Electrical stimulation for the pelvic floor
Some of the names you may see used when describing electrical stimulation :
- ES : Electrical Stimulation
- E-Stim: Electrical Stimulation
- NMES : Neuro Muscular Electrical Stimulation : used to cause muscle contractions eg when strengthening the pelvic floor muscles
- FES : Functional Electrical Stimulation : causes a muscle contraction that is functional, or the same as one we use in everyday life eg bending your elbow to bring hand to mouth.
Most often used in rehab after a stroke.
- TENS : Transcutaneous Electrical Nerve Stimulation: stimulates sensory (feeling) nerves via skin (cutaneous) electrodes.
Most often used for pain and calming bladder an bowel urgency
- SNS / SNM : Sacral Nerve Stimulation / Sacral NeuroModulation: two names for the same thing : implanted stimulators that affect the sacral nerve roots.
Most often used for bladder and bowel urgency and incontinence
- SNS: Spinal Nerve Stimulation : implanted stimulator that directly affects the spinal nerves.
Most often used for pain
- PENS : Percutaneous Electrical Nerve Stimulation : stimulates nerves via needles inserted near the nerve : often used in theatre by pain specialists for spinal nerve stimulation with the patient sedated
Different frequencies and other parameters of stimulation are used for different goals. For example we would use completely different settings for calming an urgent bladder down to those we would use to strengthen your pelvic floor muscles.
It can be confusing to know which does what and what all the terms mean! The main differences are in the parameters used, which will affect the type of nerves and muscle fibres stimulated, and the mode of delivery - across the skin (transcutaneous) or through the skin (percutaneous)
See more on parameters below.
Electrical stimulation is commonly used and recommended for many conditions including:
- Improving the strength of your pelvic floor muscles if they are very weak or deconditioned.
- Helping to locate, identify and isolate the pelvic floor muscles to help you learn how to do a pelvic floor muscle contraction correctly.
Some people have good tone in their muscles but are not 'connected' well enough to be able to voluntarily contract them. NMES can be helpful to re-educate the sensorimotor pathways to help you learn how to contract correctly.
- In the form of TENS it can be used very successfully for reducing bladder and bowel urgency which often results in loss of control.
- Persistent pelvic pain can respond very well to including some TENS in treatment.
It can replace drugs in many cases and is non- invasive, cheap and risk free with no side effects.
- Labour pain can be helped with the use of a special TENS unit with a remote control allowing you to take charge of your pain relief during labour changing the modulating input sensation when a contraction starts.
This same machine can be extremely helpful with severe pelvic pain often experienced with endometriosis.
Electrical stimulation/ neuromodulation may be able to help a range of pelvic floor dysfunctions
- Stress urinary incontinence
- Urge urinary incontinence
- Bladder urgency
- Faecal incontinence
- Faecal urgency
- Pelvic pain
- Painful sex
- Period pain
- Pelvic pain of any origin
Electrical stimulation is described in terms of parameters or settings. What do they mean?
is the measure of intensity of the electrical current, usually expressed as mA.
Electrical stimulation devices allow you to control the level of intensity, which should always be at a comfortable level.
When stimulating pelvic floor muscles to contract, the current should be strong enough to cause a contraction- this may take a few sessions to build up to as you get used to the sensation.
This is one of the main differences between a stimulated contraction and a voluntary one – you don’t get the tingling sensation with a voluntary one.
is the number of pulses that are generated per second and is expressed as Hz and pronounced “hertz”.
The best frequency for electrical stimulation varies according to the nerves being targeted and this depends on the condition being treated.
Generally, stress urinary incontinence is treated with frequencies between 20-50HZ and urge incontinence with frequencies between 10-15HZ.
Higher frequencies build strength by targeting/stimulating the faster twitch muscle fibres, helping to increase the ability of the pelvic floor muscles to help close the urethra and prevent the leakage associated with stress incontinence.
This also ‘bulks up’ the muscles over time, giving better pelvic floor support to the organs.
Low frequencies have a calming effect on the nerves that supply bladder’s muscular layer and therefore reduce bladder contractions.
However, patients with urge incontinence can often benefit from high frequency treatment as well as low frequency, as increased muscle strength also helps with controlling the urge to urinate.
Low frequencies can also calm the nerves controlling the bowel and gut contractions can be reduced in cases of faecal urgency.
is how long each of the pulses last. The higher the width, the deeper the pulse will penetrate so this affects the type of nerve fibre stimulated.
Most clinical applications use around 200uS.
Using higher and lower widths is mainly helpful in pain management and can be manipulated to give better individualised pain relief.
is how quickly the electrical current reaches the mA, or intensity, that has been set on the machine which in effect means how quickly the current gets to the muscle fibres.
The more slowly the current rises to its maximum intensity, the more comfortable the stimulation will feel. This best replicates a voluntary contraction.
The faster the ramp, the quicker it stimulates the muscle each time which can be helpful in cases where muscles awareness is needed but the faster it is the more likely you will feel some discomfort.
This is one of the main ways you can manipulate the program to make it more user friendly. Pre-set programs have set ramps. Make sure the machine you buy allows you to change the ramp if you want the best effect.
On/Off or Work/Rest time
On time is the amount of time that the electrical stimulation is active (work)
Off time is the amount of time when there is no electrical current (rest)
Off time is important to allow the muscle to recover when using it for stimulating muscle contractions. When using TENS, the current is continuous so there is no work/rest setting.
This is one of the main differences between TENS and NMES and this is why you cannot generally use a ‘TENS’ machine to stimulate muscle contractions – unless the machine allows you to change from continuous to work/rest.
How does electrical stimulation work?
When electrical stimulation is applied to the body, it creates a flow or current of electrically charged particles, which in turn creates physiological changes in the tissue through which the charge flows. Therefore if you apply electrical stimulation to the pelvic floor muscles, you can create changes in these muscles.
Pelvic floor electrical stimulation is usually a pulsed “bi-directional and biphasic” current. This means that charged particles move in one direction, drop to zero, and then change direction. This type of current reduces the chance of skin and tissue irritation.
Research suggests that electrical stimulation can:
- Increase the proportion of fast twitch fibers of the pelvic floor muscles
- Increase the number and strength of slow twitch fibers of the pelvic floor muscles making it easier to achieve stronger pelvic muscle contractions.
- Help reduce the bladder over-activity and bladder contractions that cause urge incontinence, frequency and urgency problems
- Help reduce faecal incontinence and urgency
- Help reduce the experience of pain
Some Facts About Pain
- Nerves DO NOT send pain messages to the brain. We have many types of nerve fibres and some of these have the job of relaying nociceptive (possibly dangerous or may cause damage) information to the brain. The brain’s job is to then decide how to best deal with that information at that point in time.
- TENS machines DO NOT block the nerve pain messages to the brain, stopping the pain. They can help to later that input so it is not interpreted as being so dangerous.
- Pain is an output of the brain and there are many factors influencing the pain experience.
- BUT your pain is very real, never let anyone tell you that it is ‘all in your head”
- You will still read on many websites that nerves send pain messages and these can be blocked. Messages from nerves are processed by the brain and the level of danger or threat is assessed and the response is appropriate to the situation. We can interrupt or modulate the messages going to the brain but we are not blocking them in the way we used to understand the mechanism. Pain science has come a long way in recent years and it is taking time for some to catch up on the latest research.
See my page on pelvic pain for a more in depth description.
Who should NOT use electrical stimulation?
Some people cannot use electrical stimulation including those with:
- Cardiac pacemaker or cardiac arrhythmia
- Pregnancy or planning a pregnancy
- Broken/irritated skin in the rectal, vaginal or perineal area
- Rectal bleeding or haemorrhoids
- Bladder or vaginal infections
- Seizure and dementia conditions
CAUTION check with your health professional before using internal electrical stimulation if you have:
- an IUD - do not use with a copper IUD
Check with your doctor if you have a Mirena or similar. One of the concerns is you may accidentally pull the device out when you remove the electrode from the vagina.
- a pessary in place, you can remove it before and then replace it afterwards if you have been taught how - check with your treating health professional
- had hip joint replacement if using internally for pelvic floor - check with your doctor
What does all of this mean for choosing an electrical stimulation device?
Be aware that more programs does not mean a superior machine. The value in your machine comes with its ability to have the parameters manipulated to suit your condition.
The machines that we sell are easy to use and feature pre-set programs for various conditions as well as custom programs that can be set to individualised parameters, by your health professional, specifically for your treatment.
The preset programs are named for conditions by the manufacturers which can be a little confusing.
For example your aim may be to strengthen your pelvic floor but there are no programs called Strengthen. They will usually be named Stress Incontinence - because this is the condition that most commonly requires strengthening of the pelvic floor muscles.
You may have a prolapse with a weak pelvic floor being part of the problem but there is no program called Prolapse.
If your aim is to strengthen your pelvic floor muscles then the Stress/SUI programs should generally have the correct parameters to start you off on.
*The strength or intensity of the stimulation (mA) is always under your control.
Stress Urinary Incontinence
- normally requires strengthening of the pelvic floor muscles and will use programs in the range of 20 - 40 Hz with various work/rest times
- when starting out, choose a program with a longer rest than work. As you progress you can
shorten the rest time and increase the work time which will help build endurance in your pelvic floor muscles.
Even if you don't leak, but are aiming to strengthen the pelvic floor, use these programs.
If you find the preset program in the 30-40Hz range too strong or uncomfortable, you can try the preset 20Hz program and once used to that you can change the higher frequency program of 30-40Hz.
There are programs for this in the Pelvitone and Continence
Urgency / Urge Urinary Incontinence / Faecal urgency or Incontinence
- uses lower frequencies or Hz which are aimed at calming the nerves to the bladder and
rectum, making them less irritated. These programs will normally be around 10 Hz.
- pain settings are normally at the lower end around 2-5Hz or the higher end 80- 150Hz.
- The pelvic floor stimulation machines tend to use the lower settings in the preset programs
(Pelvitone and Continence) whereas the Obstetric TENS machines use the higher end Hz.
The TENS machine uses a range of settings, allowing you to choose which works best for you.
Again, this is why any machine that allows you to custom set your own program is far better value for money.
So which machine do I choose?
It can be confusing trying to work out which is the best machine for you.
The main consideration when choosing is what do I need my machine to do?
This summary may help:
- for pain - any type
- for urinary or faecal urgency when you are going to use it to calm the bladder and bowel
- this machine will only allow the use of continuous current, you cannot use it for pelvic floor muscle strengthening as you need to be able to use work/rest settings for making muscles contract and relax
- for pain relief during labour
- for persistent pelvic pain especially when associated with Endometriosis. The cramping pain with Endometriosis is often likened to labour pain. Using an Obstetric TENS with its boost remote can be very helpful during spikes in pain
- has a range of programs for strengthening, calming and pain as well as 4 custom programs you can set your own parameters. One of these is dedicated to continuous
(as in TENS)
- this makes it our most cost-effective machine for home use.
- Does the same as the Continence and allows for a continuous program in the custom settings, however clinicians be aware that this only goes p to 100Hz so if you intend to use higher frequencies you will need a TENS machine. The difference between Pelvitone and Continence is mainly that Pelvitone also allows for a multi-phase program to be set if required. Be aware this does take experience in setting programs.
All of the electrodes that we sell are compatible with all of the machines we sell. This includes stimulation machines, TENS machines and EMG machines
Leads are supplied with your machine. These leads plug into the machine and the electrodes plug into the leads. Your electrode does NOT plug directly into your machine.
Electrodes and leads are delicate and the wires within are easily damaged. Do not pull your electrode out, or off, by the leads. Use the flange on the end of the electrode, or peel the adhesive ones carefully off via the sticky part.
We are often asked which electrode should I buy?
This is very individual and depends on a number of factors.
- Choose your internal electrode based on size and shape required.
Vaginal electrodes need to fit the hiatus or width of the vagina to get good contact.
You can learn how to test vaginal size here.
Most women who have had babies will need a wider electrode.
- Do you need an external (adhesive) electrode? Size will depend on where you will be using
it. The surface area of the electrode - the part that attaches to the skin - determines the concentration of the current felt.
So the smaller the electrode, the more concentrated the current and should be used for smaller areas.
Smaller area = smaller electrode. Larger area = larger electrode.
- Budget should be the last consideration with an electrode. You need it to do the job required so choose the most effective one for you. Often people will spend more on a stimulation machine because it has more programs so sounds better, and then less on their electrode.
In fact you only need a stimulation machine that has the correct parameters for you - often the other 10 programs are not needed for your condition. You should always buy the electrode best suited to you.
Troubleshooting with your stimulation machine
Sometimes things go wrong and your machine may appear to be malfunctioning.
All of our machines have a built in safety function that will not allow the intensity to go past 5-6mA if the circuit is incomplete.
The majority of the time this is due to a broken or damaged wire in either the electrode or the lead and this is almost always due to incorrect handling.
The leads and electrodes are delicate and the internal wires will break if roughly handled. This includes being removed via the leads rather than the flange on the end of internal electrodes, or by the leads of the adhesive electrodes (they need to be peeled off via the sticky electrode)
Stimulation machines don't like to be dropped either - this can damage the internal circuitry.
If your machine won't register past 5-6mA, your machine is working and you need to determine where the loss of contact is.
This can be:
- Lack of contact with the skin or tissue being stimulated (vaginal walls or rectum if being used internally for pelvic floor conditions)
- Broken wire in the electrode
- Broken wire in the lead
Watch our video on how to test machines, electrodes and leads with our physio Fiona Rogers.
You can also download our troubleshooting instructions to see how to fix any of these problems.
The material presented in this information sheet is intended as an information source only. The information is provided solely on the basis that readers will be responsible for making their own assessment of the matters presented herein and are advised to verify all relevant representations, statements and information. The information should not be considered complete and should not be used in place of the advice of a health care provider. Pelvic Floor Exercise does not accept liability to any person for the information or advice provided in this sheet, or for loss or damages incurred as a result of reliance upon the material contained herein.
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