Motor cortical neuromodulation of pelvic floor muscle tone: Potential implications for the treatment of urologic conditions.

ABSTRACT

AIMS: In the human brain, supplementary motor area (SMA) is involved in the control of pelvic floor muscles (PFMs). SMA dysfunction has been implicated in several disorders involving PFMs, including urinary incontinence and urologic pain. Here, we aimed to provide a proof-of-concept study to demonstrate the feasibility of modulating resting PFM activity (tone) as well as SMA activity with noninvasive stimulation of SMA. METHODS: We studied six patients (3 women + 3 men) with Urologic Chronic Pelvic Pain Syndrome. Repetitive transcranial magnetic stimulation (rTMS) was applied to SMA immediately after voiding. We tested two rTMS protocols high-frequency (HF-rTMS) which is generally excitatory, and low-frequency (LF-rTMS) which is generally inhibitory. PFM activity was measured during rTMS using electromyography. Brain activity was measured immediately before and after rTMS using functional magnetic resonance imaging. RESULTS: The rTMS protocols had significantly different effects on resting activity in PFMs (P = 0.03) HF-rTMS decreased and LF-rTMS increased pelvic floor tone. SMA activity showed a clear trend ( P = 0.06) toward the expected differential changes HF-rTMS increased and LF-rTMS decreased SMA activity. CONCLUSIONS: We interpret the differential effects of rTMS at the brain and muscle level as novel support for an important inhibitory influence of SMA activity on pelvic floor tone after voiding. This preliminary study provides a framework for designing future studies to determine if neuromodulation of SMA could augment therapy for chronic urologic conditions.