Diagnosing sacral neuro stimulation


MAPLe case

Female, 74 years of age, mother of three children. Has suffered from urinary incontinence for 15 years and fecal incontinence for the past five years. This has had a huge impact on her quality of life. She is a carer for her partner who has MS and she enjoys walking to keep fit.

Her fecal complaints are intermittent; week on and week off, varying from type 3/4 to 6. Patient is very reactive to different types of foods, but doesn’t always want to watch what she eats. A micturition diary shows that the patient urinates especially after 18:00.

Research question
The patient was referred to the pelvic physiotherapist by the colorectal surgeon with the question of whether function improvement could be expected using myofeedback? The patient is also a candidate for placement of sacral neuro stimulation.

The surgeon also reported a problem with the external anal sphincter.

Medical history
During the diagnosis, digital palpation and one-off measurements were taken using the MAPLe, first vaginally, then anally.

Following instruction, the patient is clearer on where and how to tense. This is particularly true of the vaginal area, closure of the hiatus should improve following repetition exercises.

There is little sensitivity anally and the contraction is much more difficult.

These measurements are about showing the difference between vaginally and anally measured values.

Vaginal measurements:

 Afbeelding 1 1  Afbeelding 2 2


The MAPLe-diagnosis shows a resting muscle tone of 3.1 µV (see illustration on the left), the MVC peaks at 12.9 µV and a reasonable on and offset of 0.1 and 0.4 seconds respectively. The contraction does however weaken after a number of times (see illustration on the right).

Anal measurements (focussing on the external anal sphincter):

Afbeelding 3 3  Afbeelding 4 4

The anal measurements show a resting muscle tone of 1.7 µV. The MVC peaks at 5.5 µV, with an average of 2.6 µV. The on and offset is clearly delayed. The Endurance shows a peak of 7.0 µV with an average of 3.1 µV (see illustration on the right). There is clearly little strength.

The vaginal readings were moderate but following instruction functional support was provided to the urethra and symptoms lessened. The patient continued with the exercises at home due to being a care provider for her partner. To date the patient has been adequately helped using the detailed myofeedback and she can now use it to continue progressing. Anally she had and continues to have little sensibility.

The surgeon wanted to know whether the patient was suitable for sacral neuro stimulation. Is there any contractile tissue and is the patient trainable? Anally, this proved not to be the case. The pelvic physiotherapist sent the MAPLe-images and the report to the surgeon. The patient is now on a waiting list for a sacral neuro stimulation trial placement to examine whether this does reduce symptoms.

The patient now has a better understanding of what and how to tense and is very pleased that a trial placement will be taking place.




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