BlueCross BlueShield of Tennessee Medical Policy Manual

Pelvic Floor Stimulation

DESCRIPTION

Pelvic floor stimulation (PFS) is a proposed method of nonsurgical treatment for fecal and/or urinary incontinence. This approach involves either electrical stimulation of pelvic floor musculature or extracorporeal pulsed magnetic stimulation.

PFS involves electrical stimulation of pelvic floor muscles using either a probe wired to a device for controlling the electrical stimulation or, more recently, extracorporeal electromagnetic (also called magnetic) pulses. Stimulation of the pudendal nerve to activate the pelvic floor musculature is proposed to improve urethral closure. In addition, PFS is thought to improve partially denervated urethral and pelvic floor musculature by enhancing the process of reinnervation. Methods of electrical PFS have varied in location (e.g., vaginal, rectal), stimulus frequency, stimulus intensity or amplitude, pulse duration, pulse to rest ratio, treatments per day, number of treatment days per week, length of time for each treatment session, and overall time period for device use between clinical and home settings. Variations in the amplitude and frequency of the electrical pulse are used to mimic and stimulate the different physiologic mechanisms of the voiding response, depending on the etiology of the incontinence (i.e., either detrusor instability, stress incontinence, or a mixed pattern). Individuals receiving electrical PFS may undergo treatment in a physician's office or physical therapy facility, or they may undergo initial training in a physician's office followed by home treatment with a rented or purchased pelvic floor stimulator. Examples of these devices include MyoTrac Infiniti™, a non-implanted electrical stimulator, the Pathway™ CTS 2000, NeoControl®, and the InCare® PRS.

Magnetic PFS does not require an internal electrode; instead, patients sit fully clothed on a specialized chair with an embedded magnet. Magnetic PFS may be administered in the physician's office.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION  

Well-designed, randomized, controlled trials with long-term follow-up are necessary to determine long-term benefits of pelvic floor stimulation for the treatment of urinary and fecal incontinence compared to alternative treatments.

SOURCES

Abdelbary, A.M., El-Dessoukey, A.A., Massoud, A.M., Moussa, A., Zayed, A., Elsheikh, M., et al. (2015). Combined vaginal pelvic floor electrical stimulation (PFS) and local vaginal estrogen for treatment of overactive bladder (OAB) in perimenopausal females. Randomized controlled trial (RCT). Urology, 86 (3), 482-486. Abstract retrieved April 30, 2020 from PubMed database.

American Urological Association, Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. (2014). Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. Retrieved July 6, 2018 from http://www.auanet.org/guidelines.

BlueCross BlueShield Association. Evidence Positioning System. (9:2020). Pelvic floor stimulation as a treatment of urinary and fecal incontinence (1.01.17). Retrieved February 10, 2021 from https://www.evidencepositioningsystem. (28 articles and/or guidelines reviewed)

Cao, Y., Lv, J., Zhao,C., Li, J., & Leng, J. (2016). Cholinergic antagonists combined with electrical stimulation or bladder training treatments for overactive bladder in female adults: a meta-analysis of randomized controlled trials. Clinical Drug Investigation, 36 (10), 801-808. Abstract retrieved August 7, 2017 from PubMed database.

Center for Medicare and Medicaid Services. CMS.gov. NCD forNon-implantable pelvic floor electrical stimulator (230.8). Retrieved October 12, 2016 from https://www.cms.gov.

Lim, R., Lee, S., Tan, P., Liong, M., & Yuen, K. (2015). Efficacy of electromagnetic therapy for urinary incontinence: a systematic review. Neurourology and Urodynamics, 34 (8), 713-722. Abstract retrieved August 7, 2017 from PubMed database.

National Institute for Health and Clinical Excellence (NICE). (2007). Faecal incontinence in adults: management. Retrieved August 7, 2014 from www.nice.org.uk/guidance/cg49.

National Institute for Health and Clinical Excellence (NICE). (2019, April). Urinary incontinence in women: management. Retrieved June 4, 2019 from www.nice.org.uk/guidance/cg171.

Simillis, C., Lal, N., Pellino, G., Baird, D., Nikolaou, S., Kontovounisios, C., et al. (2019). A systematic review and network meta-analysis comparing treatments for faecal incontinence. International Journey of Surgery, 66, 37-47. Abstract retrieved June 4, 2019 from PubMed database.

U. S. Food and Drug Administration. (1998, June). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K973096. Retrieved November 17, 2015 from http://www.accessdata.fda.gov.   

U. S. Food and Drug Administration. (2006, March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K053434. Retrieved November 17, 2015 from http://www.accessdata.fda.gov.  

U. S. Food and Drug Administration. (2009, July). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K083704. Retrieved June 9, 2011 from http://www.accessdata.fda.gov.  

Vonthein, R., Heimerl, T., Schwander, T., & Ziegler, A. (2013). Electrical stimulation and biofeedback for the treatment of fecal incontinence: a systematic review. International Journal of Colorectal Disease, 28 (11), 1567-1577. (Level 1 evidence)

Wang, S., Lv, J., Feng, X., Wang, G., & Lv, T. (2016). Efficacy of electrical pudendal nerve stimulation in treating female stress incontinence. Urology, 91, 64-69. Abstract retrieved October 13, 2016 from PubMed database.

Xiao-xing, M., & An Liu, M.B. (2019). Effectiveness of electrical stimulation combined with pelvic floor muscle training on postpartum urinary incontinence. Medicine (Baltimore), 98 (10), e14762. (Level 1 evidence)

Winifred S. Hayes, Inc. Medical Technology Directory. (2006, March; last update search February 2020). Pelvic floor electrical stimulation for the treatment of urinary incontinence. Retrieved April 29, 2020 from www.Hayesinc.com/subscribers. (99 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  12/1998

MOST RECENT REVIEW DATE:  4/8/2021

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