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 current can be utilized to drive charged ions, ionic medication, into the tissues. Like charges repel one another therefore positively charged medications will be delivered by the positive pole of the circuit and negative by the negative. The galvanic current penetrates only into the corium of the dermis, approximately 1 mm. The medication is then dispersed via capillary circulation to a larger amount of tissue.

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

Percutaneous tibial nerve stimulation (PTNS) involves the insertion of a fine needle electrode immediately superior to the medial malleolus. A grounding electrode is applied to the same foot medial to the calcaneus. Electrical stimulation, galvanic or sinusoidal, is applied until flexion of the phalanges occurs. This electrode placement allows for stimulation of the sacral plexus.

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).

Thermal effects

As the tissues resist the flow of current, the physiological effects of diathermy are mediated through high-frequency vibration of molecules in the treatment field. The result of the vibration is friction that creates a heating effect. The heating is to a depth of 2–5 cm depending upon type of application. The thermal effects increase tissue perfusion, increase capillary pressure and cell membrane permeability, relax muscles, increase transfer of metabolites across cell membranes, increase local metabolic rate, increase pain threshold, increase range of motion and decrease tension in collagenous tissues and enhance tissue recovery (Prentice 1998, Starkey 1999).

The degree of heat delivered to the tissue by shortwave units is not a quantified unit. Heating in tissue occurs as the equivalent of the current density squared multiplied by the resistance. Doses are measured by verbal communication from the patient as to the perceived intensity. Four levels are commonly utilized:

I: No perceived heat;

II: Mild heat;

III: Moderate heat – described by patients as a comfortable ‘velvety warmth’;

IV: Vigorous and barely tolerable heat.

Athermal effects

Pulsed diathermy allows a train of pulsed waveforms whose amplitude and frequency can be manipulated. The pulse train allows for a brief pause during which the kinetic energy can be dispersed and distributed by the target tissues. This theoretically creates an athermal treatment where the energy transferred does not appreciably absorb in the target tissues. The effect of the treatment is theorized to be a product of the primary field effect of the energy rather than the secondary effects of the heat produced (Jaskoviak 1993).

The pulsed shortwave diathermy proposes a field effect due to the influence of the electromagnetic field independent of thermal impressions. The proposed mechanism of action is via changes in cellular ion levels and cell membrane potential. The proposed mechanism of action is the influence of the wave on the cellular sodium pump that encourages normalization of the cell’s ionic balance. This proposed mechanism has not yet been substantiated (Sanseverino 1980).

Observations of the clinical effect include (Cameron 1961, Goldin et al. 1981, Van den Bouwhuijsen et al. 1990):

1. Increased number of white cells, histocytes and fibroblasts in a wound;

2. Improved rate of oedema dispersion;

3. Enhanced fat activity;

4. Encourages canalization and absorption of haematoma;

5. Reduction of the inflammatory process;

6. Promotes a more rapid rate of fibrin fibre orientation and deposition of collagen;

7. Improves collagen formation;

8. Stimulation of osteogenesis;

9. Improved healing of the peripheral and central nervous systems.

Safety and contraindications

Diathermy has been utilized for decades with a relatively strong safety record (Prentice 1998). Most of the negative reported effects attributed to diathermy were associated with microwave diathermy, and not to short-wave diathermy (Prentice 1998, Starkey 1999). The recent evidence of beneficial tissue effects of pulsed diathermy is not only a validation of the relative safety of the electromagnetic wave field but is also evidence of a positive influence of the field (Nevropatol et al. 1995, Hill et al. 2002, Kerem & Yigiter 2002).

Diathermy should never be applied directly over any metal, as metal selectively heats and can burn the patient. Likewise diathermy should not be used over anything wet as the water is likely to turn to steam, potentially resulting in a burn. Sensible precautions should be taken to ensure that the area to be treated is dried so avoiding common clinical errors.

It is best to have patients remove jewellery in the area to be treated – most dental work is safe and no adverse response to use over fillings or other dental implants has been reported. A Danish study on abdominal diathermy in women with copper IUDs demonstrated no adverse effects and the researchers concluded that it is safe in commonly used dosages (Heick 1991).

Diathermy should not to be used if a patient has a pacemaker or implanted neurological device. Patients with a pacemaker or implanted neurological device should not be allowed within a 25-foot radius of an active diathermy unit. The waveform can interfere with the functions of these devices.

Diathermy is not used directly over the abdomen of pregnant patients, and generally avoided with pregnancy primarily because of its temperature-elevating ability. The balance of studies on pregnant physiotherapist diathermy operators has shown no consistent significant differences in pregnancy outcomes or newborn health when compared with controls (Taskinen 1990, Larsen 1991, Guberan et al. 1994, Lerman et al. 2001). Studies and case reports associated with negative outcome appear to involve the microwave forms of diathermy and the high volume of exposure for operators using diathermy (Oullett Helstrom & Stewart 1993). A study on the mutagenicity for shortwave radiofrequency has demonstrated no negative effect (Hamnerius 1985).

Diathermy should not be used over an active epiphysis and is generally not advised directly over malignant tissue (Starkey 1999). The latter may change with future research as local hyperthermia is being investigated in the treatment of malignancies (Laptev 2004, Hurwitz et al. 2005, Tilly et al. 2005).

Diathermy indications

Diathermy has been validated for infectious conditions that may be a part of the underlying cause in chronic pelvic pain. Adjunctive diathermy application is indicated in infections such as prostatitis, epididymitis, gonorrhoea, chronic urethritis, and pelvic inflammatory disease (Braitsev et al. 1978, Barabanov & Pyzhik 1989, Lei˘tes et al. 1990, Stepanenko & Koliadenko 1990, Balogun & Okonofua 1988).

Relative to infection management a relevant historical passage from a 1975 electrotherapy manual states: ‘The effective use of antibiotics has eliminated the need to treat infected body cavities with diathermy over lengthy periods’ (Shriber 1975). While the advent of antibiotics may have contributed to the decline of the application of diathermy in infectious processes, with the modern rise of antibiotic resistance and the challenges of controlling tissue perfusion of medications diathermy may have a potentially much larger role to play again in the future.

Pulsed short-wave indications

Pulsed short wave has shown improvement in fibronectin synthesis with local and hepatic treatment has shown a positive influence in post-surgical healing times (Argiropol et al. 1992). Case reports and evaluation in dysmenorrhoea, endometriosis, dyspareunia, ovarian cyst and pelvic inflammatory disease (Trojel & Lebech 1969, Jorgensen et al. 1994). Chronic pelvic pain that involves vulval epithelial lesions has also shown a response (Grönroos et al. 1979).

Ultrasound

Ultrasound involves applying acoustic energy to living tissues in order to elicit a rise in tissue temperature. The acoustic energy of ultrasound can also be used to drive molecules into tissues; this method, phonophoresis, is analogous to the electrical iontophoresis of galvanism. However, phonophoresis does not utilize polarity effect and is a mechanical aspect of the acoustic energy waves (Starkey 1999).

Safety and contraindications

Care should be utilized in areas of tendon insertions and along the periosteum. Absorption of the energy produced by ultrasound is greatest in tissues with high collagen content. Treatment over the eye, implanted medical devices, a gravid uterus, malignancies, thrombophlebitis and the carotid sinus are generally contraindicated (Starkey 1999, Chaitow et al. 2008).

The effects of ultrasound include increased tissue extensibility, increased enzyme activity, increased skin and cell membrane permeability, increased mast cell degranulation, increased macrophage responsiveness, increased fibroblastic protein synthesis leading to increased collagen synthesis, and increased angiogenesis (Starkey 1999, Chaitow et al. 2008).

Indications

While the therapeutic application of ultrasound is widely known in physiotherapy, relative to chronic pelvic pain and associated diagnoses, ultrasound has primarily been evaluated and shown benefit in chronic prostatitis, plastic induration of the penis and associated sexual dysfunction of these conditions (Karpukhin & Nesterov 1975, Karpukhin et al. 1977, Papp & Csontay 1979).

Low-level laser therapy

LASER (light amplification by stimulating emission of radiation) light is a focused beam of light that emits photon energy. There are several different means by which laser light is generated including the gaseous helium-neon (HeNe) laser, the gallium-arsenide (GaAs), and the gallium-aluminium-arsenide (GaAlAs) semiconductor or diode lasers (Belanger 2002). Lasers used in physical medicine and rehabilitation are low power (1–20 mW) and athermal. As a result of this low-power intensity, this type of laser therapy is referred to as cold, low-power or low-level laser therapy (LLLT) (Shank & Randall 2002).

Laser light may be in light’s visible spectrum (390–770 nm) or invisible spectrum (600–1200 nm). Similar to most other electrotherapy modalities laser may be applied in a continuous form or a non-continuous pulsed form with varying duty cycles intensity levels. Application is made via topical probes directly or at a distance from the surface of the body and typically while moving the probe over the area of application (Smith 1991).

Mechanism of action and physiological effects

Laser light therapy activates athermic photochemical reactions dependent upon specific wavelengths and frequencies. The type of reactions is dependent upon tissue chromophores within cell membranes and organelles (mitochondria). This mechanism of action is known as photobiomodulation.

Safety and contraindications

The main contraindications for laser therapy are direct exposure over the eye, over a pregnant uterus, malignancies, photosensitive patients or those taking photosensitizing medications (Chaitow et al. 2008).

Indications

Laser therapy for conditions associated with chronic pelvic pain has primarily been in proprietary combination devices that utilize low-voltage electrical, electromagnetic and laser therapy simultaneously. These devices have demonstrated benefit in interstitial cystitis and also for associated infectious causes of chronic pelvic pain including chronic bacterial and specifically chlamydial prostatitis (Tiktinskii et al. 1997, Alekseev & Golubchikov 2002, Kalinina et al. 2004, Shaplygin et al. 2004, Shaplygin et al. 2006, Pryima et al. 1996).

Hydrotherapy

The modern field of hydrotherapy is sometimes referred to as medical hydrology. Balneology or balneotherapy is a branch of the science that studies baths and their therapeutic uses. Crenology or crenotherapy is the science and use of waters from mineral springs (Boyle & Saine 1988). Today, we use the terms hydrotherapy and medical hydrology interchangeably, with medical hydrotherapy indicating all uses of water therapeutically (Bender 2006).

History of hydrotherapy

Medical hydrology has a rich history. Water was used for healing in biblical records and by the ancient Greeks and Romans. Hippocrates (460 BCE), the father of systematic medicine, applied water for healing, along with diet, exercise, manipulation and herbs. In his tract on the use of fluids he laid down rules for the treatment of acute and chronic diseases by water, which were followed by the hydropaths in the nineteenth century and which, together with subsequent developments, place hydrotherapy among orthodox and scientific methods of treatment. Galen (129 CE), Celsus (25 BCE) and Asclepiades (100 BCE) also used water therapeutically (Baruch 1892).

Selected clinical hydrotherapy research

Laboratory and clinical research on hydrotherapy has been ongoing for well over 150 years. Awareness of the current terminology for the terms hydrotherapy, balneotherapy and spa therapy are useful for proper interpretation of the literature.

• Hydrotherapy generally refers to plumbed water applied at various temperatures, aquatic therapy and therapeutic rehabilitation methods.

• Balneotherapy is the therapeutic use of bathing agents such as mineral and thermal waters, muds and gases.

• Spa therapy combines hydrotherapy, balneotherapy and drinking cures in an inpatient setting.

Balneotherapy and chronic pelvic pain

Chronic pelvic pain symptoms and their relationship to body temperature perception

• A Swedish study documented that ambient temperature that was perceived as cold by patients suffering from chronic pelvic pain tended to aggravate symptoms while heat tended to ameliorate symptoms. This would suggest that heating methods of hydrotherapy may warrant clinical trial in chronic pelvic pain if for no reason other than symptom management (Hedelin & Jonsson 2007).

• Comparison of every other day warm water (38°C) baths for 20 minutes and water containing alum, ten bathing sessions total, in 40 patients with pelvic inflammatory disease, demonstrated improvement of symptoms in both groups with the alum-containing waters statistically more effective. Neither group showed pathological change reduction (Zámbó et al. 2008).

• While radon-containing waters have widespread application for pain reduction in musculoskeletal disorders, evaluation of the endocrine system during treatment failed to demonstrate any changes that would attribute the improvements to endocrine effects (Nagy et al. 2009).

• Research into the evaluation of C-reactive protein, cholesterol and triglycerides show a marked reduction after a series of balneotherapy (Oláh et al. 2009).

Balneotherapy with antibiotics in the management of acute adnexitis and salpingitis

• Infectious conditions associated with chronic pelvic pain include adnexitis and salpingitis. Evaluation of the co-administration of antibiotic therapy with the addition of warm water balneotherapy was performed in infertile patients. Symptom reduction was improved by the addition of balneotherapy to a statistically significant effect. The reduction in tubal occlusion and adhesion was better in the balneotherapy arm compared to antibiotic administration alone, but not in a statistically significant manner (Jaworska-Karwowska 1980, Gerber et al. 1992).

Brine electrophoresis in acute inflammation of female genitalia

• A brine from Lake Karachi electrophoretically applied reduced inflammation of uterine appendages and sclerotic alterations of ovarian stroma, repair of intramural nerves, and correction of follicular atresia (Tikhonovskaia & Logvinov 1998).

• Ultraphonophoresis of a preparation of Eplir mud in an experimental model of uterine inflammation demonstrated a reduction in scar tissue formation, follicular atresia, exudation and haemodynamic disorders when applied in combination with antibiotic therapy (Tikhonovskaia et al. 1999).

• Russian researchers report on sacroabdominal electrophoresis with vaginal baths of brine acute salpingitis (Radionchenko & Tepliakova 1989).

• Research as to the positive effect of brine and mud phonophoresis suggests that normalization of vaginal microflora is likely the beneficial mechanism of action of this approach in chronic adnexitides, pelvic inflammation and pain (Abdrakhmanov et al. 2004).

Vaginal Irrigations with arsenical-ferruginous water in chronic vaginitis and vulvovaginal dystrophy

• Italian case-controlled research demonstrated a statistically significant symptom reduction and inflammation reduction with vaginal irrigation of arsenical-ferruginous water in chronic vaginitis and vulvovaginal dystrophy (Tikhonovskaia et al. 1999, Danesino 2001, Zámbó et al. 2008).

Spa therapy and pelvic inflammatory diseases

• Russian researchers report on cases treated at health resorts for pelvic inflammatory conditions interfering with pregnancy. Twelve-month post-treatment follow-up showed no recurrence of the condition and pregnancy rate improved by 2.5 times (Vorovskaia et al. 1994).

• Czech research showed improvement in a 12-month follow-up in chronic pelvic pain with 40% of female patients indicating improvement in sexual dysfunction (Urbánek et al. 1998).

• There are numerous European, Russian and Bulgarian reports and studies that demonstrate improvement in chronic adnexal inflammation, uterine myoma, salpingitis and sterility (Prokopiev and Nikolova 1971, Korenevskaia et al. 1982, Suchy & Cekański 1982, Burgudzhieva 1981, Lytkin 1982, Bero 1977, Burgudzhieva 1984, Burgudshieva & Slaveiˇkova 1980, Maslarova 1984a, Esartiia et al. 1973, Borovskaia 1986, Burgudzhieva et al. 1981, Maslarova 1984b, Keshokova 1981) as well as case reports on balneotherapy and uterine retrodeviation (Sokolova 1981).

Case study 16.1

A 35-year-old woman presented to the naturopathic clinic with a primary complaint of abdominal pain radiating bilaterally through the inguinal region. She had previously been to her primary care physician, gynaecologist, as well as presenting to the emergency room for her current symptoms without relief of symptoms. Her gynaecological examination had been normal, normal blood counts, urinalysis, and abdominal CT negative. She had a recurring pattern of abdominal and inguinal pain for several years, since her last vaginal birth, at various levels of intensity. At the time of presentation her pain was very severe (8/10 VAS) and increasing. She had also suffered from low back pain for over 20 years and was a gymnast as a child and teenager. Her previous work-up led to no clear diagnosis or treatment recommendations. Her current pain pattern was a recurrent one that appeared several times annually.

A thorough abdominal examination was performed notable for diffuse tenderness to palpation, mostly around the umbilicus and in the region for McBurney’s point. Right thigh flexion with passive internal rotation of the femur was provocative (obturator sign). Passive side lying extension was also provocative on the right (psoas sign). Based on these physical findings with a previous negative abdominal CT scan a working diagnosis of chronic sub-acute inflammation of the appendix was made. The patient was educated about referral for laparascopic management and appendiceal removal and the option for conservative non-surgical management with the purpose of reducing inflammation. Conservative approach was agreed upon and it was understood that worsening of symptoms could necessitate emergent referral.

At that visit a hydro-electrotherapy treatment was performed. The treatment goal was reduction of abdominal pain and appendiceal inflammation. Contrast hydrotherapy to the chest and abdomen was first administered using the constitutional hydrotherapy method.

Constitutional hydrotherapy method

The patient was supine, undressed from the waist up, covered with a vellux blanket.

1. Two turkish towels, each folded in half to allow for four layers of towelling, very well wrung from hot water (130–140°F) were applied covering chest and abdomen – from clavicle to ASIS, laterally the towels reached the anterior axillary line. The patient was covered with a vellux or wool blanket.

2. At the 5-minute mark one turkish towel, folded in half, very well wrung from hot water, replaced the two turkish towels previously applied.

3. The hot towel was then quickly replaced with one turkish towel well wrung from cold water (40–55°F) and folded in half, allowing for two layers of toweling. The application covered the same area as the hot towels, from clavicle to anterior superior iliac spine, anterior axillary line to anterior axillary line. Again the patient was covered with a blanket. The cold towel remains in place for 10 minutes and will be observed to rewarm to body temperature (Chaitow et al. 2008).

After the anterior application of contrast hydrotherapy in the constitutional hydrotherapy method, high frequency was applied to the right lower abdomen for 8 minutes by means of a topical electrode. High-frequency current has anti-inflammatory, sedative and analgesic properties (Chaitow et al. 2008). Throughout the anterior treatment a trigger point needle was placed 3 inches below the acupuncture location for Stomach 36 on the right lower leg. This corresponds to the ‘extra point’ for appendicitis (the term ‘extra point’ refers to an acupuncture point not identified as a specific point on one of the primary acupuncture meridian channels and is typically associated with specific therapeutic effect).

After the application of the anterior contrast hydrotherapy according to the constitutional hydrotherapy method, high frequency to the right lower abdominal quadrant, and trigger point treatment, the patient positioned herself in a prone position and the contrast hydrotherapy treatment was applied to the back of the torso in a similar fashion:

1. Two turkish towels (the same as previously used), freshly well wrung from hot water, each folded in half for a total of four layers, were applied to the patient’s back. The towels covered from the superior edge of the scapula to the posterior superior iliac spine laterally to the posterior axillary line.

2. At the 5-minute mark, the two towels are replaced with one fresh towel wrung from hot water. This towel was quickly replaced with a towel well wrung from cold water.

3. At the 10-minute mark the patient had warmed the towel to body temperature. Finish with a dry friction rub to the back.

4. A fresh dry towel was used to give a 20–30-second dry friction rub to the patient’s back.

At the end of treatment (45 minutes) her pain on the VAS was 1/10, a reduction from 8 of 10 at the start of the procedure.

The following day the patient returned to the clinic reporting that the umbilical pain was much improved, however the inguinal pain had returned and the low back pain was still present. On physical examination the tenderness at McBurney’s point was diminished and the challenge to the obturator muscle and psoas muscle were negative suggesting reduction in the presumed appendiceal inflammation. The previous day’s treatment was repeated with the inclusion of LVAC at the end of the procedure series. The LVAC was applied in the following fashion: one 4″ × 4″ electrode pad placed on the sole of each foot. Constant tetanizing current was applied to patient tolerance for 5 minutes (this was felt by the patient as a gentle tingling and very minor contraction of the muscles of the lower leg). The therapeutic strategy was to relax muscle spasm in the pelvic girdle musculature indirectly through exhaustion of muscular spasm. A third treatment was administered 3 days later at which point the patient was not experiencing significant abdominal discomfort and the low back pain had improved. She was leaving for a 1-week holiday.

Upon return from holiday she reported that all abdominal symptoms had abated, she was able to lie on her side during sleep for the first time in a year, and she was left with only a minimal low back pain on the left side, though it did continue to radiate through the groin in a typical discogenic fashion.

Physical examination also revealed significant tenderness at the sacroiliac joints and iliolumbar ligaments bilaterally. Upon inquiry the patient revealed that her chronic low back pain followed a pattern of worsening of symptoms always in the later part of the day. Hackett identifed this pattern as one suggesting laxity of the sacroiliac and lumbar ligaments (Hackett 1958, 1991). Treatment recommended for ligament laxity is the injection of dextrose into the ligamentous tissue to provoke fibroblast formation and soft tissue production (prolotherapy) (Hackett 1991, Yelland et al. 2004).

It was now possible to perform a more thorough abdominal examination. Tenderness at the right pubis with superior pressure and iliac crest with posterior palpation was elicited corresponding to the diagnostic reflexes of kidney ptosis according to Failor (1979). Inquiry based on physical findings revealed frequent urge to pass urine but only passing small amounts of urine.

A combination of therapeutic interventions were applied over a period of 3 weeks:

1. Neuromuscular treatment according to Lief to the spine and abdomen (Chaitow 1988) and abdominal manipulation according to Ralph Failor (Failor 1979). The goal of treatment was reduction of trigger point and recurrent muscular spasm to the areas treated. This method was applied once weekly.

2. Contrast hydrotherapy according to the constitutional hydrotherapy method anterior and posterior applications with the inclusion of LVAC to the feet and high frequency to the abdomen as previously described. Therapeutic goal was to reduce pain, muscular spasm and inflammation and to improve circulation. Trigger point needling at Large Intestine 4, Liver 3, and Bai Hui was also administered (Takahashi 2011, Dorsher 2011). Therapeutic goal was to reduce pain through reflex mechanisms. This method was applied twice weekly, once in combination with the soft tissue manipulation and once independently.

The patient responded well to this combination of treatment and indicated a significant decrease in back pain and improved functions with urination. Her pubic and iliac tenderness to palpation resolved. Treatment was administered twice weekly for 3 weeks.

At the end of 3 weeks of hydroelectrotherapy treatment, injection therapy according to Hackett (prolotherapy) to the iliolumbar and sacroiliac ligament was administered and was well tolerated (Yelland et al. 2004).

During this treatment phase the patient admitted that she had also suffered since her last childbirth (6 years) significant dyspareunia at the midpoint of penile penetration which on many occasions prevented intercourse. Diluted Cactus Grandiflorus, Citrullus Colocynthis and Delphinium Staphisagria was administered orally, ten drops once daily for 3 weeks to reduce the genital pain. The hydro-electrotherapy treatment was continued once weekly according to the previous description for 4 weeks (Marzouk et al. 2010a, 2010b, Diaz et al. 2008).

At the end of 2 months of therapy her low back pain symptoms, inguinal pains, abdominal pains, urinary frequency and urgency, and dyspareunia symptoms were all fully resolved. She became pregnant 6 months later and successfully had a vaginal childbirth. At 3-year follow-up her symptoms have not returned.

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