Noot 22 Elektrostimulatie

Noot 22 Elektrostimulatie wordt op verschillende manieren toegepast, met verschillende stimulatieparameters en in combinatie met andere therapieën (zoals biofeedback of BBST). Het precieze mechanisme van elektrostimulatie is onbekend, maar er wordt verondersteld dat een transformatie optreedt van fast-twitch (vermoeibare) spiervezels (type 1) naar slow-twitch spiervezels (type 2). Daarnaast zou de dichtheid van bloedvaten toenemen. Wellicht speelt ook een verandering in vezeldiameter een belangrijke rol. Naast deze fysiologische veranderingen zou het voornaamste mechanisme een toegenomen bewustzijn van de anale sfincter kunnen zijn.⁵⁸

Er zijn 3 hypothesen opgesteld voor effectiviteit van elektrostimulatie.

Hypothese 1. Elektrostimulatie is effectiever dan welke andere behandeling ook

Osterberg et al. randomiseerden patiënten met idiopathische (neurogene) AI naar levatorplastiek of elektrostimulatie, en evalueerden het effect 3, 12, en 24 maanden na de behandeling.¹²⁶ Bij de eerste nameting hadden de patiënten die geopereerd waren een lagere incontinentiescore, maar na 12 en 24 maanden was er tussen de groepen geen verschil meer. Chirurgie bleek niet tot een verandering in de fysiologische variabelen te hebben geleid, op geen van de meetmomenten. De fysieke en sociale beperking veranderde echter wel: chirurgie leidde op deze uitkomstmaat op alle meetmomenten tot het beste resultaat. Naimy et al. vergeleken EMG-biofeedback met een anale sonde met elektrostimulatie (anale sonde).¹²⁷ Na de behandeling waren er geen verschillen tussen beide groepen. Kanttekening bij deze studies is dat de interventies in beide gevallen korter duurden dan 2 maanden.

Hypothese 2. Elektrostimulatie in combinatie met een andere behandeling is effectiever dan die andere behandeling alleen

Fynes et al. vergeleken vaginale biofeedback en BBST thuis (uitgevoerd door de continentieverpleegkundige) met anale EMG-biofeedback gecombineerd met anale elektrostimulatie en oefeningen thuis (uitgevoerd door de fysiotherapeut) bij patiënten met FI na obstetrisch letsel.⁷⁸ Twaalf weken na behandeling bleek er een significant verschil te zijn in het voordeel van de elektrostimulatiegroep. Het resultaat van deze studie is echter niet goed interpreteerbaar. Het is onduidelijk of het gevonden verschil aan de route (vaginaal/anaal) van de biofeedback ligt of aan de toevoeging van elektrostimulatie.
Mahony et al. vergeleken intra-anale EMG-biofeedback en BBST thuis met dezelfde behandeling aangevuld met elektrostimulatie.¹²⁸ Na de behandeling waren er geen verschillen tussen beide groepen.
Schwandner et al. vergeleken een triple target regime (3T) (amplitude-modulated middle-frequency elektrostimulatie (AM-MF) gecombineerd met EMG-biofeedback) en EMG-biofeedback alleen.¹²⁹ Met inachtneming van veel uitvallers in beide groepen, bleek behandeling met 3T op alle uitkomsten, behalve KvL, significant meer effect te vertonen. Kanttekening bij deze studie is de hoge uitval (61%), die mogelijk samenhangt met de hogere intensiteit van de elektrostimulatie (100 Hz) of de lange studieduur (9 maanden).

Hypothese 3. Eén modaliteit van elektrostimulatie prevaleert boven alle andere modaliteiten van elektrostimulatie

Norton et al. vonden geen verschil in effectiviteit bij een vergelijking tussen elektrostimulatie met 1 Hz en 35 Hz gedurende 8 weken.¹³⁰
Daarnaast is elektrostimulatie voor FI onderzocht in een Cochrane review.⁵⁸ In deze review werden slechts 4 gecontroleerde studies met in totaal 260 deelnemers geïncludeerd. De resultaten van deze studies zijn al separaat in hypothese 1 en 2 verwerkt.^{78,126,128,130}
Er zijn ook ongecontroleerde studies waarin over het effect van elektrostimulatie bij FI wordt gerapporteerd. Daarin staat bij herhaling: ‘De internationale literatuur, alsmede onze eigen onderzoeksresultaten bevestigen dat elektrostimulatie effectief is en dat bij sommige patiënten met AI elektrostimulatie een belangrijke rol speelt als onderdeel van de conservatieve behandeling'.^58,131

Niveau van bewijs

Niveau 1. Er is aangetoond dat er onvoldoende bewijs is om elektrostimulatie aan te bevelen bij de behandeling van FI op basis van slechts 4 studies met een heterogeen karakter qua patiëntenpopulatie, behandelprotocol en uitkomstmeting.⁵⁸
Daarnaast is het onduidelijk waarop de selectie van patiënten voor elektrostimulatie zou moeten worden gebaseerd en welke modaliteit van elektrostimulatie het meest optimaal is. Dit bewijs wordt ondersteund door consensus en aanbevelingen van de International Consultation on Incontinence.^47,48 

Niveau 4. De werkgroep is van mening dat elektrostimulatie wel inzetbaar is bij een selecte groep patiënten, met als doel de bewuste controle van de bekkenbodem te verbeteren bij patiënten zonder bewuste controle van de bekkenbodem (bij probleemgebied IA).

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