FES for the correction of urinary incontinence can be a very good method if the FES parameters are individually chosen and patients properly selected

Godec C., Cass A.S., and Ayala G.F. (1976) Electrical stimulation for incontinence. Technique, selection, and results. Urology 7, 388-397.
Abstract: Incontinence due to hyperreflexic bladder and/or pelvic floor weakness can be corrected by chronic functional electrical stimulation (FES). Cystometry, electromyography of pelvic floor muscles, and anal sphincter pressure measurements with and without electrical stimulation determines if chronic FES will be successful. Post-acute stimulation improvement occurred in patients with incontinence due to hyperreflexic bladder and/or pelvic floor weakness. A success rate of 92 per cent was achieved with chronic FES in incontinent patients with this method of selection

Godec C., Ayala G., and Cass A. (1977) Electrical stimulation of the rectal ampulla causing reflex voiding. J. Urol. 117, 770-772.
Abstract: Electrical stimulation of the rectal ampulla resulted in a desire to void and defecate in 11 patients with an intact nervous system. There was a contraction of the detrusor and the rectal ampulla with relaxation of the anal sphincter. Electrical stimulation of the rectal ampulla and anal sphincter has clinical applications in patients with incontinence of, or inability to empty, the lower urinary tract or fecal system

Godec C. and Cass A. (1978) Acute electrical stimulation for urinary incontinence. Urology 12, 340-341.
Abstract: Acute or maximal electric stimulation of the pelvic floor muscles has been used in incontinent patients who are suitable candidates for electrical stimulation, but unwilling or unable to use the anal plug electrodes. Seventeen of 20 patients had relief or improvement of their incontinence. However 5 of these 17 patients had a relapse of symptoms on follow-up, requiring a repeat treatment with acute or maximal electrical stimulation

Godec C. and Cass A.S. (1978) Electrical stimulation in the management of incontinence in children. Minn. Med. 61, 157-160.

Godec C. and Cass A.S. (1979) Electrical stimulation for voiding dysfunction after spinal cord injury. J. Urol. 121, 73-75.
Abstract: Incontinence and frequency of voiding were present after spinal cord injuries in 18 patients. A hyperreflexic bladder and/or pelvic floor weakness was found in these patients. Functional electrical stimulation resulted in relief or improvement of symptoms in 9 of the 11 patients in whom this procedure was used. An increase in anal sphincter pressure with functional electrical stimulation was a more reliable criterion than an increase in maximum urethral pressure in the selection of patients for the procedure

Godec C.J. and Cass A.S. (1978) Electrical stimulation for incontinence in myelomeningocele. J. Urol. 120, 729-731.
Abstract: Urinary incontinence is the most obvious urinary tract complication in children with myelomeningocele. Incontinence is owing to a hyperreflexic (spastic) bladder and/or pelvic floor weakness, which responds to functional electrical stimulation. Of 33 incontinent children the criteria for functional electrical stimulation were absent in 21 because of denervation of the pelvic floor muscles. Of 6 children who used functional electrical stimulation 5 had a successful result. However, incontinence recurred in 3 of the 5 patients between 6 and 18 months after functional electrical stimulation treatment was completed and they are awaiting repeat treatment

Godec C.J., Fravel R., and Cass A.S. (1981) Optimal parameters of electrical stimulation in the treatment of urinary incontinence. Invest Urol. 18, 239-241.
Abstract: We evaluated five types of electrical stimulation (continuous, intermittent pseudorandomized, randomized (stochastic), and intermittent randomized) for their effects on muscle contraction and muscle fatigue in 12 patients with urinary incontinence. Continuous stimulation, used in the available commercial stimulators, was not optimal. Randomized (stochastic) stimulation seems to be optimal although this conclusion was not statistically confirmed

Gonzalez-Chamorro F., Verdu T.F., and Hernandez F.C. (1997) [Current status of neurostimulation and neuromodulation for vesicourethral dysfunction]. Arch. Esp. Urol. 50, 687-694.
Abstract: OBJECTIVE: To describe the current indications, techniques and results of sacral root stimulation in patients with spinal cord lesions as a treatment for patients with high pressure bladders and/or urinary incontinence despite conservative management, as well as sacral root neuromodulation with permanent stimulators for complex bladder dysfunction: vesical instability, sensory urgency, chronic pelvic pain and chronic voiding dysfunction. METHODS/RESULTS: The literature is reviewed, both techniques are described and the results of the most significant series are discussed, with special reference to the first groups that utilized these techniques. CONCLUSIONS: There is ample experience in the application of sacral root electrical stimulation. The reported results are comparable with those achieved by other treatments, such as augmentation cystoplasty. Neurostimulation and neuromodulation techniques are simple, the complications are minimal and they do not prelude the use of other therapies

Gonzalez-Chamorro F., Esteban F.M., Tamayo Ruiz J.C., Angulo C.J., and Sanchez-Chapado M. (1998) [Electric stimulation of sacral roots for the treatment of urinary incontinence due to detrusor instability: application of a technique and results in a clinical case]. Arch. Esp. Urol. 51, 278-283.
Abstract: OBJECTIVE: To describe a case treated with a new technique in our therapeutic algorithm for non-neurogenic vesicourethral dysfunction. METHODS/RESULTS: A 47-year-old female underwent retropubic urethropexy for stress urinary incontinence. She remained incontinent due to detrusor instability to a degree that was socially unacceptable. After conservative treatment had failed, a percutaneous electrode was applied to the sacral nerve root and she received electrical stimulation of 4-6 milliamperes, 15 Hz and 200 microseconds duration for 7 days. Incontinence remitted for as long as 3 months after the electrode had been removed. CONCLUSION: The results achieved with sacral nerve electrical stimulation reported in the literature and our results support the use of this technique in urological clinical practice

Grandjean P., Acker M., Madoff R., Williams N.S., Woloszko J., and Kantor C. (1996) Dynamic myoplasty: surgical transfer and stimulation of skeletal muscle for functional substitution or enhancement. J. Rehabil. Res. Dev. 33, 133-144.
Abstract: Dynamic myoplasty combines muscle transfer with electrical stimulation to provide contractile function that augments or replaces impaired organ function. Dynamic cardiomyoplasty was the first clinical application in which a skeletal muscle, latissimus dorsi, was transferred and stimulated to provide cardiac assistance, a function different from its original one. The problem of early muscle fatigue that was encountered in the initial implementation of the method was solved by training the muscle with electrical stimulation and thus changing its fiber composition. With intramuscular electrodes, the conditioned latissimus dorsi is stimulated in synchrony with the heart muscle. Safeguards are built into the two-channel implanted stimulator to avoid excessively high pulse rates. Clinicians report that 80% of patients with moderate to severe heart failure prior to operation showed a clinical improvement of 1.6 New York Heart Association classes. Alternative methods of providing cardiac assistance that are also being investigated include wrapping the muscle around the aorta, creating a skeletal muscle ventricle, and using the muscle to power an implantable pump. These latter techniques are still under preclinical investigation. Compared with heart transplant, cardiomyoplasty has the great advantage of not being subject to tissue rejection. The second principal application of dynamic myoplasty is treatment of fecal incontinence through creation of an electrically stimulated skeletal muscle neosphincter (ESMNS). The gracilis muscle of the leg is mobilized, wrapped around the anal canal, and conditioned with electrical stimulation to become more fatigue resistant. To achieve continence, the muscle is continuously stimulated except when the patient wishes to defecate. Overall success rates in achieving continence are 60-65%. Both cardiomyoplasty and the ESMNS technique, and their associated devices, are being refined through ongoing clinical trials

Halverstadt D.B. (1971) Electrical stimulation of the human bladder: 3 years later. J. Urol. 106, 673-677.

Hay-Smith E.J., Bo K., Berghmans L.C., Hendriks H.J., de Bie R.A., and van W. (2001) Pelvic floor muscle training for urinary incontinence in women (Cochrane Review). Cochrane. Database. Syst. Rev. 1, CD001407.
Abstract: BACKGROUND: Pelvic floor muscle training is the most commonly recommended physical therapy treatment for women with stress leakage of urine. It is also used in the treatment of women with mixed incontinence, and less commonly for urge incontinence. Adjuncts, such as biofeedback or electrical stimulation, are also commonly used with pelvic floor muscle training. The content of pelvic floor muscle training programmes is highly variable. OBJECTIVES: To determine the effects of pelvic floor muscle training for women with symptoms or urodynamic diagnoses of stress, urge and mixed incontinence, in comparison to no treatment or other treatment options. SEARCH STRATEGY: Search strategy: We searched the Cochrane Incontinence Group trials register (May 2000), Medline (1980 to 1998), Embase (1980 to 1998), the database of the Dutch National Institute of Allied Health Professions (to 1998), the database of the Cochrane Rehabilitation and Related Therapies Field (to 1998), Physiotherapy Index (to 1998) and the reference lists of relevant articles. We handsearched the proceedings of the International Continence Society (1980 to 2000). We contacted investigators in the field to locate studies. Date of the most recent searches: May 2000. SELECTION CRITERIA: Randomised trials in women with symptoms or urodynami