Management of Pelvic Floor Dysfunction: Dry Needling, Exercise & Electroacupuncture

The prevalence of pelvic floor dysfunction varies by condition.^{1, 2} While stress and urge urinary incontinence affects 15.7% to 49.6% of women, the prevalence of pelvic organ prolapse and interstitial cystitis ranges from 2.9% to 41.1% and 2.3% to 22% of the population, respectively.² Notably, women tend to be impacted by pelvic floor dysfunction significantly more than men for a number of reasons, including differences in anatomy, hormonal changes and/or pregnancy.¹ Pelvic floor dysfunction also seems to increase with age.^{1, 2} In general, muscles, ligaments and other connective tissues tend to deteriorate with age, and the same is true for the soft tissue structures related to the pelvic floor.^{1, 2} A number of investigators have estimated that, as the population ages, the number of individuals suffering from pelvic floor dysfunction will increase from 28 million in 2010 to 44 million by 2050.¹ Therefore, the demand for affordable and effective treatment options for pelvic floor dysfunction is expected to grow exponentially.²

PELVIC FLOOR MUSCLE TRAINING

While the induction of the Women’s Health Section into the American Physical Therapy Association in 1977 brought significantly more attention to pelvic floor dysfunction, physical therapists have been treating both men and women with the condition for decades.³ Traditionally, clinicians have used exercise, manual therapy, behavioral modification and biofeedback to treat pelvic floor dysfunction.⁴ Though many have proposed that global muscle training such as yoga and Tai Chi may benefit those with stress incontinence, these exercise approaches have not yet been shown in controlled trials to affect pelvic floor dysfunction.^{5, 6} Rather, specific pelvic floor muscle strengthening and manual stretching has been found to be the most effective type of exercise for incontinence and pelvic pain.^{5, 6} Strengthening exercises have demonstrated between 35% and 80% cure rates in patients with stress incontinence at 3-6 months following intervention.^{4, 7} However, positive long-term outcomes are often not maintained due in part to poor compliance with the strengthening exercise program.^{4, 8} It is perhaps worth noting that a 2006 Cochrane review found outcomes of pelvic floor muscle training to be more robust in younger women and in women with stress incontinence versus urge or mixed incontinence.⁹ Nevertheless, this same review concluded that pelvic floor muscle training should be considered a first-line conservative treatment for urinary incontinence.⁹

Pelvic floor muscle training augmented with visual and auditory biofeedback has been shown to be effective in patients with urinary incontinence.¹⁰ According to Rett et al,¹⁰ “Bio- feedback is useful in promoting correct contraction control and visualization of muscle activity because many women are unaware of the correct way to contract their pelvic floor muscles….”⁴ In a study by Huebner et al,¹¹ women that completed pelvic floor muscle training with biofeedback combined with electric stimulation, dynamic electric stimulation or vaginal electrodes all reported significant improvements in quality of life at 4, 8 and 12 weeks post-treatment.⁴ Moreover, in a recent randomized controlled trial involving 390 women, Dannecker et al found 71% of patients with stress or mixed urinary incontinence reported significant improvements 7 years following pelvic floor muscle training combined with biofeedback.¹² Nevertheless, while a 2011 Cochrane review¹² reported an added benefit of using biofeedback with pelvic floor muscle training, it remains to be elucidated whether the feedback (i.e. supervised treatment) or biofeedback resulted in the beneficial effects. A number of authors further recommend vaginal pessaries—an intravaginal device used to support the neck of the bladder, increase urethral length, and compress the urethra against the pubic bone during intra-abdominal pressure—as a first-line treatment for urinary incontinence.^{4, 13, 14}   While behavioral modification, including bladder training (i.e. frequency and duration of normal stream), voiding diaries, fluid intake and avoidance of bladder irritants has also been shown to be an integral component to rehabilitation for urinary incontinence,^{4, 15} use of pessaries, as opposed to behavioral training alone, appears to give superior outcomes at 3 months.¹⁶

DRY NEEDLING FOR PELVIC FLOOR DYSFUNCTION

While the terminology, philosophy and theoretical constructs differ between Western-based dry needling and traditional Chinese acupuncture, the procedure of inserting monofilament needles is similar.¹⁷ Therefore, manual and electric dry needling are used synonymously with manual and electroacupuncture, respectively, throughout this article to describe needling procedures that penetrate the skin in the absence of injectate.^{17, 18} A number of clinicians have demonstrated successful outcomes by dry needling the pelvic floor, but most studies rely on an intramuscular, myofascial trigger point framework.^{19, 20} Given the poor inter-examiner reliability and lack of validity for the location of muscular trigger points using manual palpation,^{21, 22} the trauma to viable muscle tissue associated with repeated needle pistoning,²³ and the limited clinical relevance associated with elicitation of the localized twitch response,²⁴ dry needling to target and prick muscular trigger points one at time has come under increased scrutiny.^{17, 18, 24, 25} Therefore, perhaps the use of needle rotation and multiple needles in situ with electric stimulation for typically 20-30 minutes on average, as is classically and widely practiced by medical physicians, physical therapists and acupuncturists for neck and low back pain,^{18, 19, 25} deserves further consideration for the treatment of pelvic floor dysfunction.

PERI-NEURAL NEEDLING – SACRAL NERVE ROOTS & PUDENDAL NERVE

A number of case series and randomized controlled trials have reported up to 70% success rates in treating stress, urge and mixed incontinence with implanted stimulation devices in the vicinity of the sacral nerve roots and the pudendal nerve.^18–20 Nevertheless, as with any invasive surgery, major and minor adverse events can occur. More specifically, pain at the stimulation site (15.3%), new pain (9%), pain at the lead site (5.4%), suspected lead migration (8.4%), infection (6%), transient electric shock (5.5%) and changes in bowel function (3%) have all been reported as complications following implantation of stimulation devices.¹⁹ However, a number of studies have also reported success in treating urinary incontinence with electroacupuncture.^26-29 Notably, common insertion points include BL31-33 (within the S1-3 sacral foramina) and BL35 (half a fingerbreadth lateral to tip of the coccyx), which directly correspond anatomically with the S1-S3 sacral nerve roots and the pudendal nerve.²⁹ Given that the bladder is parasympathetically innervated by S2-S4, electroacupuncture at 5Hz³⁰ consistent with the S1-S3 nerve roots may facilitate better control of micturition.²⁹ More specifically, electroacupuncture at BL31-33 and BL35 may stimulate afferent fibers of the pudendal nerve to reflexively inhibit the parasympathetic innervation of the bladder and the activation of the detrusor muscle via the sacral micturition center, thereby reducing the urge to urinate.^{29, 31} In addition, electroacupuncture in the vicinity of the sacrum is thought to activate the pelvic floor muscles and the striated peri-urethral musculature, which may facilitate better active control of the urethral sphincter.^31-33 While BL31-33 and BL35 are the most frequently used acupoints for incontinence, it is also perhaps worth noting that BL23 (2 fingerbreadths lateral of the L2 spinous process), BL28 (2 fingers lateral of the S2 spinous process), and CV2-6 (over the lower abdomen between the upper margin of the pubic symphysis and just below the umbilicus) are also commonly used because of their influence on the spinal micturition center and the parasympathetic innervation of the urinary tract.^{29, 34, 35}

Studies that have attempted to treat stress and mixed urinary incontinence with sacral acupoints (3 times per week for 1 month) have reported up to 90% effectiveness rates for improvement in quality of life.^{36, 37} In a more recent case series of 25 patients with mixed urinary incontinence, Chen et al performed electroacupuncture at BL33 and BL35 (30-minute treatment sessions, 3 times per week for 12 weeks) and reported a 52% cure rate and a 96% effectiveness rate.³⁸ That is, 13 of 25 patients were cured of urinary incontinence following 12 weeks of electroacupuncture, and 24 of 25 reported significant improvement in both quality of life and psychosocial aspects of the condition.³⁸ Additionally, Si-you et al⁴⁰ reported a 100% symptom improvement in 22 of 31 patients treated for stress incontinence with 4 sacral acupoints for 21 treatments compared with 100% symptom improvement in 0 of 34 patients receiving traditional Chinese acupuncture for 30 treatments.³⁹ While the results of many of these studies sound promising, they must be considered cautiously due to low methodologic quality.^{28, 40} Nevertheless, Xu et al²⁹ recently published one of the only randomized controlled trials on the use of sacral acupoints for incontinence. After 6 weeks of verum electroacupuncture (3 times per week), patients with stress incontinence reported significantly less urine leakage, reduced frequency of incontinence episodes, improved function (International Consultation on Incontinence Questionnaire-Short Form) and satisfaction following treatment when compared to non-penetrating sham electroacupuncture.²⁸

PERI-NEURAL NEEDLING – POSTERIOR TIBIAL NERVE

A number of studies have used peri-neural needling to the posterior tibial nerve to successfully treat overactive bladder and pelvic floor dysfunction.^{30, 41-43} The posterior tibial nerve is a mixed nerve with sensory and motor components with axons that pass through the L4-S3 spinal roots, the same spinal segments that innervate the bladder and pelvic floor, which may facilitate better somatic control of the pelvic floor muscles, to include the striated urethral sphincter.^{44, 45} Electrical stimulation of the posterior tibial nerve may inhibit bladder activity by modulating the pontine micturition center (PMC).^{29, 30, 46} As the bladder fills, afferent information is delivered to the PMC via the spinotegmental tract. The PMC then sends efferent signals to inhibit the thoracolumbar sympathetic nucleus and the sacral pudendal nerves while stimulating the sacral parasympathetic nucleus, resulting in relaxation of the bladder neck and external urethral sphincter, leading to micturition.⁴⁷ Normally, the PMC is tonically inhibited by enkephalons. Previous studies have found enkephalon injections increase the threshold for micturition, while naloxone, an opioid receptor antagonist, has the opposite effect.^{47, 48} Given that acupuncture has been shown to increase opioids within the central nervous system,¹⁸ a number of researchers have hypothesized that acupuncture may strengthen the inhibition of the PMC, thereby improving symptoms related to incontinence.⁴⁹ Staskin et al found that percutaneous stimulation of the posterior tibial nerve between 5 and 30 Hz (but most commonly 20 Hz) could effectively produce inhibition of the micturition reflex pathway and thereby improve bladder capacity.³⁰

Notably, one of the safest and most effective ways of stimulating the posterior tibial nerve is through a needle insertion at SP6 (posterior to the medial border of the tibia, 4 fingerbreadths proximal to the medial malleolus).²⁹ Used for centuries within traditional Chinese medicine to treat disorders associated with the urinary system, more than 30 trials have reported outcomes on the use of electroacupuncture to the posterior tibial nerve for incontinence.⁴⁵ In a double blind, sham controlled trial, electroacupuncture at SP6 resulted in a reduction in the number of voids and urge incontinence episodes from 3 to 0.3 per day compared to 1.8 to 1 in the sham group at 12 weeks.^{45, 50} Finazzi-Agro et al⁴³ also reported a significant increase in the volume of voided urine compared to sham, and Peters et al^{45, 46} found no difference in the number of daily incontinence episodes, voids per day and nocturia between patients receiving electroacupuncture at SP6 and tolterodine, an antimuscarinic drug used to treat incontinence. Stoller et al further performed electroacupuncture on the posterior tibial nerve of patients with urinary urge incontinence and/or pelvic pain and reported an 81% success rate in 90 patients at a 5-year follow-up.⁵¹

ELECTROACUPUNCTURE FOR INCONTINENCE

In a 2013 systematic review of randomized controlled trials, Paik et al³⁰ reported insufficient evidence to support the use of [manual] acupuncture for the treatment of incontinence; however, trials using electroacupuncture were excluded from this review.

The use of electric stimulation with acupuncture has been shown to improve vasodilation^{52, 53} and reduce neural inflammation by locally inhibiting TNF-α, IL-1β, IL-6 and IL-18.^{54, 55} More specifically, electroacupuncture controls the release of CGRP and substance-P to levels sufficient for anti-inflammation and facilitates a negative feedback loop, decreasing the production and release of inflammatory factors from neural sources.^56-59 Systemically, electroacupuncture has also been shown to stimulate the HPA axis, resulting in added cortisol release to combat pain and inflammation.^{60, 61}  Despite the importance of electric stimulation for conditions such as Bell’s Palsy^62-65 and sciatica⁶⁶, its physiological purpose for urinary incontinence has yet to be elucidated.^31,67  Nevertheless, peri-neural electroacupuncture may simply provide continuous stimulation of the micturition control centers in the brainstem and sacral spinal cord to reset the balance between the sympathetic and parasympathetic nervous system.^{29, 47, 49}

DRY NEEDLING FOR PELVIC PAIN

Pelvic pain may be associated with a number of different issues, including surgery, trauma, recent pregnancy, visceral dysfunction or sexual abuse.^{19, 68} In addition, pelvic pain may also be the result of habitual holding of urine or stool secondary to incontinence.^{19, 68} Even when the actual cause of pain is not identified, physical therapy consisting of manual therapy (sacroiliac joint manipulation,^69-71 thoracic joint manipulation,^68,72 and manual pelvic floor muscle stretching^68,72), acupuncture,^{20, 73} biofeedback with surface and/or intravaginal electrodes,^{10, 12, 74} and patient education¹⁵ (self-stretching program, dilator program and behavior modification) are typically considered the cornerstones for the conservative management of this patient population.¹⁹ With regard to dry needling, studies that have attempted an intramuscular, myofascial trigger point dry needling approach have reported success in treating pelvic floor pain. According to guidelines published by the Canadian Society of Obstetricians and Gynecologists, dry needling is recommended for the management of chronic pelvic pain due to visceral dysfunction such as interstitial cystitis and irritable bowel syndrome.¹⁹ A recent case study on a patient with chronic vulvodynia using a specially designed needle (Ahn’s needle – 0.7mm in diameter and 65 mm long, streamlined, solid, flexible needle with a blunt rounded tip), revealed positive results with significant reduction in pain.⁷⁵ Dry needling was performed along the left upper and middle labiacrural fold, resulting in a 50% reduction in pain after the first treatment and a 100% reduction in pain following the second treatment.⁷⁵ Moreover, the reduction in pain was maintained at 9 months follow-up.⁷⁵ In addition, dry needling for abdominal, hip and pelvic floor muscles with trigger points may be useful in patients with pelvic floor dysfunction.¹⁹ In theory, needling these myofascial trigger points helps clear the excessive acetylcholine from the neuromuscular junction that is thought to perpetuate the cycle of hypertonicity associated with trigger point pain, thereby resolving the issue.^{76, 77}

Manual acupuncture and electroacupuncture have also been found to be useful in the treatment of pelvic pain in both men and women. In a 2004 pilot study of 10 men with non-inflammatory, chronic pelvic pain and intrapelvic venous congestion confirmed by MR venography, acupuncture with manual stimulation via rotation/winding at BL33 bilaterally, led to complete resolution of painful symptoms in four patients (40%), significant improvement of symptoms in three patients (30%), and no reduction of symptoms in three patients (30%).⁷⁸ Moreover, all 10 patients reported improved quality of life following treatment.⁷⁸ In 2008, electroacupuncture was used bilaterally at BL30, BL32-33 with electric stimulation set to 4 Hz and an intensity of 5-10 mA, to successfully treat the same patient population. An enzyme-linked, immunosorbent assay further noted a significant reduction in prostaglandin E2 and beta-endorphin levels in post-massage urine samples following electroacupuncture.⁷⁹ In addition, the 3-armed trial demonstrated that verum electroacupuncture was superior to both sham acupuncture and exercise with advice for pain reduction.⁷⁹ Tang et al⁸⁰ further reported a significant improvement in function, pain and quality of life in patients with pain related to urinary stress incontinence treated with acupuncture over the lower abdomen compared with patients receiving moxibustion at the umbilicus and pelvic floor strengthening. Therefore, the same sacral and abdominal points commonly used for peri-neural needling of the sacral nerve roots and the pudendal nerve in patients with incontinence also seem to be effective in treating pelvic pain.

CONCLUSIONS

A number of conservative treatments are effective for patients with urinary incontinence, to include pelvic floor muscle training, biofeedback, behavior modification and vaginal pessaries. In addition, there are a number of high quality trials that support the use of electroacupuncture in patients with urinary incontinence. Peri-neural dry needling to the sacral nerve roots, pudendal nerve, and posterior tibial nerve appear to play a key role in the functioning of the micturition reflex and should likely be considered as a less invasive alternative to surgically implanted nerve stimulators. Peri-neural dry needling to the sacral nerve roots and pudendal nerve combined with trigger point dry needling to local musculature appears effective in patients with pelvic pain.

AUTHORS:

Dr. Sarah Suddarth, DPT, Cert. DN, Cert. SMT, Dip. Osteopractic, FAAOMPT
Senior Physical Therapist, Benchmark Physical Therapy, Pulaski, TN
Vice President, Tennessee Physical Therapy Association

Dr. Raymond Butts, DPT, PhD, MSc, MAACP (UK), Cert. DN, Dip. Osteopractic
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Member, Acupuncture Association of Chartered Physiotherapists (UK)
Atlanta, GA

Dr. James Dunning, DPT, MSc, FAAOMPT, MAACP (UK), Dip. Osteopractic, MMACP (UK)
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Member, Acupuncture Association of Chartered Physiotherapists (UK)
Member, Manipulation Association of Chartered Physiotherapists (UK)
Montgomery, AL

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