Introduction
Women, around 40, otherwise healthy, had 1 pregnancy and has a daughter. She wants to improve micturition and reduce the urgency.
Case history
The diagnosis is dysfunctional micturition. Patient has the feeling that she cannot empty her bladder completely and sometimes has urgency feelings only 30 minutes after a toilet visit. During micturition, the flow is slow and intermittent causing the micturition to take a long time. An ultrasound flow measurement (482 ml volume, flowtime 64.6 sec, peak flow 22.1 ml/sec, average flow 7.2 ml/sec) and a micturition diary (diuresis 2250ml/24hr; micturition volume 80‑490 ml; micturition frequency 8 times per 24 hours) endorse this diagnosis. Patient’s stool is considered normal (Bristol stool type 4).
During digital palpation the strength feels good, there is a good lifting movement, a partial closure movement on the right side, the relaxation after contraction is variable (from fast to slow), and there is urethral lift. No evidence found for POP.
In sexuality there are no particularities, other than that patient suffers from vaginal flatus during intercourse.
There is normal mobility of the lumbar spine, pelvis and hip. Patient indicates no pain complaints in and around the pelvis.
Treatment goals
The primary goal is to optimize the micturition by improving the bladder volume (up to max 500 ml filling), the force and duration of the flow and decreasing the urgency. The secondary goal is to bring about a relaxation of the pelvic floor muscles.
Treatment
In the first part of the treatment (6 sessions) the attention was focussed on explaining patient’s symptoms, on pelvic floor re-education, on toilet behaviour, on pelvic floor therapy as well as relaxation instructions. In addition, two ultrasound flow measurements were carried out.
In the second part of the course of treatment (3 treatments), the MAPLe was used.
During the first measurement it appeared that at rest (between 4 and 7 µV) an overactivity was measured dorsally deep in the pelvic floor. Patient was very surprised at the location where the relaxation had to take place, much deeper and in a different place than she thought. The image gave her a lot of information and helped her become aware.
After the measurement, 10 minutes of functional electrical stimulation (FES) was given at the location of the overactivity (phase duration 300 µsec, frequency 2 Hz) so that patient could feel where she had to further relax her pelvic floor muscles. In the next treatment, the range of the rest had already been greatly reduced (3-4 µV); after this, a combination of 10 minutes FES with unchanged settings, and then with a higher frequency (50 Hz) and repeating pattern of 8 seconds in which duration contractions with relaxation were practiced
Result
The rest reduced further to an average of 2 µV and provides a regular image, overactivity dorsally deep is gone. In addition, good and fast relaxations are visible after tightening.
Anamnestically the flow has improved well, patient empties her bladder in one go and after that does not have a feeling of urgency any longer.
Thanks to the use of the MAPLe, the myofeedback, the possibility to accurately locate the activity of the parts of the pelvic floor musculature, and the possibility of local stimulation, she could feel much better how and where she had to relax. This would not have been achieved with the current equipment.
