Perineal Stimulation for Nocturia and Overactive Bladder in Elderly Women

A 2016 study by Kaori et al examined the effect of self administered perineal stimulation for nocturia in elderly women. A prior study using rodents found a soft roller used decreased overactive bladder syndrome (OAB), but a hard roller did not produce the same results. Kaori et al performed a similar study for elderly women in a randomized, placebo controlled, double blind crossover. Participants were 79-89 years old women who applied simulation to perineal skin for 1 minute at bedtime, using either active (soft, sticky elastomer) roller or a placebo (hard polylestrene roller). Participants did a 3-day baseline, followed by 3-day stimulation, then 4 days rest, then other stimuli for 3 days. There were 24 participants, 22 completed the study: 9 with OAB, 13 without OAB. The placement of the roller was not on the skin of the perineal body, but rather on the general peri-anal area with the diagram from the study showing an area just medial to the gluteal crease—where one would find the ischial tuberosity-- and anterior and lateral to the anal sphincter.

Across the subjects with OAB, change with the elastomer roller (soft and sticky feel) was more statistically significant than with the hard roller. Baseline micturition for the participants was 3.2+/- 1.2 times per night, measured as the number of urination between going to bed and arising. The group as a whole did not have a statistically significant difference, measured by at least one less time arising per night. However, in the OAB group, the difference was significant. The researchers theorized that the soft and sticky texture may induce more firing of somatic afferents nerve fibers.

The most commonly prescribed treatment for overactive bladder is anticholinergic therapy, but the side effects, including cognitive changes and lack of significant difference from controls, as well as the drying effect of these drugs in a post-menopausal-low-estrogen-pelvis, bring up questions of whether this is the best option in the elderly.(6)

In anesthetized animals, electrical stimulation and noxious stimuli decrease frequency of bladder contractions when applied to the perineal area (3-5). Somatic, afferent nerve stimuli (those theorized to be active with the soft roller) are used to treat OAB by modalities such as acupuncture and transcutaneous electrical stimulation to the perineum (2). So, stimulation of somatic visceral afferent nerves in the perineal region seems to have an effect on the bladder. However, with manual therapies, it seems we can also affect the somatic or visceral afferents. Essentially, visceral afferents convey information to the central nervous system about local changes in chemical and mechanical environments of a number of organ systems(7). Doing manual therapy between the urethral and bladder fascia would also theoretically cause stimulation of the visceral afferents to the central nervous system about that organ (bladder).

In our pelvic floor intro class (Pelvic Floor Level 1) at Herman Wallace, we discuss the role of Bradley’s neurology loop 3 and the inverse relationship between pelvic floor contraction (lifting the perineal area) and the bladder. One suppression technique we discuss is the contraction of the pelvic floor to quiet or inhibit bladder activity in the bladder retraining program. Bladder retraining has evidence level A (strong) for improving urgency and frequency with overactive bladder.

Clinicians who are ready to raise their manual game may try using the skills of prior series courses and adding the sophistication of manual techniques in the abdomen and pelvis to increase afferent firing in patients with OAB, as well as freeing up any fascial restrictions that may be interfering with full bladder excursion.

In the newly written Capstone course, we combine the prior level of education from the pelvic series (bladder strategies) with manual techniques to address the endopelvic fascia at the bladder base, in the fascial articulations along the perineum, and along its attachments to the coccyx, as well as combining internal work with sacral techniques to facilitate S234 afferents for bladder control. We discuss studies, such as this one, to explore advanced concepts of bladder and urethral fascial mechanics and neural entrapment affecting the bladder. We move out of the pelvic muscle and into the fascial contents of the abdominopelvic region, to allow such firing of the somatic afferents. And the perineal stimulation? We have an entire lab for perineal tissue and its effect on pelvic function. Physical therapists can manually address the perineum, urethral and bladder fascia with Capstone techniques. With such intervention, we get more CNS communication.

So, what about the roller? Well, the soft roller created change in rodents in a couple of studies. (Sato 2010). In this human study, it helped with OAB. Certainly, manual therapies in the region of the endopelvic fascia and suprapubic region may be of help for also stimulating the visceral afferents. Also, it could be worth it to have a high fall risk elderly patient with OAB type nocturia follow up your treatments with one minute of soft washcloth stroking in the area of the perineum for one minute at bedtime to see if it helps decrease the number of voids on a night time bladder diary.

Nari Clemons, PT, PRPC is a Herman & Wallace faculty member who helped author the Pelvic Floor Series Capstone: Advanced Topics in Pelvic Rehab course. She is also the creator and instructor of Pelvic Nerve Manual Assessment and Treatment.

Main study: PLoS One. 2016 Mar 22;11(3):e0151726. doi: 10.1371/journal.pone.0151726. eCollection 2016.Effects of a Gentle, Self-Administered Stimulation of Perineal Skin for Nocturia in Elderly Women: A Randomized, Placebo-Controlled, Double-Blind Crossover Trial.Iimura K1,2, Watanabe N2, Masunaga K3, Miyazaki S1,2,4, Hotta H2, Kim H5, Hisajima T1,4, Takahashi H1,4, Kasuya Y3.
2. Exp Ther Med. 2013 Sep;6(3):773-780. Epub 2013 Jul 9., Acupuncture for the treatment of urinary incontinence: A review of randomized controlled trials.Paik SH1, Han SR, Kwon OJ, Ahn YM, Lee BC, Ahn SY.
3. Guo ZF. Transcutaneious electrical nerve stimulation in the treatment of patients with poststroke urinary incontinence. Clin Interv Aging. 2014; 851-6.
4. Sato A, The impact of somatosensory input on autonomic functions. Reve Physiol Biochem Pharmacol. 1997;130;1-328
5. Sato A. Mechanism of the reflex inhibition of micturition conractions of the urinary bladder elicited by acupuncture-like stimulation in anesthetized rats. Neurosci res. 1992 15:189-98
6). Effects of a Gentle, Self-Administered Stimulation of Perineal Skin for Nocturia in Elderly Women: A Randomized, Placebo-Controlled, Double-Blind Crossover Trial. Iimura K, Watanabe N, Masunaga K, Miyazaki S, Hotta H, Kim H, Hisajima T, Takahashi H, Kasuya Y. PLoS One. 2016 Mar 22;11(3):e0151726. doi: 10.1371/journal.pone.0151726. eCollection 2016.
7) John C. Longhurst, Liang-Wu Fu, in Primer on the Autonomic Nervous System (Third Edition), 2012