The following blog is from one of my physios Martine Lange who attended a brilliant course run by Fiona Rogers, who is a pelvic health physiotherapist who owns an online pelvic health supplies business called Pelvic Floor Exercise. Fiona has been taking her one day course around Australia this year and is on the road next year to New Zealand and the UK. If you are a physiotherapist working in pelvic health I strongly recommend this course to you for its completeness and evidence base.
Non-obstructive urinary retention (NOUR), when it doesn’t respond simply to positional adjustment (see below), can be frustrating for therapists to treat and patients to live with, as it can often mean recurrent urinary tract infections and urinary frequency.
Position for voiding from Pelvic Floor Essentials (2018) by Sue Croft
Martine undertook Fiona’s course in July 2019 and immediately had a patient with this condition and had great success with implementing this treatment strategy as you can see in her account following.
TENS unit (image from Pelvic Floor Exercise online website)
The TENS (Trans-cutaneous Electrical Nerve Stimulation) machine has been used for years as a treatment for different aches and pains, in particular lower back pain. However, research is mounting that the humble TENS machine may actually be a viable treatment option for a number of bladder conditions such as OAB, persistent pelvic pain conditions (bladder pain syndrome, vestibulodynia, male pelvic pain), obstetric labour, faecal incontinence, period pain (primary dysmenorrhea) and what today’s blog is about which is non-obstructive urinary retention (NOUR).
NOUR refers to incomplete emptying of the bladder without any physical blockage. Often the reason for incomplete emptying maybe muscular (maybe the pelvic floor muscles or urethral sphincter muscles do not relax well) or it could be related to other conditions in the area, such as lichen sclerosus or lichen planus, cystitis, post-partum or post-operative complications.
The TENS machine is a small hand held device that emits an electrical current via 2-4 sticky electrodes which are attached to the skin. The sensation is of a tingling/ pins and needles type of feeling when it’s turned on. The machine is able to be adjusted in both frequency and intensity so that it gives a strong but comfortable sensation. This sensation tends to be calming for the nerves being stimulated, thus reducing both pain as well as reducing over-activity of the target nerves. Whilst we are not sure on exactly the mechanism of action of the neural stimulation, research does seem to indicate both a local effect on the organs and peripheral nerves as well as a central effect in the brain.
Using the TENS machine over the nerves that also supply the bladder and pelvic floor muscles has been demonstrated to improve symptoms of OAB (overactive bladder), BPS (bladder pain syndrome) as well as NOUR. The TENS electrodes are positioned to stimulate the posterior tibial nerve down near the ankle (this has a neuro-modulatory effect on the bladder and pelvic floor as they have the same spinal origin).
Image from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730708/
Most studies suggest applying the TENS electrodes over the posterior tibial nerve (this technique is called TTNS) daily for 20-30 minutes has a positive impact within 4-6 weeks on bladder emptying, holding capacity, as well as on pain. TTNS has minimal side effects and it is safe for the large majority of people to implement.
As a case example I have a 40-year-old female patient with a 3-year history of urinary retention who had tried many things including urethral dilatation, self-catheterisation, bladder stimulating machines and correct bladder emptying positions. After a 4-week trial of TTNS she had halved her urinary retention volume and reduced her urinary frequency. After 10 weeks whilst she still felt somewhat incomplete in emptying, in clinic she actually had no residual volume on emptying.
It is important if you do have urinary retention, that it is properly investigated to rule out obstructive causes. Once that is given the all-clear, it is possible to start management such as correct position for bladder / bowel emptying, knowledge and understanding of good bladder habits, good pelvic floor muscle coordination and if they have not resolved the retention we can utilize TTNS to speed up the recovery process.
Thanks Martine – a great summary for us to remember and also thanks to Fiona Rogers for her great course and online shop.
As we head towards Christmas, and we have raging bush fires in Australia – consider purchasing Christmas presents from sites that support regional areas in Australia. The hashtag #buyfromthebush will find you lots of regional Australian businesses that are often supplementing the income of primary producers, so if you need some presents think about supporting these businesses. https://www.instagram.com/buyfromthebush/
Another useful Christmas present, particularly for women (even if I do say so myself) are either of my books – Pelvic Floor Essentials (if you haven’t had any surgery) and Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery. You can purchase my books from my website Pelvic Floor Recovery books .
Another fantastic Christmas present is to do something altruistic and kind by donating to HADA – a charity which supports the wonderful fistula and prolapse repair work that Professor Judtih Goh and Dr Hannah Krause are undertaking in Africa every 3 months. The link is here.