Electrical Stimulation for Urinary Incontinence in Women: A Systematic Review

Schreiner, Lucas; Santos, Thais Guimarães dos; Souza, Alessandra Borba Anton de; Nygaard, Christiana Campani; Filho, Irenio Gomes da Silva

doi:10.1590/S1677-5538.IBJU.2013.04.02

Background

Electrical stimulation is commonly recommended to treat urinary incontinence in women. It includes several techniques that can be used to improve stress, urge, and mixed symptoms. However, the magnitude of the alleged benefits is not completely established.

Objectives

To determine the effects of electrical stimulation in women with symptoms or urodynamic diagnoses of stress, urge, and mixed incontinence.

Search Strategy: Our review included articles published between January 1980 and January 2012. We used the search terms “urinary incontinence”, “electrical stimulation”, “intravaginal”, “tibial nerve” and “neuromodulation” for studies including female patients.

Selection Criteria

We evaluated randomized trials that included electrical stimulation in at least one arm of the trial, to treat women with urinary incontinence.

Data Collection and Analysis

Two reviewers independently assessed the data from the trials, for inclusion or exclusion, and methodological analysis.

Main Results

A total of 30 randomized clinical trials were included. Most of the trials involved intravaginal electrical stimulation. Intravaginal electrical stimulation showed effectiveness in treating urge urinary incontinence, but reported contradictory data regarding stress and mixed incontinence. Tibial-nerve stimulation showed promising results in randomized trials with a short follow-up period. Sacral-nerve stimulation yielded interesting results in refractory patients.

Conclusions

Tibial-nerve and intravaginal stimulation have shown effectiveness in treating urge urinary incontinence. Sacral-nerve stimulation provided benefits in refractory cases. Presently available data provide no support for the use of intravaginal electrical stimulation to treat stress urinary incontinence in women. Further randomized trials are necessary to determine the magnitude of benefits, with long-term follow-up, and the effectiveness of other electrical-stimulation therapies.

Adult; Women; Electrical Stimulation; Urinary Incontinence

[1] Correspondence address:, Dr. Lucas Schreiner, Avenida Ipiranga, 6690 / 612, Centro Clínico, Jardim Botânico, Porto Alegre, 90610-001, Brazil, Fax: +55 51 3320-5179, E-mail: schreinerlucas@hotmail.com

First Author/ Year	N	Comparison (s) group (s)	Outcome measures	Clinical outcomes	Significance between groups
Alves 2011 (¹⁹19. Alves PG, Nunes FR, Guirro EC: Comparison between two different neuromuscular electrical stimulation protocols for the treatment of female stress urinaryincontinence: a randomized controlled trial. Rev Bras Fisioter. 2011; 15: 393-8.)	20	IVES medium x low frequency	Pad Test Subjective	Significant improvement related to baseline in both groups. No difference between groups.	p > 0.05
Santos 2009 (²⁰20. Santos PF, Oliveira E, Zanetti MR, Arruda RM, Sartori MG, Girão MJ, et al.: Electrical stimulation of the pelvic floor versus vaginal cone therapy for the treatment of stress urinary incontinence. Rev Bras Ginecol Obstet. 2009; 31: 447-52.)	45	IVES x vaginal cones	Pad Test QoL Bladder Diary Subjective	Significant improvement related to baseline in both groups. No difference between groups.	p > 0.05
Castro 2008 (²¹21. Castro RA, Arruda RM, Zanetti MR, Santos PD, Sartori MG, Girão MJ: Single-blind, randomized, controlled trial of pelvic floor muscle training, electrical stimulation, vaginal cones, and no activetreatment in the management of stress urinary incontinence. Clinics (Sao Paulo). 2008; 63: 465-72.)	101	IVES x PFMT x Vaginal Cones x No treatment	Pad Test QoL- IQOL Bladder Diary Subjective	Significant improvement related to baseline and no treatment in both groups. No difference between treatment groups.	Treatment x No treatment: p < 0.001 (QoL) p = 0.003 (pad test) p < 0.001 (bladder diary)
Seo 2004 (²²22. Seo JT, Yoon H, Kim YH: A randomized prospective study comparing new vaginal cone and FES-Biofeedback. Yonsei Med J. 2004; 45: 879-84.)	120	IVES x Vaginal cones	Pad Test Subjective	Significant improvement related to baseline in both groups. No difference between groups	p > 0.05
Goode 2003 (¹⁸18. Goode PS, Burgio KL, Locher JL, Roth DL, Umlauf MG, Richter HE, et al.: Effect of behavioral training with or without pelvic floor electrical stimulation on stress incontinence in women: a randomized controlled trial. JAMA. 2003; 290: 345-52.)	200	IVES x Behavioral training x Self help booklet	QoL-IIQ, SF-36 Bladder Diary Subjective	Significant improvement related to baseline in both groups. No difference between groups	p > 0.05
Bo 1999 (²³23. Bø K, Talseth T, Holme I: 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. 1999; 318: 487-93.)	107	IVES x PFMT x Vaginal Cones x No treatment	Pad Test Bladder Diary Subjective	Significant improvement PFMT related to IVES, Vaginal cones and No treatment.	p = 0.01 (bladder diary) p = 0.038 (pad test) p < 0.001 (subjective)
Luber 1997 (²⁴24. Luber KM, Wolde-Tsadik G: Efficacy of functional electrical stimulation in treating genuine stress incontinence: a randomized clinical trial. Neurourol Urodyn. 1997; 16: 543-51.)	44	IVES x Sham therapy	Bladder Diary Subjective Urodynamics	No difference between groups	p > 0.05
Brubaker 1997 (²⁵25. Brubaker L, Benson JT, Bent A, Clark A, Shott S: Transvaginal electrical stimulation for female urinary incontinence. Am J Obstet Gynecol. 1997; 177: 536-40.)	60	IVES x Sham therapy	Bladder Diary QoL Urodynamics Subjective	No difference between groups	p > 0.05
Smith 1996 (²⁶26. Smith JJ 3rd: Intravaginal stimulation randomized trial. J Urol. 1996; 155: 127-30.)	18	IVES x PFMT	Bladder Diary Subjective	Significant improvement related to baseline in both groups). No difference between groups.	p > 0.05
Sand 1995 (²⁷27. Sand PK, Richardson DA, Staskin DR, Swift SE, Appell RA, Whitmore KE, et al.: Pelvic floor electrical stimulation in the treatment of genuine stress incontinence: a multicenter, placebo-controlled trial. Gynecol. 1995; 173: 72-9.)	52	IVES x Sham therapy	Pad Test QoL- SF-36 Bladder Diary Subjective	Significant improvement IVES related to sham. No difference in QoL.	p > 0.05 (QoL) p = 0.01 (pad test) p = 0.02 (bladder diary) No significance test in subjective parameters

First Author/ Year	N	Comparison (s) group (s)	Outcome measures	Clincal outcomes	Significance between groups
Franzén 2010 (²⁹29. Franzén K, Johansson JE, Lauridsen I, Canelid J, Heiwall B, Nilsson K: Electrical stimulation compared with tolterodine for treatment of urge/urge incontinence amongst women-a randomizedcontrolled trial. Int Urogynecol J. 2010; 21: 1517-24.)	61	IVES x Tolterodine 4mg once daily	Bladder Diary QoL- KHQ Subjective	Significant improvement related to baseline in both groups. No difference between groups.	p > 0.05
Ozdedeli 2008 (³⁰30. Ozdedeli S, Karapolat H, Akkoc Y: Comparison of intravaginal electrical stimulation and trospium hydrochloride in women with overactive bladder syndrome: arandomized controlled study. Clin Rehabil. 2010; 24: 342-51.)	31	IVES x Trospium 45mg/day	Bladder Diary QoL-IIQ Subjective	Significant improvement related to baseline in both groups. No difference between groups.	p > 0.05
Arruda 2007 (³¹31. Arruda RM, Castro RA, Sousa GC, Sartori MG, Baracat EC, Girão MJ: Prospective randomized comparison of oxybutynin, functional electrostimulation, and pelvic floor training for treatment ofdetrusor overactivity in women. Int Urogynecol J Pelvic Floor Dysfunct. 2008; 19: 1055-61.)	64	IVES x Oxybutinin 10mg/day x PFMT	Bladder Diary Subjective	Significant improvement related to baseline in both groups. No difference between groups.	p > 0.05
Wang 2006 (³²32. Wang AC, Chih SY, Chen MC: Comparison of electric stimulation and oxybutynin chloride in management of overactive bladder with special reference tourinary urgency: a randomized placebo-controlled trial. Urology. 2006; 68: 999-1004.)	68	IVES x Oxybutinin 7.5 mg/day x Placebo	Pad Count QoL- KHQ	Significant improvement in IVES related to Oxybutinin and placebo. Significant improvement related to baseline in IVES and Oxybutinin.	Pad count/24h p = 0.018 (x Oxy) p = 0.012 (x plac) Qol - KHQ total p < 0.001 (x Oxy) p = 0.006 (x plac)
Wang 2004 (²⁸28. Wang AC, Wang YY, Chen MC: Single-blind, randomized trial of pelvic floor muscle training, biofeedback-assisted pelvic floor muscle training, andelectrical stimulation in the management of overactive bladder. Urology. 2004; 63: 61-6.)	103	IVES x PFMT x BAPFMT	QoL Subjective	Significant improvement in IVES and BAPFMT related to PFMT. No subjective differences between groups.	Qol - KHQ total p = 0.952 (x BAPFMT) p = 0.004 (x PFMT) Subjective p = 0.567.
Berghans 2002 (³³33. Berghmans B, van Waalwijk van Doorn E, Nieman F, de Bie R, van den Brandt P, Van Kerrebroeck P: Efficacy of physical therapeutic modalities in women with proven bladder overactivity. Eur Urol. 2002; 41: 581-7.)	68	IVES x PFMT x IVES+PFMT x No treatment	DAI	Significant improvement IVES related to no treatment.	Treatment x no treatment) DAI p = 0.032
Yamanishi 2000 (³⁴34. Yamanishi T, Yasuda K, Sakakibara R, Hattori T, Suda S: Randomized, double-blind study of electrical stimulation for urinary incontinence due to detrusor overactivity. Urology. 2000; 55: 353-7.)	68	IVES x Sham therapy	Bladder Diary QoL Subjective	Significant improvement IVES related to sham therapy.	Bladder diary p = 0.006 Quality of life p = 0.045
Brubaker 1997 (²⁵25. Brubaker L, Benson JT, Bent A, Clark A, Shott S: Transvaginal electrical stimulation for female urinary incontinence. Am J Obstet Gynecol. 1997; 177: 536-40.)	33	IVES x Sham therapy	Subjective Urodynamic	Significant improvement IVES related to sham therapy	Subjective P = 0.027 Urodynamic p = 0.004
Smith 1996 (²⁶26. Smith JJ 3rd: Intravaginal stimulation randomized trial. J Urol. 1996; 155: 127-30.)	38	IVES x Propantheline bromide	Bladder Diary Subjective	Significant improvement related to baseline in both groups. No difference between groups	p > 0.05

First Author/ Year	N	Comparison (s) group (s)	Outcome Measures	Clincal outcomes	Significance between groups
Schmidt 2009 (³⁶36. Schmidt AP, Sanches PR, Silva DP Jr, Ramos JG, Nohama P: A new pelvic muscle trainer for the treatment of urinary incontinence. Int J Gynaecol Obstet. 2009; 105: 218-22.)	32	IVES x Biofeedback x PFMT	Bladder Diary QoL-KHQ	Significant improvement related to baseline in both groups. No difference between groups.	p > 0.05
Amaro 2006 (³⁵35. Amaro JL, Gameiro MO, Kawano PR, Padovani CR: Intravaginal electrical stimulation: a randomized, double-blind study on the treatment of mixed urinary incontinence. Acta Obstet Gynecol Scand. 2006; 85: 619-22.)	40	IVES x Sham therapy	Pad test Subjective	Significant improvement related to baseline in both groups. No difference between groups.	p > 0.05
Barroso 2004 (³⁷37. Barroso JC, Ramos JG, Martins-Costa S, Sanches PR, Muller AF: Transvaginal electrical stimulation in the treatment of urinary incontinence. BJU Int. 2004; 93: 319-23.)	36	IVES x Placebo	Bladder Diary	Significant improvement in IVES related to baseline and placebo.	p < 0.001
Spruijt 2003 (³⁸38. Spruijt J, Vierhout M, Verstraeten R, Janssens J, Burger C: Vaginal electrical stimulation of the pelvic floor: a randomized feasibility study in urinary incontinent elderly women. Acta Obstet Gynecol Scand. 2003; 82: 1043-8.)	35	IVES x PFMT	Pad test Subjective	No significant improvement related to baseline in both groups. No difference between groups.	p > 0.05

First Author/ Year	N	Comparison (s) group (s)	Outcome measures	Clinical outcomes	Significance between groups
Schreiner 2010 (⁴⁰40. Schreiner L, dos Santos TG, Knorst MR, da Silva Filho IG: Randomized trial of transcutaneous tibial nerve stimulation to treat urge urinary incontinence in older women. Int Urogynecol J. 2010; 21: 1065-70.)	51	TTNS +PFMT + BR x PFMT + BR	QoL- KHQ Bladder Diary Subjective	Significant improvement related to baseline in both groups Significant improvement TTNS group related to PFMT + BR	Bladder diary p < 0.001 Subjective p = 0.0017 QoL p < 0.05
Sancaktar 2010 (⁴¹41. Sancaktar M, Ceyhan ST, Akyol I, Muhcu M, Alanbay I, Mutlu Ercan C, et al.: The outcome of adding peripheral neuromodulation (Stoller afferent neuro-stimulation) to anti-muscarinic therapy in womenwith severe overactive bladder. Gynecol Endocrinol. 2010; 26: 729-32.)	38	PTNS + Tolterodine x Tolterodine	QoL- IIQ Bladder Diary	Significant improvement related to baseline in both groups Significant improvement PTNS group related to Tolterodine.	Bladder diary p < 0.001 QoL p < 0.05
Peters 2010 (³⁹39. Peters KM, Carrico DJ, Perez-Marrero RA, Khan AU, Wooldridge LS, Davis GL, et al.: Randomized trial of percutaneous tibial nerve stimulation versus Sham efficacy in the treatment of overactive bladdersyndrome: results from the SUmiT trial. J Urol. 2010; 183: 1438-43.)	174	PTNS x Sham therapy	QoL- OAB-q, SF-36 Bladder Diary Subjective	Significant improvement related to baseline in both groups Significant improvement PTNS group related to Sham.	Bladder diary p < 0.001 Subjective p < 0.001 QoL p < 0.05
Peters 2009 (⁴²42. Peters KM, Macdiarmid SA, Wooldridge LS, Leong FC, Shobeiri SA, Rovner ES, et al.: Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactivebladder innovative therapy trial. J Urol. 2009; 182: 1055-61.)	97	PTNS x Tolterodine	QoL- OAB-q, SF-36 Subjective	Significant improvement related to baseline in both groups Significant improvement PTNS group related to Tolterodine. No differences in QoL between groups.	Bladder diary p = 0.006 Subjective p = 0.01 QoL p > 0.05
Karademir 2005 (⁴³43. Karademir K, Baykal K, Sen B, Senkul T, Iseri C, Erden D: A peripheric neuromodulation technique for curing detrusor overactivity: Stoller afferent neurostimulation. Scand J Urol Nephrol. 2005; 39: 230-3.)	38	PTNS x PTNS + Oxibutynin	Bladder Diary Subjective	Significant improvement related to baseline in both groups. No difference between groups	p > 0.05
Finazzi Agró 2005 (⁴⁴44. Finazzi Agrò E, Campagna A, Sciobica F, Petta F, Germani S, Zuccalà A, et al.: Posterior tibial nerve stimulation: is the once-a-week protocol the best option? Minerva Urol Nefrol. 2005; 57: 119-23.)	28	PTNS once weekly x PTNS 3 times per week	Bladder Diary QoL- I-QoL, SF-36 Urodynamics Subjective	Significant improvement related to baseline in both groups. No difference between groups	p > 0.05

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