Position for voiding from Pelvic Floor Essentials (2022) by Sue Croft
Non-obstructive urinary retention (NOUR), when it doesn’t respond simply to positional management (see above) and complete abdominal and pelvic floor relaxation can be frustrating for therapists to treat and patients to live with, as it can often mean recurrent urinary tract infections and problematic urinary frequency.
This blog is covering a case report of a lady who had excellent results from using TTNS (Transcutaneous Tibial Nerve Stimulation) as an addition to the usual position and muscle relaxation.
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, during labour and for low back pain. However there is a lot of research more recently that using the TENS unit with electrodes placed over the tibial nerve (called TTNS) has good results with a number of bladder conditions such as overactive bladder (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 autoimmune skin conditions (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 is turned on. The machine is able to be adjusted in both frequency and intensity so that it gives a strong but comfortable sensation but in the case of using trans tibial application of the electrodes we don’t want a toe twitch. 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 neuromodulation, 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 tibial nerve down near the ankle (see image below) – 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 tibial nerve (TTNS) for 5 out of 7 days for 20-45 minutes and this has a positive impact within 4-6 weeks on bladder emptying, holding capacity, as well as on pain. It is mandatory to watch Netflix (or the news 🙂 and of course you can read a book) while applying it but you don’t have to do anything else. (One paper on TTNS for OAB only used it one day a week and had improvement so if you have a busy week it will still potentially help). TTNS has minimal side effects and it is safe for the large majority of people to implement. Its use is contraindicated if you have a pacemaker in situ. The settings are pulse rate 10-20Hz, pulse width (frequency) 200uS and 1-7 days for 30-45 mins at moderate intensity (but definitely with no toe twitch).
Here is a case example from one of my physiotherapists: She had 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 the 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.
For physiotherapists, here is a link to the courses run by Fiona Rogers on the use of electrotherapy in Pelvic Health. These evidence-based courses are invaluable in understanding the research behind TTNS and all other electrotherapy modalities.
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.