16 Electrotherapy and hydrotherapy in chronic pelvic pain
Goals of hydrotherapy and electrotherapy treatment in chronic pelvic pain
Low-voltage electrical stimulation
Transcutaneous electrical nerve stimulation
Percutaneous tibial nerve stimulation
Magnetic and pulsed electromagnetic therapy
Modalities
For purposes of convenience, hydrotherapy and electrotherapy are discussed as separate entities. However, these modalities are commonly employed simultaneously, along with other interventions relevant to the management of associated causes of chronic pelvic pain. In the case of women with chronic pelvic pain, consideration of the endocrine changes associated with the menstrual cycle may be of significant importance to symptomatic improvement along with electotherapeutic and hydrotherapy interventions (Zharkin et al. 1991).
During the discussion of electrotherapy methods, the electrical aspects of neuromuscular junction depolarization should be considered. For example, research has demonstrated neuromuscular dysfunction in non-bacterial prostatitis (Hellstrom et al. 1987). It has also been demonstrated that baseline study and evaluation of sympathetic skin response of the lower abdomen to electrical stimulation of the dorsal nerve may be a useful means of evaluating response to treatment (Opsomer et al. 1996). The implications of this will become more apparent as individual modalities and their therapeutic effectiveness are examined.
Electrotherapy
Mechanism of action and physiological effects
The galvanic current produces predictable electrochemical and physiological effects at the site of application (Jaskoviak 1993) (Table 16.1).
Table 16.1 The physiological and electrochemical effects of positive and negative poles
| Positive pole (anode) | Negative pole (cathode) |
|---|---|
| Electrochemical effects | |
| Attracts acids | Attracts bases (alkaloids) |
| Attracts oxygen | Attracts hydrogen |
| Promotes oxidation | |
| Physiological effects | |
| Stops haemorrhage | Increases haemorrhage |
| Relieves acute inflammation | Relieves chronic inflammation |
| Dehydrates/hardens tissue | Congests/irritates tissue |
| Constricts arterioles | Dilates arterioles |
| Decreases nerve irritability | Increases nerve irritability |
Safety and contraindications
The galvanic current is relatively safe. Caution should be observed for allergic sensitivity to ions applied. Electrode pads should not be applied over broken skin. Patients with electronic implants should not be treated with galvanism or there is risk of interference with the operation of the implant. Tissues that have impaired pain sensation should not have electrodes applied to them (Starkey 1999).
Galvanic treatment has demonstrated benefit in pelvic floor dyssynergia, levator syndrome, urinary incontinence and vaginal muscle stimulation for sexual dysfunction (Chiationi et al. 2004, Nicosia et al. 1985, Scott & Hsueh 1979, Hull et al. 1993). The therapeutic benefits of electrogalvanic treatment for these conditions of discordant muscular synchronization appear to be retained over time.
Galvanic current and levator ani syndrome
In one study 45 patients with levator syndrome were treated by negative high-voltage electrogalvanic stimulation of the levator ani with an intra-anal probe (150–400 volts, 80 cycles per second, 20-minute application every other day). An average of five treatments was needed for complete pain relief. Excellent results (total pain relief) were obtained in 36 patients, good results in five, fair results in two, and poor results (no relief) in two (Nicosia et al. 1985). Note that this method utilized high-voltage galvanic which has a high voltage and low amperage output.
Galvanic iontophoresis
Galvanic iontophoresis has demonstrated benefit in chronic prostatitis, adnexal inflammation, epididymitis and urethritis. Associated diagnosis of these conditions as underlying causes in chronic pelvic pain warrants consideration of their use. Iontophoretic medication for chronic pelvic pain may include potassium iodide, brine extract, therapeutic mud (esobel), shrishal concentrate (containing magnesium sulphate) and other drugs. The brine, mud and shirshal are naturally occurring substances containing antimicrobial and anti-inflammatory compounds (Iunda & Grinchuk 1980, Tikhonovskaia et al. 2000, Tikhonovskaia & Logvinov 1998, Lei˘tes et al. 1990, Dikke & Ruzaeva 1993, Reshetov et al. 1996).
Additional naturopathic indications
Naturopathic physicians have historically described various methods of clinical application of medical galvanism and iontophoresis. Relative to chronic pelvic pain and associated diagnoses adjunctive galvanic treatment is recommended in dysmenorrhoea, amenorrhoea, adhesion resorption, colitis, endometritis, uterine and intestinal haemorrhage, pelvic inflammation, orchitis and salpingitis (Lust 1939, Scott 1990). This clinical documentation is consistent with the modern research listed above.
Low-voltage electrical stimulation
Low-voltage alternating current is a biphasic current produced with a low voltage and low amperage. There are a variety of biphasic waveforms such as rectangular, sawtooth and square. However, the sinusoidal current can be considered as representative. Unlike galvanic treatment the biphasic waveform does not produce any polarity effect (Starkey 1999).
Mechanism of action and physiological effects
The sinusoidal current is utilized to depolarize sensory and motor nerves. The depolarization of the sensory nerves is utilized in transcutaneous electrical nerve stimulation (TENS), which is discussed in detail later in this chapter, for pain control. Muscle stimulators employ the sinusoidal output. The sensory nerves are stimulated in a fashion that disrupts pain perception through gate control or opiate system mechanisms (Starkey, 1999). The stimulation of the motor nerves elicits muscular contractions.
The physiological effects of the sine wave encourage tissue healing by promoting increased tissue perfusion of arterial blood, increased venous return and increased lymphatic circulation. These effects can be utilized to mechanically reduce oedema. The sinusoidal current can also be used for muscular re-education, strengthening and relaxation of muscular spasm by causing muscular fatigue. The sinusoidal current is typically applied in a constant, surging or pulsed fashion (Jaskoviak 1993).
Safety and contraindications
Low-voltage current has a long history of use with a relatively high margin of safety. Implanted neurological devices and cardiac pacemakers or defibrillators should be considered contraindications. Diminished neurological sensation or motor capabilities should be approached with caution. Active contraction of muscular tissue in the vicinity of a thrombotic clot may precipitate emboli. Caution should be exercised in the event of vascular insufficiency (Starkey 1999).
Indications
Intravaginal low-volt alternating current (LVAC) application has demonstrated improved pelvic floor functioning and re-education in chronic pelvic pain with a reduction in pain (Skilling & Petros 2004, de Oliveira Bernardes et al. 2005). Levator ani spasm has also demonstrated improvement from intravaginal application (Fitzwater et al. 2003). LVAC has shown benefit in a variety of conditions that may be the underlying cause of chronic pelvic pain such as chronic prostatitis (Iunda et al. 1990, Pryima et al. 1996) and salpingitis (Evseeva et al. 2006). Fallopian tube postsurgical application has demonstrated improvement in fertility and pain reduction if applied early after surgery (Tereshin et al. 2008). Chronic prostatitis may benefit from improved non-surgical drainage via transurethral electrical stimulation (Gus’kov et al. 1997).
Intravaginal electrical stimulation in chronic pelvic pain
Twenty-four women with chronic pelvic pain with no identifiable cause underwent ten sessions of intravaginal electrical stimulation (8 Hz frequency, pulse train 1 msec, intensity to patient tolerance). Applications were administered 2–3 times weekly for 30 minutes. Visual analogue scale of pain was evaluated pre- and post-treatment and at the end of the treatment series. Follow-up pain evaluation was performed at 2 weeks, 4 weeks and 7 months. Pain reduction was statistically significant with fewer complaints of dyspareunia and benefit was retained at the 7-month evaluation (de Oliveira Bernardes et al. 2005).
The therapeutic re-education of muscular activity is largely the province of LVAC (Yamanishi & Yasuda 1998). In this regard conditions associated with chronic pelvic pain and disorders such as stress incontinence and sexual dysfunction such as dyspareunia and vaginismus have shown benefit from low-voltage sinusoidal treatment (Castro et al. 2004, Yamanishi & Yasuda 1998, Nappi et al. 2003, Castro et al. 2008, Lorenzo et al. 2008, Santos et al. 2009, Eyjólfsdóttir et al. 2009). Interestingly vaginal electrical stimulation may not actually cause pelvic muscle contraction directly suggesting other mechanisms of action may be present to explain the therapeutic effect (Bø & Maanum 1996). Biofeedback (see Chapter 13) along with intravaginal electrical stimulation has shown benefit in pelvic floor re-education and symptom reduction and may be a worthwhile direction to explore to understand these benefits (Bendaña et al. 2009).
Transcutaneous electrical nerve stimulation
TENS is an electrotherapy utilizing a biphasic sinusoidal waveform similar to LVAC. TENS is primarily a non-invasive alternative to pharmacological pain management. The therapy activates sensory nerves through electrical stimulation. The sensory stimulation interferes with pain transmission at the associated spinal level reflexogenically via gate control (proposed by Melzack & Wall 1965).
TENS is primarily indicated for pain management and has been validated for chronic prostatitis, interstitial cystitis and detrusor overactivity, and stress incontinence. Treatment is generally required for a considerable (3 months or longer) period of time and daily application is required. Units are typically prescribed for home use and are relatively simple, safe and cost-effective as the units are relatively inexpensive (Fall et al. 1980, Bristow et al. 1996, Everaert et al. 2001, Sikiru et al. 2008).
TENS in the symptomatic management of chronic pelvic pain
Twenty-four patients with chronic prostatitis/chronic pelvic pain were treated with analgesics, no treatment, or TENS treatment. All patients received concurrent antibiotic treatment. The TENS groups received treatment 5 days weekly for 4 weeks (60 Hz, 100 μsec, 25 mA, 20 minutes). Post-treatment pain level evaluation demonstrated a statistically significant benefit from the inclusion of TENS treatment (Sikiru et al. 2008).
Electroacupuncture
Electroacupuncture involves a combination of electrical stimulation device and TENS with insertion of thin trigger point needles. Electrodes are attached to inserted needles and electrical stimulation is applied to sensation or beyond to muscular contraction. The proposed mechanism of action is through modulation of ergoreceptors and somatic modulation of sympathetic nerve activity (Stener-Victorin et al. 2009).
Electroacupuncture has shown benefit in chronic prostatitis, prostodynia and chronic pelvic pain associated with those diagnoses. Electroacupuncture outperformed sham electroacupuncture and yielded improvement in pain scores as well as measurements of inflammatory substances in prostatic massage (Lee & Lee 2009). Cases that were refractory to medical treatment have also demonstrated significant response when treatment was directed to utilize the electroacupuncture in a local fashion to reduce prostatic congestion (Ikeuchi & Iguchi 1994).
Electroacupuncture has also demonstrated benefit via reduction of high muscle sympathetic nerve activity in polycystic ovary syndrome with associated symptomatic improvement (Stener-Victorin et al. 2009). Combined with moxabustion electroacupuncture has also shown benefit in chronic pelvic infection disease (Wang 1989). Both ear and body electroacupuncture have demonstrated benefit in dysmenorrhoea associated with endometriosis (Jin et al. 2009).
Electroacupuncture relieves pain in chronic prostatitis/chronic pelvic pain
Sixty-three participants were randomized to three treatment groups. Group 1 received advice and exercise prescription with electroacupuncture, Group 2 received the same with sham electroacupuncture, Group 3 received advice and exercise prescription. Six acupuncture points were chosen to stimulate the sacral plexus and piriformis muscle. Response was evaluated with the NIH Chronic Prostatitis Symptom Index, prostaglandin E2 and beta-endorphin levels in postmassage urine samples. At 6 weeks Group 1 had statistically significant benefit as compared to Group 2 and 3 in pain perception and decreased prostaglandin level (Lee & Lee 2009).
Percutaneous tibial nerve stimulation
The therapeutic rationale of PTNS is primarily for pain and symptom management, and is not directed at underlying conditions. For this reason the therapeutic response dissipates with discontinuation over time. The therapeutic response requires weekly treatment for up to 12 weeks and may also require periodic maintenance therapy (van der Pal et al. 2006, Zhao et al. 2008). The need for ongoing therapeutic impression has led to consideration of implantable devices (van Belken 2007). The current approach includes periodic maintenance treatment every 21 days to maintain the gains of the initial 12 week course (MacDiarmid et al. 2010).
Similar methods of reflex electrical stimulation for dysfunction not associated directly with the anatomic region are also applied in other conditions such as trigeminal neuralgia, occipital neuralgia, angina and peripheral ischaemia (Lou 2000). The therapeutic impression appears to be beyond the local reflex influence of the sacral plexus. Research into the physiological response to PTNS for overactive bladder has demonstrated changes in cortical somatosensory pathways (Finazzi-Agro et al. 2009).
PTNS has been found to be effective for chronic pelvic pain as well as a variety of associated diagnoses (van Balken et al. 2003, Finazzi-Agro et al. 2009) including chronic prostatitis, interstitial cystitis, urinary incontinence, faecal incontinence, various types of lower urinary dysfunction in children, overactive bladder and various types of neurogenic bladder pain (Capitanucci et al. 2009, Kabay et al. 2009). An important theoretical consideration is that the needle of PTNS is inserted at the site of the acupuncture point San Yin Jiao, Spleen 6. Spleen 6 is an important acupuncture point for abdominal and pelvic complaints. Perhaps PTNS is more accurately described as a specific electro-acupuncture protocol.
Posterior tibial nerve stimulation in chronic prostatitis/chronic pelvic pain
Eighty-nine patients with category IIIB chronic non-bacterial prostatitis/chronic pelvic pain that were therapy-resistant were randomized to receive either nerve stimulation or sham treatment. The NIH Chronic Prostatitis Symptom Index and VAS (visual analogue scale) were used to evaluate response at 12 weeks of treatment and showed statistically significant improvement (Kabay et al. 2009).
Magnetic and pulsed electromagnetic therapy
Magnet therapy is the application of static or pulsed magnetic fields to the patient. Magnetic application can be applied as a static or electromagnetic field of varying Gauss strength. Early ideas as to the mechanism of action focused upon blood microcirculation enhancement via magnetic field influence upon the iron in haemoglobin. However, the mechanism of action relative to microcirculation appears to be influenced through calcium ion channels (Okano & Ohkubo 2001, Skalak & Morris 2008). This influence may be through inflammation reduction via capillary constriction and may influence neurological signalling of pain (Gmitrov et al. 2002). There are several magnetotherapy units that also apply concurrent laser and electrical stimulation.
Indications
Magnetotherapy alone has shown benefit in urinary stress incontinence and chronic abacterial prostatitis, and some research has demonstrated benefit for chronic pelvic pain syndrome with others showing limited or no benefit (Kirschner-Hermanns & Jakse 2003, Leippold et al. 2005, Shaplygin et al. 2006, Nei˘mark et al. 2009). Magnetotherapy combined with laser and electrical stimulation has also shown long-term remission in chronic prostatitis patients (Alekseev & Golubchikov 2002). Some reduction in uterine myoma has also been demonstrated in long-term follow-up after a series of magnetotherapy treatments when compared with controls (Kulishova et al. 2005).
Application has consistently demonstrated improvement in pelvic floor functioning when applied in incontinence (Takahashi & Kitamura 2003, Kirschner-Hermanns & Jakse 2007). Chronic salpingitis has also shown positive response to magnetotherapy, particularly with the addition of iodine-bromine balneotherapy, discussed later in this chapter (Iarustovskaia et al. 2005). Infectious prostatitis similarly demonstrates magnetotherapy response when combined with chymotrypsin galvanic electrophoresis (Churakov et al. 2007).
Magnetic therapy for stress incontinence
Twenty-seven patients were treated with magnetic stimulation with pulsating fields by sitting on a therapeutic chair for 20 minutes, twice a week, for 2 weeks. Females with grade I and II stress incontinence, who could not actively flex the pelvic floor musculature during physiotherapy treatment, and who had been previously unresponsive to anticholinergic therapy, demonstrated the best response. Incontinence episodes were decreased 67%. Non-organically tangible pelvic pain syndrome did not benefit (Kirschner-Hermanns & Jakse 2003).
Diathermy and inductothermy
Diathermy literally means ‘through heat’. The depth of penetration of the therapeutic heat is one of the deepest produced by physiotherapy modalities (Jaskoviak 1993). The heat is generated by the resistance of the tissues to the passage of the current. Inductothermy is another term for an inductance-type applicator of diathermy. For a period of time microwave diathermy units were produced but have demonstrated some deleterious health risk and their clinical use is uncommon today. Note: Shortwave diathermy is discussed in this section, whereas microwave diathermy is not (Prentice 1998, Starkey 1999).
Mechanism of action of shortwave diathermy
Shortwave diathermy produces an electromagnetic radio wave. The most common frequency is 27.12 MHz which produces an 11-metre wavelength. The waveform can be delivered in a constant or pulsed fashion at a variety of intensity settings. The absorption of the electromagnetic energy by the tissues in the treatment field results in increased kinetic energy and therefore heat. The high frequency of the diathermy wave (greater than 10 MHz) does not elicit muscular contraction or nerve depolarization (Starkey 1999). The absorption of energy, increased kinetic energy, and therefore heat increases cellular metabolism in the treatment field (Jaskoviak 1993
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