Abstract
Pelvic floor dysfunction is commonly observed in individuals with spinal cord injury, often resulting in urinary, gastrointestinal, and sexual disturbances. Although pelvic floor rehabilitation is a widely accepted treatment for pelvic floor dysfunction in the general population, its application in spinal cord injury remains insufficiently explored. This study presents clinical experiences with pelvic floor rehabilitation in patients with incomplete motor spinal cord injury, aiming to contribute to the growing body of literature.
This case series includes three patients with incomplete spinal cord injury, American Spinal Injury Association Impairment Scale, Grade-D, who underwent individualized multimodal pelvic floor rehabilitation programs. Interventions targeted urinary, bowel, and sexual dysfunctions using pelvic floor muscle training, biofeedback, electrical stimulation, tibial nerve stimulation, and sensory retraining strategies. All three patients demonstrated notable improvements in bladder and bowel continence, voluntary voiding, and sexual function. Subjective reports indicated enhanced functional independence and quality of life. Pelvic floor rehabilitation shows promise as an effective therapeutic option for managing neurogenic pelvic floor dysfunction in patients with incomplete spinal cord injury. Further randomized controlled trials are warranted to establish its efficacy and define optimal intervention protocols.
Pelvic floor rehabilitation (PFR) is a targeted intervention designed to optimize the function of the pelvic floor muscle (PFM) complex and restore coordinated neuromuscular activity in individuals with pelvic floor dysfunction (PFD).1 Standard PFR modalities include pelvic floor muscle training (PFMT),2 biofeedback (BF),3 electrical stimulation (ES),4 tibial nerve stimulation (TNS),5 and adjunctive methods such as manual myofascial release and connective tissue mobilization.6
Spinal cord injury (SCI) significantly compromises pelvic floor function depending on the injury level and extent of neurological involvement.7,8 Resulting dysfunctions—such as urinary incontinence, fecal incontinence, constipation, and sexual impairment—contribute not only to physical disability but also to reduced quality of life and psychosocial distress.9
While PFR has shown proven efficacy in managing PFD in non-neurological populations,10 its integration into SCI rehabilitation is limited and lacks robust clinical data.11 This study aimed to present real-world outcomes from three patients with incomplete motor SCI who underwent multimodal PFR, thereby offering insights into the potential role of PFR in this unique clinical population.
Case Series
Case 1
A male patient, age 46 years, presented 7 months post-injury with a traumatic L3 American Spinal Injury Association Impairment Scale (AIS),Grade-D SCI. Complaints included impaired gait, urinary incontinence, and fecal incontinence. Post-catheter removal, a residual urine volume of 60 mL was identified, leading to initiation of clean intermittent catheterization (CIC) and trospium chloride.
PFR Intervention
Interferential current therapy (8 sessions, 50 Hz, anal probe)
Electromyelogram (EMG)-based biofeedback (20 sessions)
Daily Kegel and core stabilization exercises
Concurrent Transcutaneous Tibial Nerve Stimulation (TTNS) (30-minute sessions, 2–3 times/week)
Outcome
Marked reduction in urinary incontinence and fecal incontinence episodes, improved pelvic awareness, and subjective improvement in quality-of-life (QoL).
Case 2
A female patient, age 35 years, was diagnosed with cauda equina syndrome secondary to lumbar disc herniation. After emergency decompression, she reported perineal numbness, voiding dysfunction, and constipation. CIC was initiated.
PFR Intervention
Interferential current therapy (8 sessions, 10 Hz, vaginal probe)
EMG-based biofeedback (20 sessions)
Daily Kegel and core exercises
TTNS
Sensory re-education (tactile and vibratory stimuli)
Bladder diary tracking
Outcome
Initiation of voluntary micturition, improved voiding efficiency, and enhanced QoL perception.
Case 3
A male patient, age 44 years, sustained T7–T9 fractures and underwent spinal fixation. On admission (L3 AIS-D), he reported inability to void and erectile dysfunction.
PFR Intervention
Kegel and core stabilization exercises
EMG biofeedback via anal probe
TTNS
Structured gait training
Outcome
Achieved independent public ambulation with a cane, regained voluntary voiding, prolonged erection time, and improved sexual satisfaction.
Post-discharge
All patients adhered to prescribed exercise, dietary, and voiding routines and are under continued follow-up.
Discussion
Spinal cord injury frequently results in neurogenic pelvic floor dysfunction, including urinary incontinence, fecal incontinence, and sexual dysfunction. Effective rehabilitation requires a combination of neuromodulation, proprioceptive training, and muscle strengthening.
The International Continence Society (ICS) recommends pelvic floor muscle training (PFMT) as the first-line treatment for urinary incontinence and pelvic dysfunction (Grade A).9 PFMT is based on repetitive, graded contractions to restore muscular endurance, tone, and coordination.2,12,13 However, active contraction capacity may be limited in SCI patients, necessitating passive facilitation such as electrical stimulation at initial stages.
ICS endorses ES for all types of urinary incontinence and neurogenic detrusor overactivity (Grade 2B).12 High-frequency stimulation (40–50 Hz) targets efferent pudendal fibers to induce PFM contractions and increase urethral closure pressure, while low-frequency ES (5–10 Hz) modulates afferent input to suppress detrusor hyperactivity.14 Combining frequencies may offer dual benefits in detrusor control and PFM conditioning.7 Despite its theoretical benefits, evidence for ES in neurological conditions is sparse. Only two randomized controlled trials (RCTs) have reported moderate improvements in urinary incontinence in post-stroke and MS patients.10,15
Biofeedback (BF) complements PFMT by offering real-time auditory/visual feedback for muscle contraction awareness. It has been validated in enhancing training outcomes when paired with PFMT.16–18
Tibial nerve stimulation (TNS) modulates sacral plexus pathways controlling bladder and pelvic organs.19,21 ICS recommends TNS for urinary incontinence symptom relief and QoL enhancement (Grade 2B).12 TTNS is equally as effective as PTNS, but TTNS is preferred due to its non-invasive profile and patient comfort.22
In all three cases, multimodal PFR—including TTNS, EMG-biofeedback, sensory retraining, and core stabilization—was associated with clinically meaningful improvements across bladder, bowel, and sexual domains, consistent with the literature supporting comprehensive neuromuscular rehabilitation for neurogenic pelvic floor dysfunction.
Conclusion
Pelvic floor rehabilitation (PFR) is an evidence-based intervention for addressing urinary, gastrointestinal, and sexual dysfunctions in patients with PFD. While its application in SCI remains under-investigated, findings from this case series suggest that multimodal PFR can result in significant functional gains in patients with incomplete SCI.
Observed improvements in continence, voluntary voiding, and sexual function support the inclusion of PFR in routine neurorehabilitation. However, the small sample size and observational design limit the generalizability of our findings. Future randomized controlled trials with standardized outcome measures are essential to validate these results and determine optimal treatment algorithms for this population.
Footnotes
Disclosures: The authors have declared no personal or professional conflicts of interest related to this work and declare the study has not received any specific funding from public, commercial, or not-for-profit funding agencies. The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials. Written informed consent to participate was obtained from all patients.
Author Contributions: All authors were equally involved in the planning of the manuscript, selection of patients, treatment of patients, evaluation of outcomes, writing and revision of the manuscript.
- Received November 19, 2024.
- Revision received June 12, 2025.
- Accepted June 26, 2025.
References
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