Medical policy: Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter

Policy number: MP 2.096

Effective date: 9/1/2026

Policy

Needle and non-needle electromyography (EMG) of the anal or urethral sphincter may be considered medically necessary for the following indications:

• For initial diagnostic evaluation of an individual with an evacuation or voiding dysfunction (e.g., fecal incontinence, urinary incontinence, bladder outlet obstruction, detrusor sphincter dyssynergia, neurogenic conditions) when the test is likely to affect the course of therapy (e.g., pelvic floor training, surgical intervention, pharmacologic intervention, biofeedback therapy or other clinically accepted interventions)
• For the repeat assessment of an individual with neurogenic conditions of the anal or urethral sphincter resulting from disorders such as, but not limited to, multiple sclerosis, spinal cord injury, paralysis, or motor neuron disease. For these individuals, EMG testing of the anal or urethral sphincter may be required up to two times per year.

Policy guidelines

Note: Electromyography (EMG) performed as part of biofeedback therapy is inherent to the biofeedback service. EMG should not be reported in addition to biofeedback.

Cross-references:

• MP 1.109 Periurethral Bulking Agents as a Treatment of Vesicoureteral Reflux
• MP 2.030 Intraoperative Neurophysiologic Monitoring (Sensory Evoked Potentials, Motor Evoked Potentials, EEG Monitoring)
• MP 2.063 Electromyography and Nerve Conduction Studies

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP medical policy manual. The FEP medical policy manual can be found at: FEP Medical Policy Manual.

Description/Background

Electromyography (EMG) of the anal or urethral sphincter is a urodynamic study that quantitatively assesses the electrical activity from the striated muscles of the urethral or anal sphincter or from the perineal floor muscles. EMG provides objective data about the innervation to these muscles and the synchronization between the detrusor muscle of the bladder and the external sphincter; it is most useful to evaluate sphincter relaxation during voluntary detrusor contraction. EMG is used in the diagnosis and follow-up of known or suspected neurogenic (originating in nervous tissue) and non-neurogenic (originating in areas other than nervous tissue) conditions of the anal or urethral sphincters. An EMG of the anal or urethral sphincter can be performed using a needle electrode, a fine wire electrode, a surface electrode on the perianal skin, an anal plug, or an assembly of multiple-surface EMG electrodes placed in the anal canal.

Conditions commonly evaluated by EMG (needle and non-needle):

• Fecal Incontinence.
• Urinary incontinence.
• Bladder outlet obstruction (a blockage at the base of the bladder that reduces or prevents the flow of urine into the urethra).
• Detrusor sphincter dyssynergia (a neurogenic abnormality that involves an impaired coordination between bladder contraction and sphincter relaxation).
• Neurogenic conditions of the anal or urethral sphincter resulting from disorders such as, but not limited to, multiple sclerosis, spinal cord injury, paralysis, or motor neuron disease.

An EMG alone gives useful information about sphincteric function. However, an EMG is more valuable when performed in conjunction with cystometry to determine whether the striated sphincter appropriately increases its activity during bladder filling and whether rest occurs normally before and during bladder contraction. EMG is useful in diagnosing detrusor sphincter dyssynergia, which can occur in individuals with neurogenic conditions such as multiple sclerosis, spinal cord injury, or other neurologic lesions. EMG is also valuable in conjunction with pressure-flow studies, which analyze detrusor pressure and flow rate during the voiding phase. EMG during pressure-flow studies is useful in diagnosing conditions such as detrusor sphincter dyssynergia, dysfunctional voiding (non-neurogenic), bladder outlet obstruction, or incontinence.

When injury to the sacral roots of the spinal cord is suspected, a separate study of the anal sphincter using needle EMG may be required, as this is the only muscle accessible to needle EMG examination that receives its innervation through these roots. Needle EMG of the anal sphincter may also be performed to assess the innervation and anatomic integrity of the sphincters. In addition, characteristics of neurogenic bladders can change with time and disease progression; therefore, re-evaluation may be needed when symptoms change despite medical intervention.

Rationale

The 2012 American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU) Guideline on Adult Urodynamics recommends EMG testing in patients with relevant neurologic disease at risk for neurogenic bladder, or in patients with other neurologic disease and elevated post void residual (PVR) volume or urinary symptoms (Evidence Strength - Grade C).

The signal source for measurement of EMG activity is the activity of the external urethral sphincter, the external anal sphincter, and the pelvic floor musculature. The two most commonly used sources of measurement are surface electrodes and concentric needle electrodes. Needle placement may be a significant source of discomfort for patients, and reproducibility may be an issue without significant operator experience. The surface electrode has the advantage of ease (reproducibility) of placement and patient comfort. Although the signal source is less specific, surface electrodes can provide a good quality signal if properly used. The practical application of EMG involves determination of whether the perineal muscles are relaxed or contracting. The most important information provided by the EMG is the determination of whether perineal contractions are coordinated or uncoordinated with detrusor contractions.

The major limitation of EMG testing is that it is technically challenging and often non-specific within urodynamic studies. Artifacts are common, and accurate interpretation requires close interaction between the clinician and the patient. The clinician must have a solid understanding of the patient’s history and relevant physical findings. EMG by itself rarely establishes a diagnosis of an uncoordinated sphincter; instead, the findings must be interpreted alongside fluoroscopy, cystometry, and flow rate to achieve the most accurate diagnosis.

Definitions

N/A

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the member’s benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Covered when medically necessary:

References

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2. American Urological Association. Adult Urodynamics: AUA/SUFU Guideline (2012).
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5. Gill, B. Neurogenic bladder. [eMedicine Web site]. 05/15/14. Updated December 24, 2020.
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7. Elneil S. Urinary retention in women and sacral neuromodulation. Int Urogynecol J Pelvic Floor Dysfunct. 2010; 21 Suppl 2:475-483
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11. Novitas Solutions, Inc. Local Coverage Determination (LCD). L35081: Nerve Conduction Studies and Electromyography. Effective 10/1/17
12. Novitas Solutions, Inc. Local Coverage Determination (LCD). L34977: Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters. Effective 10/1/16.
13. Peterson AC, Webster GD. Urodynamic and videourodynamic evaluation of voiding dysfunction. Campbell-Walsh's Urology, 9th edition. Philadelphia: WB Saunders, Chapter 28, 2007
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15. Robson, K. Lembo A. Fecal Incontinence in Adults: Etiology and Evaluation. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated February 27, 2025
16. Sakakibara R, Uchiyama T, Yamanishi T, et al. Sphincter EMG as a diagnostic tool in autonomic disorders. Clin Auton Res. 2009; 19(1):20-31
17. Scott SM, Gladman MA. Manometric, sensorimotor, and neurophysiologic evaluation of anorectal function. Gastroenterol Clin North Am. 2008; 37(3):511-538
18. Ginsberg DA, Boone TB, Cameron AP et al: The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation. J Urol 2021; 206: 1097
19. Wald, Arnold MD, MACG; Bharucha, Adil E. MBBS, MD²; Limketkai, Berkeley MD, PhD, FACG³; Malcolm, Allison MBBS, FRACP⁴; Remes-Troche, Jose M. MD, MSc⁵; Whitehead, William E. PhD⁶; Zutshi, Massarat MD⁷,⁸. ACG Clinical Guidelines: Management of Benign Anorectal Disorders. The American Journal of Gastroenterology 116(10): p 1987-2008, October 2021. DOI: 10.14309/ajg.0000000000001507
20. Ginsberg DA, Boone TB, Cameron AP, Gousse A, Kaufman MR, Keays E, et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-up. Journal of Urology [Internet]. 2021 Nov 1 [cited 2024 Sep 20];206(5):1106-13
21. Ginsberg DA, Boone TB, Cameron AP, Gousse A, Kaufman MR, Keays E, et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation. Journal of Urology [Internet]. 2021 Nov 1 [cited 2024 Sep 20];206(5):1097-105