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Hady DAA. Effect of Transcutaneous Tibial Nerve Stimulation in Multiparous Egyptian Women with Vaginal Laxity: A Randomized Controlled Trial. ARCHIVES OF SEXUAL BEHAVIOR 2025; 54:1121-1128. [PMID: 39930034 PMCID: PMC11926003 DOI: 10.1007/s10508-025-03093-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/28/2024] [Accepted: 01/14/2025] [Indexed: 03/21/2025]
Abstract
Vaginal laxity (VL) is a common symptom of pelvic floor disorder, an underreported condition, and has a substantial impact on women's sex lives and relationships. The study aimed to determine the effect of transcutaneous tibial nerve stimulation (TTNS) on women with VL. Fifty women with vaginal laxity were chosen from an outpatient clinic in Egypt. They were randomly split into two equal categories (A and B). Group A (n = 25) received pelvic floor exercises (PFE), while Group B (n = 25) received TTNS and PFE. Every week, both groups performed three sessions for three months. The outcomes were evaluated both before and following treatment using ultrasound imaging to assess pelvic floor muscle (PFM) function and the Female Sexual Function Index to measure sexual function. Vaginal Laxity Questionnaire (VLQ) were used to examine vaginal looseness. The analysis demonstrated a significant improvement in vaginal laxity in both groups. Post-treatment comparisons revealed a statistically significant difference in VLQ scores and PFM strength between Groups B and A. These findings indicate that TTNS is notably more effective in improving PFM activity and VLQ scores in women with vaginal laxity.
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Affiliation(s)
- Doaa A Abdel Hady
- Department of Physical Therapy for Women's Health, Deraya University, Minia, 61511, Egypt.
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Giannopapas V, Smyrni V, Kitsos DK, Chasiotis AK, Stavrogianni K, Papagiannopoulou G, Tsivgoulis G, Voumvourakis K, Giannopoulos S, Bakalidou D. Tibial nerve stimulation in the management of primary sexual dysfunction in patients with multiple sclerosis: a pilot randomized control trial. Neurol Sci 2024; 45:5849-5858. [PMID: 39009893 DOI: 10.1007/s10072-024-07687-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/04/2024] [Indexed: 07/17/2024]
Abstract
INTRODUCTION Sexual dysfunction (SD) is a common symptom that affects 40-90% of patients with multiple sclerosis (MS). Previous studies have highlighted the negative impact of sexual dysfunction in the mental health status and overall quality of life in patients with MS. METHODS The aim of this study was to examine the effects of transcutaneous tibial nerve stimulation (TTNS) in the primary SD symptoms in patients with MS. A total of 40 participants were randomized (1:1 ratio) to either TTNS or Sham group and received three 20 min sessions over the course of two months. Pre and post intervention SD was evaluated using the Multiple Sclerosis Intimacy Questionnaire (MISQ-15). RESULTS Statistically significant improvements in the aspects of primary sexual dysfunction were observed in the TTNS group pre-post intervention (specifically erectile function (for males)/vaginal lubrication (for females) (p < .001), orgasm quality and satisfaction for both male and female patients (p < .001), sexual desire (p < .05) and bladder related symptomatology (p < .005). In the sham group pre-post intervention, the only observed improvement was in the sexual desire aspect (p < .05). Post intervention the groups significantly differed erectile function/vaginal lubrication and orgasm quality and satisfaction (p < .05). CONCLUSIONS Our findings underline the efficacy of TTNS in improving primary SD symptoms as well as bladder problems in both male and female patients with MS. TTNS demonstrated significant improvement in the following domains: erectile function, vaginal lubrication, orgasm quality, satisfaction, bladder-related symptoms, and sexual desire.
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Affiliation(s)
- Vasileios Giannopapas
- Second Department of Neurology, University of Athens, Athens, Greece
- Department of Physical Therapy, University of West Attica, Athens, Greece
- Laboratory of Neuromuscular and Cardiovascular Study of Motion, University of West Attica, Athens, Greece
| | - Vassiliki Smyrni
- Second Department of Neurology, University of Athens, Athens, Greece
| | | | - Athanasios K Chasiotis
- Second Department of Neurology, University of Athens, Athens, Greece
- Department of Physical Therapy, University of West Attica, Athens, Greece
- Laboratory of Neuromuscular and Cardiovascular Study of Motion, University of West Attica, Athens, Greece
| | - Konstantina Stavrogianni
- Second Department of Neurology, University of Athens, Athens, Greece
- Department of Physiology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | | | | | | | | | - Daphne Bakalidou
- Department of Physical Therapy, University of West Attica, Athens, Greece
- Laboratory of Neuromuscular and Cardiovascular Study of Motion, University of West Attica, Athens, Greece
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Zachariou A, Giannakis I, Kaltsas A, Zikopoulos A, Skentou C, Stavros S, Potiris A, Zachariou D, Baltogiannis D, Phuc CHN, Sopheap B, Tien DMB, Sofikitis N. Percutaneous Tibial Nerve Stimulation's Impact on Sexual Function in Female Patients with Neurogenic Detrusor Overactivity, Sexual Dysfunction, and Multiple Sclerosis. J Clin Med 2024; 13:6042. [PMID: 39457993 PMCID: PMC11508524 DOI: 10.3390/jcm13206042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Revised: 10/01/2024] [Accepted: 10/06/2024] [Indexed: 10/28/2024] Open
Abstract
Background/Objectives: Multiple sclerosis (MS) frequently results in both urinary and sexual dysfunction, which significantly impairs quality of life. Conventional treatments for bladder dysfunction often prove insufficient, leading to the exploration of alternative therapies such as percutaneous tibial nerve stimulation (PTNS). This study aimed to assess the impact of PTNS on sexual function and bladder symptoms in female MS patients with neurogenic detrusor overactivity (NDO) and female sexual dysfunction (FSD). Methods: A total of 65 female MS patients with NDO were evaluated and underwent 12 weeks of standardized PTNS treatment. Sexual function was assessed using the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale-Revised (FSDS-R), while bladder symptoms were evaluated using the OAB-v8 questionnaire. Participants were grouped based on the presence of sexual dysfunction and distress and compared to a control group of 20 patients who declined PTNS. Results: Significant improvements were observed in FSFI scores across multiple domains (desire, arousal, lubrication, orgasm, satisfaction, and pain) in the treatment groups (p < 0.05). Additionally, 58.46% of patients showed positive responses to PTNS regarding overactive bladder symptoms (OAB-v8 score), while the control group showed no significant changes. Conclusions: PTNS appears to be an effective therapeutic option for improving sexual function and urinary symptoms in female MS patients with NDO and FSD, offering a promising non-invasive alternative for managing these conditions.
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Affiliation(s)
- Athanasios Zachariou
- Department of Urology, Medical School of Ioannina, University General Hospital, 455 00 Ioannina, Greece; (I.G.); (D.B.)
- Outpatient Urology Department, Physical Medicine and Rehabilitation Medicine Centre, 382 22 Volos, Greece;
| | - Ioannis Giannakis
- Department of Urology, Medical School of Ioannina, University General Hospital, 455 00 Ioannina, Greece; (I.G.); (D.B.)
| | - Aris Kaltsas
- Third Department of Urology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 157 72 Athens, Greece;
| | - Athanasios Zikopoulos
- Department of Obstetrics and Gynecology, Royal Cornwall Hospital, Truro TR1 3LJ, UK;
| | - Charikleia Skentou
- Department of Obstetrics and Gynecology, Medical School of Ioannina, University General Hospital, 455 00 Ioannina, Greece;
| | - Sofoklis Stavros
- Third Department of Obstetrics and Gynecology, University General Hospital ATTIKON, Medical School, National and Kapodistrian University of Athens, 157 72 Athens, Greece; (S.S.); (A.P.)
| | - Anastasios Potiris
- Third Department of Obstetrics and Gynecology, University General Hospital ATTIKON, Medical School, National and Kapodistrian University of Athens, 157 72 Athens, Greece; (S.S.); (A.P.)
| | - Dimitrios Zachariou
- Outpatient Urology Department, Physical Medicine and Rehabilitation Medicine Centre, 382 22 Volos, Greece;
| | - Dimitrios Baltogiannis
- Department of Urology, Medical School of Ioannina, University General Hospital, 455 00 Ioannina, Greece; (I.G.); (D.B.)
| | | | - Bou Sopheap
- Department of Urology, Cambodia-China Friendship Preah Kossamak Hospital, Phnom Penh 120406, Cambodia;
| | - Dung Mai Ba Tien
- Department of Andrology, Binh Dan Hospital, Ho Chi Minh City 700000, Vietnam;
| | - Nikolaos Sofikitis
- Department of Urology, Medical School of Ioannina, University General Hospital, 455 00 Ioannina, Greece; (I.G.); (D.B.)
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Ippolito GMR, Palanjian RR, Mao-Draayer Y, Capizzano A, Barboglio-Romo P, Clemens JQ, Gupta P, Dunn R, O'Dell D, Daignault-Newton S, Van Til M, Cameron AP, Stoffel JT. A Prospective Observational Study of Posterior Tibial Nerve Stimulation in Multiple Sclerosis. Int Urogynecol J 2024; 35:1605-1612. [PMID: 38942931 DOI: 10.1007/s00192-024-05836-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/17/2024] [Indexed: 06/30/2024]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to examine the outcomes of posterior tibial nerve stimulation (PTNS) on bladder, bowel, and sexual health-related quality of life among a cohort of patients with multiple sclerosis (MS) with refractory lower urinary tract symptoms (LUTS). METHODS Patients with MS and refractory LUTS were recruited for a prospective, observational study using PTNS to treat their symptoms. Patients underwent 12 weekly 30-min PTNS sessions and bladder, bowel, and sexual symptoms were evaluated at baseline, 3, 12, and 24 months with voiding diaries, visual analog scales (VAS), and validated patient-reported questionnaires, including the American Urological Association Symptom Score (AUA-SS), Neurogenic Bladder Symptom Score (NBSS), Michigan Incontinence Symptom Index (M-ISI), Health Status Questionnaire, Sexual Satisfaction Scale, and Bowel Control Scale. RESULTS A total of 23 patients were recruited: 18 started PTNS and 14 completed 3 months of PTNS. Of the 18 who started PTNS, the mean age was 52 years (SD 12), 61% were female, 83% were white, and most patients had relapsing remitting (39%) MS. Baseline (n=18) and 3-month voiding (n=11) outcomes showed no significant change in number of voids or incontinence episodes. The median VAS symptom improvement was 49 (IQR 26.5, 26) and 9 (53%) patients elected for monthly maintenance PTNS. On paired analysis, there was a significant improvement in median change in NBSS, AUA-SS, and M-ISI. There was no significant change in bowel or sexual dysfunction. CONCLUSIONS This prospective, observational study of PTNS in patients with MS with refractory LUTS shows improvement in patient-reported bladder outcomes, but not in number of voids per day or bowel or bladder function.
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Affiliation(s)
| | - Rita R Palanjian
- Department of Urology, University of Arizona, Formerly University of Michigan Medical School, Tucson, AZ, USA.
| | - Yang Mao-Draayer
- Oklahoma Medical Research Foundation, Formerly Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | | | | | - J Quentin Clemens
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Priyanka Gupta
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Rodney Dunn
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Diana O'Dell
- Department of Anesthesiology, University of Michigan, Formerly Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | | | - Monica Van Til
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne P Cameron
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - John T Stoffel
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
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Bottorff EC, Gupta P, Ippolito GM, Moore MB, Rodriguez GM, Bruns TM. Short-Term Dorsal Genital Nerve Stimulation Increases Subjective Arousal in Women With and Without Spinal Cord Injury: A Preliminary Investigation. Neuromodulation 2024; 27:681-689. [PMID: 38573280 DOI: 10.1016/j.neurom.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 12/23/2023] [Accepted: 02/13/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVES Female sexual dysfunction (FSD) affects an estimated 40% of women. Unfortunately, FSD is understudied, leading to limited treatment options for FSD. Neuromodulation has shown some success in alleviating FSD symptoms. We developed a pilot study to investigate the short-term effect of electrical stimulation of the dorsal genital nerve and tibial nerve on sexual arousal in healthy women, women with FSD, and women with spinal cord injury (SCI) and FSD. MATERIALS AND METHODS This study comprises a randomized crossover design in three groups: women with SCI, women with non-neurogenic FSD, and women without FSD or SCI. The primary outcome measure was change in vaginal pulse amplitude (VPA) from baseline. Secondary outcome measures were changes in subjective arousal, heart rate, and mean arterial pressure from baseline. Participants attended one or two study sessions where they received either transcutaneous dorsal genital nerve stimulation (DGNS) or tibial nerve stimulation (TNS). At each session, a vaginal photoplethysmography sensor was used to measure VPA. Participants also rated their level of subjective arousal and were asked to report any pelvic sensations. RESULTS We found that subjective arousal increased significantly from before to after stimulation in DGNS study sessions across all women. TNS had no effect on subjective arousal. There were significant differences in VPA between baseline and stimulation, baseline and recovery, and stimulation and recovery periods among participants, but there were no trends across groups or stimulation type. Two participants with complete SCIs experienced genital sensations. CONCLUSIONS To our knowledge, this is the first study to measure sexual arousal in response to short-term neuromodulation in women. This study indicates that short-term DGNS but not TNS can increase subjective arousal, but the effect of stimulation on genital arousal is inconclusive. This study provides further support for DGNS as a treatment for FSD.
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Affiliation(s)
- Elizabeth C Bottorff
- Biomedical Engineering Department, University of Michigan, Ann Arbor, MI, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA
| | - Priyanka Gupta
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | | | - Mackenzie B Moore
- Biomedical Engineering Department, University of Michigan, Ann Arbor, MI, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA
| | - Gianna M Rodriguez
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Tim M Bruns
- Biomedical Engineering Department, University of Michigan, Ann Arbor, MI, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA.
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Albayrak H, Atli E, Aydin S, Ozyemisci-Taskiran O. Successful outcome following a multimodal pelvic rehabilitation program in a woman with neurogenic bladder and bowel dysfunction: A case report. Physiother Theory Pract 2024; 40:1083-1090. [PMID: 36369853 DOI: 10.1080/09593985.2022.2144561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 10/29/2022] [Accepted: 10/30/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Neurogenic bladder and bowel dysfunctions lead to physical, social, and emotional disability and affects one's quality of life. Initial treatment is conservative including several rehabilitation techniques such as pelvic floor muscle training, biofeedback, electrical stimulation, and posterior tibial nerve stimulation. OBJECTIVE In this case report, a 45-year-old woman with neurogenic bladder and bowel dysfunction was presented. CASE DESCRIPTION Her urinary and fecal incontinence symptoms began twenty years before this episode of care, after an incomplete spinal cord injury secondary to spinal ependymoma and syringomyelia. She discontinued medical treatments due to side effects and ceased intermittent catheterization. A multimodal pelvic rehabilitation program was administered consisting of posterior tibial nerve stimulation, active pelvic floor muscle training accompanied by biofeedback, and electrical stimulation of pelvic floor muscles. OUTCOMES There were clinically important favorable differences in the scores of King's health questionnaire (reductions in symptom severity from 25 to 18 and in each of the impact of incontinence, physical and social limitations, personal relationships, sleep/energy, and severity measures from 100 to 67), pelvic floor distress inventory (decreased from 257 to 146) and female sexual function index (increased from 15.1 to 25.1) after 12 weeks of a multimodal pelvic rehabilitation program. Manual muscle tests demonstrated improvements in pelvic floor muscle strength and endurance. CONCLUSION A 12-week multimodal pelvic rehabilitation program reduced urinary and fecal incontinence symptoms, together with improvements in her sexual life and alleviation of neuropathic pain.
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Affiliation(s)
- Havvanur Albayrak
- Department of Physical Medicine and Rehabilitation, Koç University Hospital, Topkapi, Turkey
| | - Ecenur Atli
- Department of Physical Medicine and Rehabilitation, Koç University Hospital, Topkapi, Turkey
| | - Serdar Aydin
- Department of Obstetric and Gynecology, Koç University School of Medicine, Topkapi, Turkey
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Zimmerman LL, Mentzelopoulos G, Parrish H, Marcu VI, Luma BD, Becker JB, Bruns TM. Immediate and Long-Term Effects of Tibial Nerve Stimulation on the Sexual Behavior of Female Rats. Neuromodulation 2024; 27:343-352. [PMID: 36609088 DOI: 10.1016/j.neurom.2022.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVES There are limited treatment options for female sexual dysfunction (FSD). Percutaneous tibial nerve stimulation (PTNS) has shown improvements in FSD symptoms in neuromodulation clinical studies, but the direct effects on sexual function are not understood. This study evaluated the immediate and long-term effects of PTNS on sexual motivation and receptivity in a rat model of menopausal women. Our primary hypothesis was that long-term PTNS would yield greater changes in sexual behavior than short-term stimulation. MATERIALS AND METHODS In two experiments, after receiving treatment, we placed ovariectomized female rats in an operant chamber in which the female controls access to a male by nose poking. We used five treatment conditions, which were with or without PTNS and no, partial, or full hormone priming. In experiment 1, we rotated rats through each condition twice with behavioral testing immediately following treatment for ten weeks. In experiment 2, we committed rats to one condition for six weeks and tracked sexual behavior over time. We quantified sexual motivation and sexual receptivity with standard measures. RESULTS No primary comparisons were significant in this study. In experiment 1, we observed increased sexual motivation but not receptivity immediately following PTNS with partial hormone priming, as compared with priming without PTNS (linear mixed effect models; initial latency [p = 0.34], inter-interval latency [p = 0.77], nose poke frequency [p = 0.084]; eight rats). In experiment 2, we observed trends of increased sexual receptivity (linear correlation for weekly group means; mounts [p = 0.094 for trendline], intromissions [p = 0.073], lordosis quotient [p = 0.58], percent time spent with a male [p = 0.39], decreased percent time alone [p = 0.024]; four rats per condition), and some sexual motivation metrics (linear correlation for weekly group means; nose pokes per interval [p = 0.050], nose poke frequency [p = 0.039], decreased initial latency [p = 0.11]; four rats per condition) when PTNS was applied long-term with partial hormone priming, as compared with hormone-primed rats without stimulation. CONCLUSIONS PTNS combined with hormone priming shows potential for increasing sexual motivation in the short-term and sexual receptivity in the long-term in rats. Further studies are needed to examine variability in rat behavior and to investigate PTNS as a treatment for FSD in menopausal women.
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Affiliation(s)
- Lauren L Zimmerman
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA
| | - Georgios Mentzelopoulos
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA; Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI, USA
| | - Hannah Parrish
- Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA; Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI, USA
| | - Vlad I Marcu
- Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA; Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI, USA; Department of Engineering Physics, University of Michigan, Ann Arbor, MI, USA
| | - Brandon D Luma
- Michigan Neuroscience Institute, University of Michigan, Ann Arbor, MI, USA
| | - Jill B Becker
- Michigan Neuroscience Institute, University of Michigan, Ann Arbor, MI, USA; Department of Psychology, University of Michigan, Ann Arbor, MI, USA
| | - Tim M Bruns
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA.
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Bottorff EC, Gupta P, Ippolito GM, Moore MB, Rodriguez GM, Bruns TM. Acute dorsal genital nerve stimulation increases subjective arousal in women with and without spinal cord injury: a preliminary investigation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.24.23288935. [PMID: 37163021 PMCID: PMC10168483 DOI: 10.1101/2023.04.24.23288935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Introduction Female sexual dysfunction (FSD) impacts an estimated 40% of women. Unfortunately, female sexual function is understudied, leading to limited treatment options for FSD. Neuromodulation has demonstrated some success in improving FSD symptoms. We developed a pilot study to investigate the short-term effect of electrical stimulation of the dorsal genital nerve and tibial nerve on sexual arousal in healthy women, women with FSD, and women with spinal cord injury (SCI) and FSD. Methods This study consists of a randomized crossover design in three groups: women with SCI, women with non-neurogenic FSD, and women without FSD or SCI. The primary outcome measure was change in vaginal pulse amplitude (VPA) from baseline. Secondary outcome measures were changes in subjective arousal, heart rate, and mean arterial pressure from baseline. Participants attended one or two study sessions where they received either transcutaneous dorsal genital nerve stimulation (DGNS) or tibial nerve stimulation (TNS). At each session, a vaginal photoplethysmography sensor was used to measure VPA. Participants also rated their level of subjective arousal and were asked to report any pelvic sensations. Results We found that subjective arousal increased significantly from before to after stimulation in DGNS study sessions across all women. TNS had no effect on subjective arousal. There were significant differences in VPA between baseline and stimulation, baseline and recovery, and stimulation and recovery periods among participants, but there were no trends across groups or stimulation type. Two participants with complete SCIs experienced genital sensations. Discussion This is the first study to measure sexual arousal in response to acute neuromodulation in women. This study demonstrates that acute DGNS, but not TNS, can increase subjective arousal, but the effect of stimulation on genital arousal is inconclusive. This study provides further support for DGNS as a treatment for female sexual dysfunction.
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Affiliation(s)
- Elizabeth C. Bottorff
- University of Michigan, Biomedical Engineering Department, Ann Arbor, MI, USA
- University of Michigan, Biointerfaces Institute, Ann Arbor, MI, USA
| | - Priyanka Gupta
- University of Michigan, Department of Urology, Ann Arbor, MI, USA
| | | | - Mackenzie B. Moore
- University of Michigan, Biomedical Engineering Department, Ann Arbor, MI, USA
| | - Gianna M. Rodriguez
- University of Michigan, Department of Physical Medicine and Rehabilitation, Ann Arbor, MI, USA
| | - Tim M. Bruns
- University of Michigan, Biomedical Engineering Department, Ann Arbor, MI, USA
- University of Michigan, Biointerfaces Institute, Ann Arbor, MI, USA
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Jin MY, D'Souza RS, Abd-Elsayed AA. Efficacy of Neuromodulation Interventions for the Treatment of Sexual Dysfunction: A Systematic Review. Neuromodulation 2023; 26:1518-1534. [PMID: 35981957 DOI: 10.1016/j.neurom.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/11/2022] [Accepted: 07/12/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The primary aim of this review was to analyze the literature for the efficacy of neuromodulation interventions in treating both male and female sexual dysfunction. MATERIALS AND METHODS Studies were identified from PubMed, Scopus, PsychINFO, CINAHL, and Cochrane. Results were synthesized qualitatively without pooling owing to the heterogeneous nature of outcome assessments. RESULTS Overall findings from studies generally supported that neuromodulation interventions were associated with improvement in sexual function. Specific domains that improved in male patients included erectile function, desire, and satisfaction, whereas desire, arousal, orgasm, lubrication, quality of "sex life," intercourse capability, and dyspareunia improved in female patients. Male ejaculation, orgasm, and intercourse capability were the only domains that continued to decline after the use of neuromodulation interventions, although this was only reported in one study. CONCLUSION Our review suggests that there may be promise and potential utility of neuromodulation in improving sexual dysfunction; however, further research is needed.
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Affiliation(s)
- Max Y Jin
- Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI, USA; Mayo Clinic, Rochester, MN, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alaa A Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI, USA; Mayo Clinic, Rochester, MN, USA.
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Yu ZT, Song JM, Qiao L, Wang Y, Chen Y, Wang EH, Zhang SC. A Randomized, Double-Blind, Controlled Trial of Percutaneous Tibial Nerve Stimulation With Pelvic Floor Exercises in the Treatment of Childhood Constipation. Am J Gastroenterol 2023; 118:553-560. [PMID: 36734654 DOI: 10.14309/ajg.0000000000002188] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/10/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The management of childhood constipation is challenging. Pelvic floor dysfunction (PFD) is one of the most common causes of childhood constipation. Percutaneous tibial nerve stimulation (PTNS) with pelvic floor exercises (PFE) has achieved a satisfactory outcome in the elderly individuals and women with PFD. The efficacy of PTNS with PFE in childhood constipation has not been established. METHODS A randomized, double-blind, controlled trial with 84 children who met the inclusion criteria was conducted. All participants were randomly assigned to PTNS with PFE or sham PTNS with PFE groups and received their individual intervention for 4 weeks with a 12-week follow-up evaluation. The spontaneous bowel movements (SBM) ≥3 per week were the main outcomes, and the risk ratio (RR) with 95% confidence interval (CI) were calculated. High-resolution anorectal manometry and surface electromyography were used for the assessment of pelvic floor function, and the adverse effects were assessed based on symptoms. RESULTS At the end of the follow-up period, 26 patients (61.9%) in the PTNS with PFE group and 15 patients (35.7%) in the sham group had ≥3 SBM per week compared with baseline (net difference 26.2%, 95% CI 5.6%-46.8%; RR 2.750, 95% CI 1.384-5.466; P < 0.05). PFD remission occurred in 49 children, 33 (78.6%) in the PTNS with PFE group and 16 (38.1%) in the sham group (RR 2.063, 95% CI 1.360-3.128, P < 0.05). No adverse effects occurred. DISCUSSION PTNS with PFE is a safe and effective method in the treatment of childhood constipation, particularly in children with PFD or dyssynergic defecation.
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Affiliation(s)
- Zheng-Tong Yu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jun-Min Song
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Lei Qiao
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yang Wang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ying Chen
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - En-Hui Wang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shu-Cheng Zhang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
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Wang ZH, Liu ZH. Treatment for overactive bladder: A meta-analysis of tibial versus parasacral neuromodulation. Medicine (Baltimore) 2022; 101:e31165. [PMID: 36253991 PMCID: PMC9575790 DOI: 10.1097/md.0000000000031165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The study aimed to assess the efficacy and safety of parasacral neuromodulation (PNS) versus tibial nerve stimulation (TNS) for patients with overactive bladder (OAB). METHODS Databases including PubMed, Embase, clinicalTrial.gov, and Cochrane Library Central Register of Controlled Trials were systematically searched from January 1, 1999 to September 9, 2022. The improvements in a 3-day voiding diary were set as the primary outcomes. Then, the scores of overactive bladder-validated 8-question awareness tool (OAB-V8), King's health questionnaire (KHQ), and international consultation on incontinence questionnaire overactive bladder (ICIQ-OAB) were also evaluated. RESULTS Five articles (4 randomized controlled trials [RCTs] and 1 prospective study) including 255 OAB patients were enrolled. Two kinds of neuromodulations had similar performances in the micturition (mean difference [MD] = 0.26, 95% confidence interval [CI]: -0.51 to 1.04, P = .50), urgency episodes (MD = -0.16, 95% CI: -0.64 to 0.31, P = .50), incontinence episodes (MD = 0.09, 95% CI: -0.41 to 0.59, P = .72), as well as in the nocturia episodes (MD = 0.04, 95% CI: -0.45 to 0.52, P = .89). Furthermore, there was no difference regarding ICIQ-OAB scores (P = .83), KHQ (P = .91), and OAB-V8 scores (P = .83). Importantly, included studies reported no adverse events in the 2 groups. CONCLUSION TNS and PNS had similar effectiveness for the treatment of OAB, moreover, without any identified adverse events in both groups. However, well-designed RCTs are stilled needed to verify our results.
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Affiliation(s)
- Zhi-Hong Wang
- Department of Urology, West China Hospital, Sichuan University, Chengdu, P.R.C China
| | - Zhi-Hong Liu
- Department of Urology, West China Hospital, Sichuan University, Chengdu, P.R.C China
- *Correspondence: Department of Urology, West China Hospital, Sichuan University, Chengdu, P.R.C China (e-mail: )
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12
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Díaz-Ruiz MDC, Romero-Galisteo RP, Arranz-Martín B, Palomo-Carrión R, Ando-Lafuente S, Lirio-Romero C. Vibration or Transcutaneous Tibial Nerve Stimulation as a Treatment for Sexual Dysfunction in Women with Spinal Cord Injury: Study Protocol for a Randomized Clinical Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031478. [PMID: 35162500 PMCID: PMC8835312 DOI: 10.3390/ijerph19031478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Women with spinal cord injuries usually suffer from sexual dysfunction, such as alterations during arousal and an increase in the time to reach orgasm. However, little evidence has been found on its physiotherapeutic approach, as well as poor adherence to the latter. The aim of this study is to determine the effectiveness of two interventions to improve sexual dysfunction: the application of genital vibration and transcutaneous tibial nerve stimulation. METHODS This is a randomized clinical trial that will recruit 54 women who, one year after a spinal cord injury, suffer from sexual dysfunction associated with the latter. The participants will be randomized to three groups: (a) intervention group 1 treated with transcutaneous tibial nerve electrostimulation (n = 18), (b) intervention group 2 treated with genital vibration (n = 18), and (c) a control group (n = 18). The treatment time will be 12 weeks. Adherence to the treatment will be evaluated, as well as the effectiveness of the treatment, through the Female Sexual Function Index, the Sexual Quality of Life-Female questionnaire, quantitative sensory tests, and the improvement reported by the patient in terms of arousal and orgasm. The evaluations will be carried out before the treatment, at the end of the treatment and 3, 6 and 12 months after the end of the treatment.
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Affiliation(s)
| | - Rita-Pilar Romero-Galisteo
- Department of Physiotherapy, Faculty of Science Health, University of Málaga, 29016 Málaga, Spain
- Correspondence:
| | - Beatriz Arranz-Martín
- Department of Nursing, Physiotherapy and Occupational Therapy, Faculty of Physiotherapy and Nursing, University of Castilla-La Mancha, 45071 Toledo, Spain; (B.A.-M.); (R.P.-C.); (S.A.-L.); (C.L.-R.)
| | - Rocío Palomo-Carrión
- Department of Nursing, Physiotherapy and Occupational Therapy, Faculty of Physiotherapy and Nursing, University of Castilla-La Mancha, 45071 Toledo, Spain; (B.A.-M.); (R.P.-C.); (S.A.-L.); (C.L.-R.)
| | - Sara Ando-Lafuente
- Department of Nursing, Physiotherapy and Occupational Therapy, Faculty of Physiotherapy and Nursing, University of Castilla-La Mancha, 45071 Toledo, Spain; (B.A.-M.); (R.P.-C.); (S.A.-L.); (C.L.-R.)
| | - Cristina Lirio-Romero
- Department of Nursing, Physiotherapy and Occupational Therapy, Faculty of Physiotherapy and Nursing, University of Castilla-La Mancha, 45071 Toledo, Spain; (B.A.-M.); (R.P.-C.); (S.A.-L.); (C.L.-R.)
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13
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Shawer S, Khunda A, Waring GJ, Ballard P. Impact of intravesical onabotulinumtoxinA (Botox) on sexual function in patients with overactive bladder syndrome: a systematic review and meta-analysis. Int Urogynecol J 2022; 33:235-243. [PMID: 35024885 DOI: 10.1007/s00192-021-05072-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/21/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The association between overactive bladder (OAB) syndrome and sexual dysfunction is well documented. Intra-detrusor onabotulinumtoxinA (Botox) has proven to be effective treatment for OAB syndrome. Our aim was to examine the impact of intravesical Botox injection on sexual function in patients with OAB, by systematically reviewing the literature. METHODS We reviewed the literature for studies that reported a change in sexual function after Botox treatment in patients suffering from OAB. This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement using pre-agreed keywords, from database inception to December 2020. Statistical analyses were performed using Review Manager (RevMan; v.5.4). RESULTS Initial results yielded 455 citations. Seven articles met our inclusion criteria. One article was double-reported, leaving 6 studies in the systematic review. Three observational before-and-after studies used the Female Sexual Function Index (FSFI) with sufficient information, and therefore were included in our meta-analysis. The pooled number of participants in all studies was 119 patients. In the meta-analysis, there was significant improvement in the following domains of the FSFI after Botox injection; desire (mean difference (MD) -0.51, p = 0.02), arousal (MD -0.86, p = 0.02), lubrication (MD -0.57, p = 0.03), orgasm (MD -0.65, p = 0.0003) and satisfaction (MD -0.46, p = 0.05). Pain was the only domain that did not show improvement (MD -0.07, p = 0.79). The total FSFI score was reported in 88 patients (two studies) showing significant improvement (MD -0.77, p = 0.006). CONCLUSIONS We report a systematic review of the effect of Botox treatment on sexual function in patients with OAB. Although studies are small, the results indicate a positive effect in patients with OAB.
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Affiliation(s)
| | - Aethele Khunda
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Gareth J Waring
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Paul Ballard
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
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14
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Siegal A, Chubak BM. Pharmaceutical and Energy-Based Management of Sexual Problems in Women. Urol Clin North Am 2021; 48:473-486. [PMID: 34602169 DOI: 10.1016/j.ucl.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article summarizes and critiques the evidence for use of available pharmacotherapies (vasoactive, psychoactive, and hormonal medications) and energy-based therapies (laser, radiofrequency, shockwave, and neurostimulation) for treatment of female sexual dysfunction. The enthusiasm with which energy-based treatments for sexual dysfunction have been adopted is disproportionate to the amount of data currently available to support their clinical use. Pharmacotherapy for female sexual dysfunction has considerably more research evidence to justify its use. Patients must be empowered to make an informed, autonomous determination as to whether the risk/reward ratio favors the use of pharmacotherapy, energy-based therapy, or some other treatment intervention.
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Affiliation(s)
- Alexandra Siegal
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, 6th Floor, New York, NY 10029, USA
| | - Barbara M Chubak
- Department of Urology, Icahn School of Medicine at Mount Sinai, 10 Union Square #3A, New York, NY 10003, USA.
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15
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Polat Dunya C, Tülek Z, Kürtüncü M, Gündüz T, Panicker JN, Eraksoy M. Evaluating the effects of transcutaneous tibial nerve stimulation or pelvic floor muscle training on sexual dysfunction in female multiple sclerosis patients reporting overactive bladder. Neurourol Urodyn 2021; 40:1661-1669. [PMID: 34174117 DOI: 10.1002/nau.24733] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/15/2021] [Accepted: 06/02/2021] [Indexed: 01/04/2023]
Abstract
AIMS Sexual dysfunction (SD) is common in female patients with multiple sclerosis (MS) reporting overactive bladder (OAB) symptoms. The aim of the study was to evaluate the effects of transcutaneous tibial nerve stimulation (TTNS) and pelvic floor muscle training (PFMT) with biofeedback on SD in female patients with MS reporting OAB symptoms. METHODS Patients with overactive bladder and SD were allocated to receive TTNS or PFMT daily. Overactive bladder symptoms, sexual functions, and sexual quality of life were assessed at baseline and 6th weeks. Female Sexual Function Index (FSFI), Overactive Bladder Questionnaire (OABv-8), and Sexual Quality of Life-Female (SQoL-F) questionnaires were used. RESULTS Thirty patients (TTNS = 10, PFMT = 20) were included in the study. Compared to baseline, total FSFIOABv-8, and SQoL-F scores improved in both TTNS (p = 0.005, p = 0.011, p = 0.444, respectively) and PFMT (p = 0.002, p = 0.001, p = 0.001, respectively) groups. Between-group comparisons did not show any significant differences. CONCLUSION This study demonstrates the efficacy of both TTNS and PFMT for improving sexual function in female MS patients with OAB symptoms, but did not show superiority of any particular method. Further studies are required to investigate the differences between these two non-invasive methods.
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Affiliation(s)
- Cansu Polat Dunya
- Division of Nursing, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Zeliha Tülek
- Division of Nursing, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Murat Kürtüncü
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Tuncay Gündüz
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Jalesh N Panicker
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Mefkure Eraksoy
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Yang DY, Zhao LN, Qiu MX. Treatment for overactive bladder: A meta-analysis of transcutaneous tibial nerve stimulation versus percutaneous tibial nerve stimulation. Medicine (Baltimore) 2021; 100:e25941. [PMID: 34011072 PMCID: PMC8137095 DOI: 10.1097/md.0000000000025941] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/25/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND We aim to compare the safety and effectiveness of transcutaneous tibial nerve stimulation (TTNS) versus percutaneous tibial nerve stimulation (PTNS) in treating overactive bladder. METHODS A systematical search on PubMed, Embase, clinicalTrial.gov, and Cochrane Library Central Register of Controlled Trials from January 1, 1999 to November 1, 2020 was performed. The primary outcomes were the changes in a 3-day voiding diary. Quality of life scores were also evaluated. Review Manager 5.3 (Cochrane Collaboration, Oxford, UK) was applied to conduct all statistical analyses. RESULTS A total of 4 trials (2 randomized controlled trials, 1 retrospective study, and 1 before-after study) with 142 patients were eventually enrolled. Compared with PTNS, TTNS had a similar performance in the voiding frequency in 24 hours (mean difference [MD] = -0.65, 95% confidence interval [CI]: -1.35 to 0.05, P = .07), the number of urgency episodes in 24 hours (MD = 0.13, 95% CI: -0.36 to 0.62, P = .60), the number of incontinence episodes in 24 hours (MD = 0.01, 95% CI: -0.13 to 0.14, P = .93), as well as in the nocturia frequency (MD = -0.14, 95% CI: -0.52 to 0.24, P = .47). Moreover, comparable results were observed regarding HRQL scores (P = .23) and incontinence quality of life scores (P = .10) in both groups. The total complication rate in the current study was 2.1% (3/142). No adverse events were identified in the TTNS group. CONCLUSION Current data supported that TTNS is as effective as PTNS for the treatment of overactive bladder, moreover, with no reported adverse events. However, the evidence is low-grade and well-designed prospective studies with a large sample size are warranted to verify our findings.
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Affiliation(s)
| | - Liu-Ni Zhao
- Department of Urology, People's Hospital of Sichuan Province, Chengdu, People's Republic of China
| | - Ming-Xing Qiu
- Department of Urology, People's Hospital of Sichuan Province, Chengdu, People's Republic of China
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17
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Bovbjerg ML. Current Resources for Evidence-Based Practice, September 2020. J Obstet Gynecol Neonatal Nurs 2020; 49:487-499. [PMID: 32805207 PMCID: PMC7428455 DOI: 10.1016/j.jogn.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of “spin” in scientific reporting and its effect on summaries and syntheses of the literature and commentaries on reviews about early versus late amniotomy as part of labor induction protocols and the economic burden associated with maternal morbidity.
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18
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8 versus 12 weeks of percutaneous tibial nerve stimulation and response predictors for overactive bladder. Int Urogynecol J 2020; 31:905-914. [DOI: 10.1007/s00192-019-04191-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/14/2019] [Indexed: 01/16/2023]
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19
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Bhide AA, Tailor V, Fernando R, Khullar V, Digesu GA. Posterior tibial nerve stimulation for overactive bladder-techniques and efficacy. Int Urogynecol J 2019; 31:865-870. [PMID: 31853597 PMCID: PMC7210232 DOI: 10.1007/s00192-019-04186-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 11/13/2019] [Indexed: 01/16/2023]
Abstract
The ideal treatment for overactive bladder is still elusive. In those where medication fails to improve symptoms options include invasive treatments such as botulinum toxin-A, sacral neural stimulation or posterior tibial nerve stimulation. Scientific professional society guidelines advise percutaneous posterior tibial nerve stimulation as a third line treatment option only after multi-disciplinary team review as well as failure of both conservative and pharmacological management. The aim of this article is to review all techniques for tibial nerve stimulation and their efficacy.
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Affiliation(s)
- Alka A Bhide
- St Mary's Hospital, Imperial College NHS Trust, London, UK.
| | - Visha Tailor
- St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - Ruwan Fernando
- St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - Vik Khullar
- St Mary's Hospital, Imperial College NHS Trust, London, UK
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