Transcutaneous posterior tibial nerve stimulation versus extended release oxybutynin in overactive bladder patients. A prospective randomized trial

Efficacy and safety of tibial nerve stimulation using a wearable device for overactive bladder

OBJECTIVE

To evaluate the efficacy and safety of a wearable, smartphone-controlled, rechargeable transcutaneous tibial nerve stimulation (TTNS) device in patients with overactive bladder (OAB).

PATIENTS AND METHODS

This multicentre, prospective, single-blind, randomised clinical trial included eligible patients with OAB symptoms who were randomly assigned to the stimulation group or sham group. The primary efficacy outcome was change from baseline in voiding frequency/24 h after 4 weeks of treatment. The secondary efficacy outcomes included changes in bladder diary outcomes (urgency score/void, nocturia episodes/day, micturition volume/void, and incontinence episodes/day), questionnaires on Overactive Bladder Symptom Score (OABSS), Patient Perception of Bladder Condition (PPBC), and American Urological Association Symptom Index Quality of Life Score (AUA-SI-QoL) at baseline and after 4 weeks of treatment. Device-related adverse events (AEs) were also evaluated.

RESULTS

In the full analysis set (FAS), the mean (sd) change of voiding frequency/24 h in the stimulation group and sham group at 4 weeks were -3.5 (2.9) and -0.6 (2.4), respectively (P < 0.01). Similar results were obtained in the per-protocol set (PPS): -3.5 (2.9) vs -0.4 (2.3) (P < 0.01). In the FAS and PPS, micturition volume/void significantly improved at 4 weeks (P = 0.01 and P = 0.02). PPBC improvement almost reached significance in the FAS (P = 0.05), while it was significant in the PPS (P = 0.02). In the FAS and PPS, AUA-SI-QoL significantly improved at 4 weeks in the two groups (P < 0.01 and P < 0.01), whereas there were no significant differences in urgency score/void, nocturia episodes/day or OABSS between the groups. Also, no device-related serious AEs were reported.

CONCLUSIONS

The non-invasive neuromodulation technique using the novel ambulatory TTNS device is effective and safe for treating OAB. Its convenience and easy maintenance make it a new potential home-based treatment modality. Future studies are warranted to confirm its longer-term efficacy.

Effects of Transcutaneous Tibial Nerve Stimulation in Women Refractory to and Never Used Pharmacological Agents for Idiopathic Overactive Bladder

INTRODUCTION AND HYPOTHESIS

The aim of this study is to compare the effectiveness of transcutaneous tibial nerve stimulation (TTNS) on quality of life (QoL) and clinical parameters related to incontinence in pharmacological agents (PhAs) naive and refractory women with idiopathic overactive bladder (iOAB).

METHODS

In this prospective nonrandomized clinical trial, women with resistance to PhAs were included in the first group (n=21), PhA-naive women were included in the second group (n=21). TTNS was performed 2 days a week, a total of 12 sessions for 6 weeks. Every session lasted 30 min. Women were evaluated for the severity of incontinence (Pad test), 3-day voiding diary (voiding frequency, nocturia, incontinence episodes, and number of pads), symptom severity (Overactive Bladder Questionnaire-V8), quality of life (Incontinence Impact Questionnaire-7), treatment satisfaction, positive response, and cure-improvement rates.

RESULTS

A statistically significant improvement was found in all parameters for each group at the 6th week compared with the baseline values (p<0.05). It was found that the severity of incontinence, incontinence episodes, symptom severity, treatment satisfaction, and QoL parameters were significantly improved in PhA-naive group compared with the PhA-resistant group at the 6th week (p<0.05). There were no statistically significant differences in the frequency of voiding, nocturia, and number of pads between the two groups (p>0.05). Positive response rates, the primary outcome measure, were statistically significantly higher in the PhA-naive group than in the PhA-resistant group.

CONCLUSIONS

Although TTNS is more effective in PhA-naive women with iOAB, it appears to be an effective therapy that can also be used in the management of PhA-resistant women with iOAB.

Comparative Efficacy of Neuromodulation Technologies for Overactive Bladder in Adults: A Network Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The aim of this study was to investigate the comparative efficacy of neuromodulation technologies for overactive bladder (OAB) syndrome in adults.

DATA SOURCES

A computerized search was conducted of Cochrane Library, EMBASE, MEDLINE (via PubMed), Web of Science, CNKI, Wan Fang Data, and ClinicalTrials.gov up to April 21, 2022.

STUDY SELECTION

The search selected clinical trials with random allocation to percutaneous tibial nerve stimulation (PTNS), transcutaneous tibial nerve stimulation (TTNS), vaginal electrical stimulation (VES), sacral neuromodulation (SNM), parasacral stimulation (PS), pudendal neuromodulation, or placebo.

DATA EXTRACTION

The main outcomes were the voiding diary, OAB-related quality of life, and positive response rate. The Cochrane Risk of Bias tool (RoB 2.0) was used to assess the risk of bias of each included study, and the Grading of Recommendations Assessment, Development, and Evaluation tool was used to evaluate the overall evidence quality of key outcomes.

DATA SYNTHESIS

The study included 21 randomized controlled trials involving 1433 participants, and all trials were used for the meta-analysis. In the network meta-analyses, five of six neuromodulation technologies, including PTNS, TTNS, VES, SNM, and PS, were related to higher efficacy than the placebo. Ranking probability showed that SNM was the most efficacious therapy for improving OAB-related quality of life, urinary episodes, and urinary frequency. For urgency incontinence episodes and the number of pads, PTNS and TTNS were the most efficacious modalities, respectively.

CONCLUSION

Neuromodulation technologies, including PTNS, TTNS, VES, SNM, and PS, may be effective and safe solutions for OAB syndrome in adults. Moreover, SNM is the most efficacious regimen for OAB-related quality of life, urinary episodes, and urinary frequency. PTNS and TTNS are the most efficacious modalities for reducing urgency incontinence episodes and the number of pads, respectively. Future studies should pay more attention to the quality of study design and report, patients who may benefit the most from neuromodulation, and the long-term effect, cost-effectiveness, and satisfaction of neuromodulation.

What Are the Short-term Benefits and Potential Harms of Therapeutic Modalities for the Management of Overactive Bladder Syndrome in Women? A Review of Evidence Under the Auspices of the European Association of Urology, Female Non-neurogenic Lower Urinary Tract Symptoms Guidelines Panel

CONTEXT

Overactive bladder syndrome (OAB) is highly prevalent among women and has a negative impact on their quality of life. The current available treatments for OAB symptoms include conservative, pharmacological, or surgical modalities.

OBJECTIVE

To provide an updated contemporary evidence document regarding OAB treatment options and determine the short-term effectiveness, safety, and potential harms of the available treatment modalities for women with OAB syndrome.

EVIDENCE ACQUISITION

The Medline, Embase, and Cochrane controlled trial databases and clinicaltrial.gov were searched for all relevant publications up to May 2022. The risk of bias assessment followed the recommended tool in the Cochrane Handbook for Systematic Reviews of Interventions, and quality of evidence was assessed using the modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. A meta-analysis was performed where appropriate.

EVIDENCE SYNTHESIS

Antimuscarinics and beta-3 agonists were significantly more effective than placebo across most outcomes, with beta-3 agonists being more effective at reducing nocturia episodes and antimuscarinics causing significantly higher adverse events. Onabotulinumtoxin-A (Onabot-A) was more effective than placebo across most outcomes, but with significantly higher rates of acute urinary retention/clean intermittent self-catheterisation (six to eight times) and urinary tract infections (UTIs; two to three times). Onabot-A was also significantly better than antimuscarinics in the cure of urgency urinary incontinence (UUI) but not in the reduction of mean UUI episodes. Success rates of sacral nerve stimulation (SNS) were significantly higher than those of antimuscarinics (61% vs 42%, p = 0.02), with similar rates of adverse events. SNS and Onabot-A were not significantly different in efficacy outcomes. Satisfaction rates were higher with Onabot-A, but with a higher rate of recurrent UTIs (24% vs 10%). SNS was associated with 9% removal rate and 3% revision rate.

CONCLUSIONS

Overactive bladder is a manageable condition, with first-line treatment options including antimuscarinics, beta-3 agonists, and posterior tibial nerve stimulation. Second-line options include Onabot-A bladder injections or SNS. The choice of therapies should be guided by individual patient factors.

PATIENT SUMMARY

Overactive bladder is a manageable condition. All patients should be informed and advised on conservative treatment measures in the first instance. The first-line treatment options for its management include antimuscarinics or beta-3 agonists medication, and posterior tibial nerve stimulation procedures. The second-line options include onabotulinumtoxin-A bladder injections or sacral nerve stimulation procedure. The therapy should be chosen based on individual patient factors.

Transcutaneous medial plantar nerve stimulation in women with idiopathic overactive bladder

PURPOSE

To define transcutaneous medial plantar nerve stimulation (T-MPNS) as a new neuromodulation method and assess the efficacy of T-MPNS on quality of life (QoL) and clinical parameters associated with incontinence in women with idiopathic overactive bladder (OAB).

MATERIALS AND METHODS

Twenty-one women were included in this study. All women received T-MPNS. Two self-adhesive surface electrodes were positioned with the negative electrode near the metatarsal-phalangeal joint of the great toe on the medial aspect of the foot and the positive electrode 2 cm inferior-posterior of the medial malleolus (in front of the medio-malleolar-calcaneal axis). T-MPNS was performed 2 days a week, 30 minutes a day, for a total of 12 sessions for 6 weeks. Women were evaluated for incontinence severity (24-h pad test), 3-day voiding diary, symptom severity (Overactive Bladder Questionnaire [OAB-V8]), QoL (Quality of Life-Incontinence Impact Questionnaire [IIQ-7]), positive response and cure-improvement rates, and treatment satisfaction at baseline and at the 6th week.

RESULTS

Statistically significant improvement was found in the severity of incontinence, frequency of voiding, incontinence episodes, nocturia, number of pads, symptom severity, and QoL parameters at the 6th week compared with baseline. Treatment satisfaction, treatment success, and cure or improvement rates were found to be high at the 6th week.

CONCLUSIONS

T-MPNS was first described in the literature as a new neuromodulation method. We conclude that T-MPNS is effective on both clinical parameters and QoL associated with incontinence in women with idiopathic OAB. Randomized controlled multicenter studies are needed to validate the effectiveness of T-MPNS.

Update on Overactive Bladder Therapeutic Options

BACKGROUND

Millions of Americans are burdened by overactive bladder (OAB) syndrome and the psychogenic and economic hardships that accompany it. Several theories attempt to explain OAB as a neurogenic dysfunction, myogenic dysfunction, urothelial dysfunction, or decreased expression of a channel protein secondary to bladder outlet obstruction. Given that the etiology of OAB is a working theory, the management of OAB is also an evolving subject matter in medicine. There are uncertainties surrounding the pathophysiology of OAB, the strength of a clinical diagnosis, and accurate reporting because of the disease's stigma and decreased use of health care.

DATA SOURCES

This is a narrative review that used PubMed, Google Scholar, Medline, and ScienceDirect to review literature on current and future OAB therapies.

RESULTS

Currently, first-line treatment for OAB is behavioral therapy that uses lifestyle modifications, bladder-control techniques, and psychotherapy. Second-line therapy includes antimuscarinic agents or beta 3 adrenergic agonists, and studies have shown that combination therapy with antimuscarinics and beta 3 adrenergic agonists provides even greater efficacy than monotherapy. Third-line therapies discussed include onabotulinumtoxinA, posterior tibial nerve stimulation, and sacral neuromodulation. OnabotulinumtoxinA has been FDA-approved as a nonpharmaceutical treatment option for refractory OAB with minimal side effects restricted to the urinary tract. Posterior tibial nerve modulation and sacral neuromodulation are successful in treating refractory OAB, but the costs and complication rates make them high-risk procedures. Therefore, surgical intervention should be a last resort. Estrogen therapy is effective in alleviating urinary incontinence in postmenopausal women, consistent with the association between estrogen deficiency and genitourinary syndrome. Potassium channel activators, voltage-gated calcium channel blockers, and phosphodiesterase inhibitors look to be promising options for the future of OAB management. As new therapies are developed, individuals with OAB can better personalize their treatment to maximize their quality of life and cost-effective care.

Acupuncture for Women with Overactive Bladder: Perspective of Traditional Chinese Medicine and Related Mechanism

Purpose

Overactive bladder (OAB) syndrome is one of the most common diseases in urology and affects quality of life. Although the current treatment for OAB is based on oral medications, there are limitations and many patients have difficulty accepting drug-induced adverse effects. This review aimed to analyze the efficacy of acupuncture and its related mechanisms and provide a preliminary therapeutic regimen.

Methods

Two authors independently searched PubMed, Embase, and Cochrane Library up to April 2022. They searched related English literature and extracted the data under a standard form based on the search strategy. Clinical trials which included OAB women with the treatment of acupuncture were included. Common acupuncture alone without other pharmacotherapy, external treatments was in the treatment group. The control interventions may include any active treatments, sham placebo, or no establishment of a control group. Outcomes included 3-day or 24-hour voiding diary, overactive bladder symptom score, etc. The Cochrane risk of bias tool was also used to assess the methodological quality of the randomized controlled trials (RCTs).

Results

We analyzed five RCTs and one comparative study on acupuncture for OAB to review and discuss the acupoint location, treatment course, and retention time based on clinical evidence and treatment ideas in traditional Chinese medicine. Additionally, we used the available evidence to reveal and discuss the acupuncture mechanisms for OAB. Acupuncture may regulate bladder function by inhibiting C-fibers, modulating nerve growth factors and reducing spontaneous contractions of the detrusor muscle.

Conclusion

Combined with the available evidence, the combination of local acupoints and distal acupoints should be necessary to consider, especially the lumbosacral acupoints, the small abdomen acupoints and the lower limb acupoints. Among them, acupuncture at SP4, CV4 and KI3 are strongly recommended. The treatment course of acupuncture should be no less than 4 weeks and maintain the frequency of acupuncture no less than once a week. The duration of each session should be no less than 20 minutes. In addition, investigations remain necessary to verify acupuncture's efficacy and precise mechanism for OAB treatment in further exploration.

Non-inferior and more feasible transcutaneous tibial nerve stimulation in treating overactive bladder: A systematic review and meta-analysis

OBJECTIVES

Overactive bladder (OAB) is identified as a urinary urgency accompanied by frequency and nocturia with or without urgency urinary incontinence in the nonexistence of a urinary tract infection or other evident pathologies. This systematic review and meta-analysis aimed to evaluate the efficacy of the transcutaneous tibial nerve stimulation (TTNS) versus percutaneous tibial nerve stimulation (PTNS) or anticholinergic drugs in reducing symptoms and improving the quality of life for OAB patients.

METHODS

We performed a systematic search in Medline, Embase, and CENTRAL, in which we included randomized controlled trials that compared TTNS with anticholinergic drugs or PTNS in treating idiopathic OAB. We evaluated the following outcomes: 3-day voiding diary (voiding frequency/day, daytime micturition frequency/day, nighttime micturition frequency/day, number of urgency episodes/day, number of incontinence episodes/day, and mean voiding volume), symptom bother, health related quality of life (HRQoL), and adverse events. We used 95% as a confidence interval (CI) and p < 0.05. Standardized mean difference (SMD) was used for continuous outcomes, and the risk ratio (RR) was used for dichotomous outcomes.

RESULTS

There was no significant difference comparing TTNS with anticholinergic drugs or PTNS regarding voiding frequency/day (SMD = -0.01, 95% CI -0.33 to 0.32), nighttime micturition frequency/day (SMD = -0.28, 95% CI -0.94 to 0.37), number of urgency episodes/day (SMD = -0.05, 95% CI -0.36 to 0.26), number of incontinence episodes/day (SMD = -0.04, 95% CI -0.32 to 0.25), symptom bother (SMD = -0.19, 95% CI -0.55 to 0.16), HRQoL (SMD = 0.27, 95% CI -0.32 to 0.85), and adverse events (RR = 0.07, 95% CI 0.01 to 0.54).

CONCLUSION

The current meta-analysis reveals that there is no statistically significant difference between TTNS versus PTNS or anticholinergic drugs for the nonsurgical management of OAB patients.

Home-based transcutaneous tibial nerve stimulation for overactive bladder syndrome: a randomized, controlled study

Purpose

Transcutaneous posterior tibial nerve stimulation (TPTNS) for the treatment of overactive bladder syndrome (OAB), with or without urge urinary incontinence (UUI) using electrodes imbedded in the fabric of a conventional sock and an attachable battery-operated stimulation device (ZIDA^®—Exodus Innovations, Sufa, Israel), was compared for effectiveness and safety to a sham procedure in a prospective, blinded, randomized, controlled trial.

Methods

Forty patients with diagnosed with OAB were recruited from a single site. There were two groups: a treatment group (21 patients, mean age 64), which used an active ZIDA^® activation device (ZIDA) and a sham control group (SCG, 19 patients, mean age 72) randomized in a 1:1 ratio. After individual fitting of the sock and face-to-face instruction in the use of the device, patients in both groups self-administered the treatment once weekly for 30 min at home for a duration of 12 weeks. Prior to randomization and in Week 12, patients completed two 3-day bladder diaries and a quality-of-life (QOL) survey. Treatment success was defined as at least a 50% reduction in urgency voids with or without incontinence or at least a 30% reduction in 24-h frequency from baseline to Week 12. The key secondary endpoint was change in QOL from baseline to Week 12.

Results

The success rate for the primary endpoint in the ZIDA group was 80% (n = 16/20) versus 39% (n = 7/18) in the SCG (p = 0.02). For QOL, the least squares mean difference in change from baseline to Week 12 between the ZIDA and sham control arms total score was − 12.7 (95% CI − 20.2 to − 5.1). No significant adverse effects were observed.

Conclusion

TPTNS using the ZIDA home-based stimulation device offers a safe and effective treatment for patients with OAB syndrome and improves QOL.

Trial regestration

TRN: NCT04470765.

Feasibility of a Transcutaneous Tibial Nerve Stimulation Device Use in Overactive Bladder Patients: A Pilot Study From a Single Tertiary Care Center

Purpose

To evaluate the preliminary efficacy, safety, and acceptability of a transcutaneous tibial nerve stimulation (TTNS) device in overactive bladder (OAB) patients.

Methods

Twenty OAB patients who failed with conservative treatments were recruited consecutively. All patients received 60 min of daily unilateral stimulation for 4 weeks using a smart wearable transcutaneous tibial nerve stimulation device and the stimulations were at 20 Hz frequency, 200 μs pulse width. OAB symptoms were observed at baseline and week 4, using a 3-days voiding diary, the overactive bladder symptom score (OABSS), the perception of bladder condition (PPBC), and the American Urological Association Symptom Index Quality of Life Score (AUA-SI-QoL). Urodynamic characteristics were measured to determine the pilot efficacy of the device during the treatment comparing the baseline parameters to the post-treatment parameters.

Results

Among the patients, 15 cases were OAB-dry and five cases were OAB-wet. All patients were evaluated at the end of the study and no significant side effects were found during the treatment. The daily micturition frequency and the number of incontinence episodes per day were reduced from 15.10 ± 1.61 to 12.00 ± 4.56, and 3.20 ± 0.80 to 0.47 ± 0.38, respectively. The mean voiding volume was increased from 130.10 ± 53.07 to 157.30 ± 66.95 mL. The OABSS, AUA-SI-QoL, and PPBC were reduced from 9.35 ± 1.39 to 5.9 ± 2.36, 5.70 ± 0.47 to 3.85 ± 1.04, and 5.70 ± 0.47 to 4.35 ± 0.86, respectively. The first sensation of bladder filling (1st SBF), maximal bladder capacity (MBC), and mean compliance were increased from 87.50 (60.00–167.50) to 150.00 (104.00–211.30) mL, 175.00 (120.30–354.00) to 255.00 (151.50–491.50) mL, and 36.67 (12.44–39.69) to 40.00 (20.00–52.50) mL/cmH2O, respectively. The maximum detrusor pressure (Pdet. max) was reduced from 14.50 (5.00–35.25) to 11.00 (6.00–20.00) cmH2O.

Conclusion

The preliminary results demonstrated that the TTNS device was safe, effective, and acceptable to use in OAB patients, but the results need to be substantiated by conducting more randomized controlled studies further.

Neuromodulation of the Posterior Tibial Nerve for the Control of Urinary Incontinence

Urinary incontinence is considered a health problem that both elderly and young people can suffer, most often elderly women. This problem can lead to difficulties in establishing social relationships and dependence, negatively affecting the quality of life of the people who suffer from it. To evaluate and analyze the studies that demonstrate the efficacy of interventions based on the neuromodulation of the posterior tibial nerve as a treatment for the control of urinary incontinence. The search period for articles focused on those published between March 2011 to March 2021, in five databases (Pubmed, Cochrane Library, Scielo, Google Academic and WOS) based on the clinical question, using the keywords derived from the DeCS and MeSH thesauri, combined with the Boolean operators “AND”, “NOT” and “OR”. The search was limited to publications from the last 10 years, in English and Spanish. After applying the selection criteria and evaluating the quality of the methodology, 5.28% (n = 27) of the 511 results were included with filters: 9 systematic reviews, 10 cohorts and 8 randomized controlled trials. After comparing the different articles, it was found that percutaneous stimulation of the tibial nerve is a suitable technique for treating overactive bladder. It is a promising technique in case of pelvic floor dysfunctions and effective for the control of urinary incontinence.

Pooled analysis of the efficacy and safety of tibial nerve stimulation versus antimuscarinic agents in the management of overactive bladder syndrome

OBJECTIVES

The purpose of this meta-analysis was to evaluate the efficacy and safety of tibial nerve stimulation (TNS) versus antimuscarinic agents in the management of overactive bladder (OAB) syndrome.

METHODS

The databases MEDLINE, EMBASE, the Cochrane Controlled Trial Register of Controlled Trials from 2000 to May 2021 were searched to identify randomized controlled trials that referred to the use of TNS and antimuscarinic agents for the treatment of OAB syndrome. A systematic review and meta-analysis was conducted.

RESULTS

Eight publications involving 420 patients were included in the meta-analysis. In the analysis, we found TNS had a comparable effect with antimuscarinic agents on micturition per day, nocturia, urge incontinence, and voided volume (P = .9; .4; .78; .44, respectively). Scores measured by questionnaires Overactive Bladder Symptom Score and Overactive Bladder questionnaire Short Form items also indicated no statistical difference between 2 groups. TNS group had a significantly less discontinuation rate and adverse events (P = .003; .0001).

CONCLUSIONS

TNS is as effective as antimuscarinic agents for the treatment of OAB. Moreover, TNS appears to be more tolerable and safer than antimuscarinic agents.

Peroneal Electric Transcutaneous NeuroModulation (eTNM®): A Novel Method for the Treatment of the Overactive Bladder

Overactive bladder syndrome (OAB) is a prevalent medical problem with a significant impact on the quality of life of the affected individuals. Pharmacotherapy is considered the main treatment method, although it is discontinued in a significant proportion of patients due to inefficacy or associated side effects. If pharmacotherapy fails, patients can undergo peripheral neuromodulation of the somatic nerves of the lower limb or sacral neuromodulation; however, neither of these represents an ideal therapeutic tool. The Peroneal electric Transcutaneous NeuroModulation (Peroneal eTNM^®), based on the selective stimulation of the peroneal nerve, is the new fully noninvasive neuromodulation method intended to treat OAB. The URIS^® neuromodulation system, engineered to provide Peroneal eTNM^®, consists of the URIS^® device, URIS^® active electrodes, and the biofeedback foot sensor (BFS). The unique design of the URIS^® device and URIS^® active electrodes allows for the use of a low voltage and current during neuromodulation, which significantly reduces the unpleasant sensations. The BFS allows for precise localization of the active electrodes and for continuous adjustment of the voltage and frequency to achieve the optimal therapeutic effect. The URIS^® system adopts several principles of telemedicine, which makes it compatible with the US Food and Drug Administration (FDA) and European Union (EU) regulations for home-based use. This article describes both the Peroneal eTNM^® method and the URIS^® neuromodulation system, including its technical specifications and data from laboratory testing. Preclinical and early clinical data demonstrate the feasibility of this new method for noninvasive OAB treatment and possible implications for clinical practice.

[Transcutaneous stimulation of the posterior tibial nerve modifies the sympathetic skin response and improves overactive bladder syndrome: Case series and possible diagnostic test]

OBJECTIVE

(a) To assess the effect of transcutaneous neuromodulation (TNM) of the posterior tibial nerve plus biofeedback on the sympathetic skin response (SSR). (b) Evaluate its effect on clinical symptoms. (c) Consider SSR as a probable neurophysiological test useful both for diagnosis and for follow-up in patients with overactive bladder (OAB). (d) Evaluate its cost compared to other techniques.

MATERIAL AND METHODS

A prospective quasi-experimental before and after study in 10 OAB patients.

OUTCOME VARIABLES

daytime (DUF) and nighttime (NUF) urinary frequency, strength of the pelvic floor muscles measured by manometry (maximum and mean pressure) and sympathetic skin response (SSR).

RESULTS

DUF improved from 10.3±5.45 to 5.9±2.42 episodes (P=.0050). The NUF improved from 2.4±1.5 to 0.6±0.69 episodes (P=.0012). The maximum pressure ranged from 34.7±16.51 to 39.7±3.65mmHg (P=.0195). The mean pressure of the pelvic floor muscles improved from 6.6±3.65 to 9.3±5.43mmHg (P=.0333). SSR changed from 100% hyperexcitability prior to treatment to 50±14.14% (P=.0000).

CONCLUSION

TNM plus biofeedback could modify SSR and improve clinical and manometry variables in a series of patients with OAB. The probable diagnostic and prognostic utility of this neurophysiological test in OAB and detrusor hyperactivity is reported for the first time. A larger sample study is needed to confirm the promising findings seen in this preliminary study.

Real-life patient experiences of TTNS in the treatment of overactive bladder syndrome

Introduction and objectives:

Overactive bladder syndrome (OAB) is defined as urinary urgency, with or without urgent urinary incontinence; it is often associated with urinary frequency and nocturia, in the absence of any pathological or metabolic conditions that may cause or mimic OAB. The aim of this study was to evaluate the long-term real-life adherence of transcutaneous tibial nerve stimulation (TTNS) in the treatment of OAB, patient satisfaction of the treatment, and reasons for quitting therapy.

Materials and methods:

In this single center study, all patients who had a positive effect on percutaneous tibial nerve stimulation (PTNS) and continued to receive home-based treatment with TTNS since 2012 were included for analysis. Patients were retrospectively asked to fill out a questionnaire regarding satisfaction, reasons for quitting, and additional or next line of therapy.

Results:

We included 42 patients for this study, 81% of these patients were female (n = 34). The median age was 67 years (range 36–86). Most of the patients (64%, n = 27) were diagnosed with OAB wet. The median TTNS treatment persistence was 16 months (range 1–112 months). Reasons and percentages for stopping therapy were: 55% stopped treatment due to loss of effect, and 24% stopped because of preferring other type of neuromodulation. The mean satisfaction score (scale 1–10) in patients who continued TTNS was 6.2 (n = 9, SD 1.30) versus 5.4 (n = 29, SD 2.24) for patients who quit therapy. We did not find a statistically significant difference between the two groups (p = 0.174).

Conclusion:

TTNS, although effective in the short-term, is not effective in the long-term. In combination with a low satisfaction rate among patients, there is a need for improvement in terms of OAB treatment modalities.

Tibial nerve stimulation compared with sham to reduce incontinence in care home residents: ELECTRIC RCT

BACKGROUND

Urinary incontinence is prevalent in nursing and residential care homes, and has a profound impact on residents' dignity and quality of life. Treatment options are limited in these care contexts and care homes predominantly use absorbent pads to contain incontinence, rather than actively treat it. Transcutaneous posterior tibial nerve stimulation is a non-invasive, safe, low-cost intervention that is effective in reducing urinary incontinence in adults.

OBJECTIVE

To determine the clinical effectiveness of transcutaneous posterior tibial nerve stimulation to treat urinary incontinence in care home residents and to determine the associated costs of the treatment.

DESIGN

A multicentre, pragmatic, participant and outcome assessor-blind, randomised placebo-controlled trial.

SETTING

A total of 37 UK residential and nursing care homes.

PARTICIPANTS

Care home residents with at least weekly urinary incontinence that is contained using absorbent pads and who are able to use a toilet/toilet aid with or without assistance.

INTERVENTIONS

Residents were randomised (1 : 1) to receive 12 30-minute sessions of transcutaneous posterior tibial nerve stimulation or sham stimulation over a 6-week period.

MAIN OUTCOME MEASURES

Primary outcome - change in volume of urine leaked over a 24-hour period at 6 weeks. Secondary outcomes - number of pads used, Perception of Bladder Condition, toileting skills, quality of life and resource use.

RESULTS

A total of 408 residents were randomised (transcutaneous posterior tibial nerve stimulation, n = 197; sham stimulation, n = 209); two exclusions occurred post randomisation. Primary outcome data were available for 345 (85%) residents (transcutaneous posterior tibial nerve stimulation, n = 167; sham stimulation, n = 178). Adherence to the intervention protocol was as follows: 78% of the transcutaneous posterior tibial nerve stimulation group and 71% of the sham group received the correct stimulation. Primary intention-to-treat adjusted analysis indicated a mean change of -5 ml (standard deviation 362 ml) urine leakage from baseline in the transcutaneous posterior tibial nerve stimulation group and -66 ml (standard deviation 394 ml) urine leakage in the sham group, which was a statistically significant, but not clinically important, between-group difference of 68-ml urine leakage (95% confidence interval 0 to 136 ml; p = 0.05) in favour of the sham group. Sensitivity analysis supported the primary analysis. No meaningful differences were detected in any of the secondary outcomes. No serious adverse events related to transcutaneous posterior tibial nerve stimulation were reported. Economic evaluation assessed the resources used. The training and support costs for the staff to deliver the intervention were estimated at £121.03 per staff member. Estimated costs for delivery of transcutaneous posterior tibial nerve stimulation during the trial were £81.20 per participant. No significant difference was found between participants' scores over time, or between transcutaneous posterior tibial nerve stimulation and sham groups at any time point, for resident or proxy quality-of-life measures.

CONCLUSIONS

The ELECTRIC (ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes) trial showed, in the care home context (with a high proportion of residents with poor cognitive capacity and limited independent mobility), that transcutaneous posterior tibial nerve stimulation was not effective in reducing urinary incontinence. No economic case for transcutaneous posterior tibial nerve stimulation was made by the cost-consequences analysis; however, the positive reception of learning about urinary incontinence for care home staff supports a case for routine education in this care context.

LIMITATIONS

Completing 24-hour pad collections was challenging for care home staff, resulting in some missing primary outcome data.

FUTURE WORK

Research should investigate transcutaneous posterior tibial nerve stimulation in residents with urgency urinary incontinence to determine whether or not targeted stimulation is effective. Research should evaluate the effects of continence training for staff on continence care in care homes.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98415244 and ClinicalTrials.gov NCT03248362.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 41. See the NIHR Journals Library website for further project information.

Transcutaneous Electrical Stimulation for Neurogenic Bladder Dysfunction Following Spinal Cord Injury: Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

To assess the efficacy of transcutaneous electrical nerve stimulation (TENS) for neurogenic bladder dysfunction secondary to spinal cord injury (SCI).

MATERIALS AND METHODS

A systematic search of MEDLINE, EMBASE, Web of Science, Scopus, and Cochrane libraries up to February 2021 was performed using PRISMA methodology. All randomized controlled trials (RCTs) that studied TENS for neurogenic bladder in a SCI population were included. The primary outcomes of interest were maximum cystometric capacity (MCC) and maximum detrusor pressure (Pdet). Meta-analysis was conducted with RevMan v5.3.

RESULTS

Six RCTs involving 353 participants were included. Meta-analysis showed that TENS significantly increased MCC (standardized mean difference 1.11, 95% confidence interval [CI] 0.08-2.14, p = 0.03, I²  = 54%) in acute SCI. No benefits were seen for maximum Pdet. TENS was associated with no major adverse events.

CONCLUSIONS

TENS may be an effective, safe intervention for neurogenic bladder dysfunction following SCI. Further studies are essential to confirm these results and more work is required to determine optimal stimulation parameters and duration of the treatment.

Randomized clinical trials assessing third-line therapies to treat non-neurogenic overactive bladder syndrome: a review about methodology

INTRODUCTION AND HYPOTHESIS

Using similar methodologies and outcome measures is crucial to allow pertinent literature reviews and meta-analyses. Therefore, this scoping review aims to compare methodologies of randomized clinical trials (RCTs) assessing the efficacy of third-line therapies to treat non-neurogenic OAB: intradetrusor onabotulinumtoxinA (BoNTA) injections, sacral neuromodulation (SNM) and posterior tibial nerve stimulation (PTNS).

METHODS

A literature search was conducted using the PubMed search database. Using filters, the search was limited to RCTs conducted on humans and written in English or French since 2000 which evaluated BoNTA injections, SNM and/or PTNS. RCTs focusing on pediatric or neurogenic OAB were excluded. For each included RCT, methodology was assessed using a standardized form investigating the study design, clinical outcomes and urodynamic outcomes. Inclusion criteria, sex ratio, blinding strategies, treatment arms, primary outcomes and delays for reevaluation were assessed. Availability of clinical and urodynamic outcomes was reported at baseline, 3 months and 6 months.

RESULTS

Thirty-one RCTs were included in the final synthesis. The most frequent main outcome measure was change in the number of urinary incontinence episodes in 35.5% and in the number of voids per day in 25.8%. Bladder diaries were lacking in 12.9%, 32.3% and 80.1% at baseline, 3 and 6 months, respectively, while 26% of studies reported the results of urodynamic studies at any point.

CONCLUSION

Heterogeneity in study designs and data collection was pointed out between RCTs assessing the efficacy of third-line therapies to treat non-neurogenic OAB. We therefore advocate for the development of specific research guidelines focusing on OAB-related therapies.

Diagnosis and management of overactive bladder: A review

AIM

Overactive bladder (OAB) is a common and troublesome condition that can significantly impair quality of life. This review aims to educate providers of obstetrics and gynecology services about available therapies for OAB and what to expect following treatment.

METHODS

Here, we review published data from studies that have evaluated available treatments for OAB. Relevant articles published over the past 2 decades, including large multicenter trials, were identified through a literature search using PubMed.gov, and the references in those articles were also manually searched to find additional articles. Treatment guidelines and product labels were also reviewed.

RESULTS

Behavioral therapy is recommended as a first choice for OAB management; pharmacologic treatment (anticholinergics, β₃ -adrenoceptor agonists) as second-line treatment; and onabotulinumtoxinA, peripheral tibial nerve stimulation, and sacral nerve stimulation as third-line therapy for patients refractory or intolerant to first- and second-line treatments. A stepwise approach to treatment through first-, second-, and third-line therapies is recommended, recognizing this may not be appropriate for all patients.

CONCLUSIONS

To optimize symptom control and set realistic expectations, patients should be carefully monitored and counseled appropriately on available treatment options.

Efficacy of percutaneous and transcutaneous tibial nerve stimulation in women with idiopathic overactive bladder: A prospective randomised controlled trial

BACKGROUND

Different studies have reported the efficacy of percutaneous tibial nerve stimulation (PTNS) and transcutaneous tibial nerve stimulation (TTNS) in treating idiopathic overactive bladder (OAB). However, no study has compared the effectiveness of PTNS and TTNS added to bladder training (BT) in idiopathic OAB.

OBJECTIVE

To compare the efficacy of PTNS and TTNS added to BT in women with idiopathic OAB.

METHODS

We randomised 60 women with idiopathic OAB into 3 groups. Group 1 (n=19) received BT, Group 2 (n=19) received PTNS in addition to BT, and Group 3 (n=20) received TTNS in addition to BT. PTNS and TTNS were performed 2 days a week, for 30 min a day, for a total of 12 sessions for 6 weeks. Patients were evaluated by incontinence severity (pad test), a 3-day voiding diary (frequency of voiding, incontinence episodes, nocturia and number of pads used), symptom severity, quality of life, treatment success (positive response rate), treatment satisfaction (Likert scale), discomfort level and preparation time for stimulation (sec).

RESULTS

At the end of treatment; severity of incontinence, frequency of voiding, incontinence episodes, nocturia, number of pads used, symptom severity and quality of life were significantly improved in Groups 2 and 3 versus Group 1 (p<0.0167). Treatment success and treatment satisfaction were higher in Groups 2 and 3 than Group 1 (p<0.001 and p<0.0167, respectively). Level of discomfort was lower, treatment satisfaction was higher and preparation time for stimulation was shorter in Group 3 than Group 2 (p<0.05).

CONCLUSION

Both the PTNS plus BT and TTNS plus BT were more effective than BT alone in women with idiopathic OAB. These 2 tibial nerve stimulation methods had similar clinical efficacy but with slight differences: TTNS had shorter preparation time, less discomfort level and higher patient satisfaction than PTNS.

Transcutaneous tibial nerve home stimulation for overactive bladder in women with Parkinson's disease: A randomized clinical trial

AIMS

This study aims to investigate the efficacy of transcutaneous tibial nerve home stimulation for overactive bladder (OAB) in women with Parkinson's disease (PD).

METHODS

The current study is a prospective, randomized, double-blind, sham-controlled trial. Home intervention was carried out and assessments were conducted at a tertiary hospital in South Brazil. Women with PD and OAB symptoms were included in the study. Patients were randomly divided into two groups: (1) stimulation and (2) sham. Both groups underwent intervention at home for 12 weeks. Patients were evaluated at baseline and at 12 weeks (end of intervention), 30- and 90-day follow-up. The primary outcome was the mean reduction in the number of urgency incontinence episodes, and secondary outcomes included daytime and nighttime urinary frequency, urinary urgency episodes, use of pad (reported in a 24-h bladder diary), OAB-V8 and King's Health Questionnaire scores, and maintenance of symptom relief after discontinuation of the intervention.

RESULTS

In total, 30 consecutive patients completed the study (15/group). The stimulation group showed a reduction in nighttime urinary frequency (0.9 ± 0.6), urinary urgency (1.0 ± 1.2), urgency incontinence episodes (0.5 ± 0.6), use of pads (1.3 ± 1.2), and OAB-V8 (1.3 ± 1.2) and King's Health Questionnaire scores. In a 30-day and 90-day follow-up, 8 (53.3%) and 5 (33.3%) stimulation patients, respectively, reported full maintenance of symptom relief after discontinuation of the intervention. Stimulation patients presented a statistically significant improvement of symptoms as compared with sham patients (p = .001).

CONCLUSIONS

Transcutaneous tibial nerve home stimulation can be used in clinical practice as an effective nonpharmacological resource for the reduction of OAB symptoms in women with PD, and the resulting relief seems to persist in the follow-up (30 and 90 days).

[Treatment for refractory non-neurogenic overactive bladder]

INTRODUCTION

The aim was to synthesize current knowledge on refractory overactive bladder treatments.

METHOD

A systematic literature review based on PubMed, Embase and Google Scholar was conducted in July 2020.

RESULTS

Today, refractory overactive bladder treatment includes tibial nerve stimulation, whether percutaneously or transcutaneously, sacral neuromodulation, and botulinum toxin A detrusor injections. These conservative treatments have marginalized surgical treatments, which mainly involve supratrigonal cystectomy with augmentation cystoplasty. Several potential new treatments are being evaluated but can only be currently offered as part of clinical research protocols.

CONCLUSION

"Conservative" treatments for refractory overactive bladder have been shown to be effective. Other treatments could enrich the treatment options.

The long-lasting post-stimulation inhibitory effects of bladder activity induced by posterior tibial nerve stimulation in unanesthetized rats

Tibial nerve stimulation (TNS) is one of the neuromodulation methods used to treat an overactive bladder (OAB). However, the treatment mechanism is not accurately understood owing to significant differences in the results obtained from animal and clinical studies. Thus, this study was aimed to confirm the response of bladder activity to the different stimulation frequencies and to observe the duration of prolonged post-stimulation inhibitory effects following TNS. This study used unanesthetized rats to provide a closer approximation of the clinical setting and evaluated the changes in bladder activity in response to 30 min of TNS at different frequencies. Moreover, we observed the long-term changes of post-stimulation inhibitory effects. Our results showed that bladder response was immediately inhibited after 30 min of 10 Hz TNS, whereas it was excited at 50 Hz TNS. We also used the implantable stimulator to observe a change in duration of the prolonged post-stimulation inhibitory effects of the TNS and found large discrepancies in the time that the inhibitory effect lasted after stimulation between individual animals. This study provides important evidence that can be used to understand the neurophysiological mechanisms underlying the bladder inhibitory response induced by TNS as well as the long-lasting prolonged post-stimulation effect.

Different electrode positioning for transcutaneous electrical nerve stimulation in the treatment of urgency in women: a study protocol for a randomized controlled clinical trial

BACKGROUND

Urgency is a complaint of sudden, compelling desire to pass urine, which is difficult to defer, caused by involuntary contraction of the detrusor muscle during the bladder-filling stage. To enable detrusor inhibition, electrotherapy resources such as transcutaneous tibial nerve stimulation (TTNS) and parasacral transcutaneous electrical stimulation (PTES) have been used. The objective this study is to publish the study protocol that aims to investigate whether urgency decreases after treatment with both of the techniques.

METHODS

This randomized controlled clinical trial will include 99 women, aged more than 18 years old, with urgency (score ≥ 8 in the Overactive Bladder-Validated 8-Question Awareness Tool [OAB-V8]). Women will be randomly allocated into three groups: TTNS, PTES, and placebo. The following questionnaires will be applied: the Anamnesis Record, the Incontinence Questionnaire Overactive Bladder, the King's Health Questionnaire, the 24-Hour Voiding Diary, and the OAB-V8, at four different time points: at baseline prior to the first session, at the 6th session, the 12th session and at follow-up. The current used for the transcutaneous electrical stimulation will be a symmetrical balanced biphasic pulsed current, for 12 sessions, twice a week, for 20 minutes. Qualitative variables will be displayed as frequency and percentage, quantitative variables as mean and standard deviation. Comparison of urgency severity among groups will be performed with a repeated measures ANOVA, considering the effect of the three groups and the four evaluations, and interactions among them.

DISCUSSION

The present study aims to contribute evidence for a more in-depth discussion on electrode positioning for electrostimulation used in urgency treatment. It should be emphasized that, based on the possibility of confirming the hypothesis that urgency will decrease in a similar way after both treatments (TTNS and PTES), the PTES will be used as an option for positioning the electrodes alternatively to the tibial nerve region in special populations, such as amputees or people with severe lower limb sensory impairment.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (ReBEC) ID: RBR-9rf33n, date of registration: 17 May 2018.

Posterior tibial nerve stimulation for overactive bladder-techniques and efficacy

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.

Comparação entre oxibutinina, eletroestimulação do nervo tibial posterior e exercícios perineais no tratamento da síndrome da bexiga hiperativa

RESUMO Objetivou-se avaliar a eficácia dos exercícios perineais, da eletroestimulação transcutânea do nervo tibial posterior (ETNTP) e da oxibutinina em mulheres com síndrome da bexiga hiperativa, que é a segunda causa mais comum de incontinência urinária, com sintomas urinários extremamente incômodos que prejudicam a qualidade de vida. Foram randomizadas 65 mulheres, das quais 57 completaram o tratamento. Formaram-se três grupos: o de exercícios perineais, ETNTP e o grupo controle, que utilizou oxibutinina. Os exercícios foram realizados em grupo, nas posições em pé, supino e sentado, duas vezes por semana, com duração de 30 minutos cada sessão, totalizando 12 sessões. Na ETNTP utilizou-se eletrodo transcutâneo posicionado em maléolo medial e outro 10cm acima, com frequência de 10Hz e largura de pulso de 200 microssegundos, por 30 minutos, duas vezes por semana, totalizando 12 sessões. Na medicação as pacientes receberam oxibutinina de 10mg/dia de liberação imediata divididos e duas doses de 5mg/dia, durante 12 semanas consecutivas. Antes e depois dos tratamentos, as pacientes passaram por uma avaliação composta pela análise do diário miccional, avaliação funcional do assoalho pélvico e aplicação de questionário de qualidade de vida OAB-V8. Houve redução da incontinência de urgência em 50%, 70,5% e 41% nos grupos de exercício, ETNTP e oxibutinina, respectivamente, com significância estatística somente da eletroestimulação. As três modalidades de tratamento foram eficazes na melhora da qualidade de vida para a terapêutica em curto prazo, estatisticamente semelhantes entre si.

Neuromodulation - a therapeutic option for refractory overactive bladder. A recent literature review

Overactive bladder (OAB) affects approximately 17% of the population. The treatment of this clinical condition is challenging, especially when conservative therapy is not effective. There are limited options for the treatment of recurrent OAB. Neuromodulation has taken a significant place in the therapy of recalcitrant lower urinary tract dysfunctions over the past 20 years. The aim of this study was to review the literature evaluating the different forms of neuromodulation in various urological clinical conditions and to show the future prospects of this treatment method. Further studies are necessary to determine the effectiveness of neuromodulation and to identify the prognostic factors of therapeutic success. This could be helpful in the selection of patients who will be most likely to respond positively to the treatment.

Characterizing the transcutaneous electrical recruitment of lower leg afferents in healthy adults: implications for non-invasive treatment of overactive bladder

BACKGROUND

As a potential new treatment for overactive bladder (OAB), we investigated the feasibility of non-invasively activating multiple nerve targets in the lower leg.

METHODS

In healthy participants, surface electrical stimulation (frequency = 20 Hz, pulse width = 200 μs) was used to target the tibial nerve, saphenous nerve, medial plantar nerve, and lateral plantar nerve. At each location, the stimulation amplitude was increased to define the thresholds for evoking (1) cutaneous sensation, (2) target nerve recruitment and (3) maximum tolerance.

RESULTS

All participants were able to tolerate stimulation amplitudes that were 2.1 ± 0.2 (range = 2.0 to 2.4) times the threshold for activating the target nerve.

CONCLUSIONS

Non-invasive electrical stimulation can activate neural targets at levels that are consistent with evoking bladder-inhibitory reflex mechanisms. Further work is needed to test the clinical effects of stimulating one or more neural targets in OAB patients.

[Not Available]

Zusammenfassung. In der Grundversorgerpraxis ist die überaktive Blase (OAB) bei der älteren, polymorbiden Patientin ein immer häufiger auftretendes Krankheitsbild. Die OAB wird definiert als imperativer Harndrang mit oder ohne Inkontinenz sowie Pollakisurie und Nykturie ohne Harnwegsinfektion oder andere Pathologie. Die Symptomatik schränkt die Betroffenen im Alltag deutlich ein. Das Behandlungskonzept basiert auf einer Stufentherapie. Neben Verhaltensschulung und Beckenbodentherapie gibt es auch die Möglichkeit einer medikamentösen Therapie. Diese ist jedoch wegen häufiger Nebenwirkungen und Wechselwirkungen nicht für alle Patientinnen geeignet. In Kombination mit medikamentöser Therapie oder bei Kontraindikation oder Versagen derselben gibt es die Möglichkeit der perkutanen posterioren tibialen Nervenstimulation (PTNS). Diese Therapieform kann ambulant angewendet werden, ist minimalinvasiv, nebenwirkungsarm und häufig erfolgreich.

[Outcomes of transcutaneous posterior tibial nerve stimulation for overactive bladder in diabetic patients]

OBJECTIVE

Treatment with transcutaneous posterior tibial neurostimulation (NTPT) has been shown to be effective in the treatment of overactive bladder (OAB), but its outcomes in diabetic patients have never been assessed. The aim of this study was to compare the efficacy of NTPT in diabetic OAB patients and in OAB patients without diabetes.

METHODS

A single-center prospective study included all patients treated with NTPT for lower urinary tract storage symptoms between 2012 and 2016. The primary endpoint was symptoms improvement≥50% assessed using a Visual Analog Scale (VAS) two months after starting NTPT. Treatment consisted in a daily 20-minute NTPT single-session. The secondary endpoints were lower urinary tract symptoms reported by bladder diary, the Urinary Symptom Profile, the impact on mood and on daily activities.

RESULTS

Seventy-one patients were included, 10 of whom were diabetic. The efficacy rate (EVA>50%) was not significantly different in the diabetic group (70% vs. 44.1%, P=0.17), like the mean EVA efficacy was similar in both groups (4/10 vs. 4/10, P=0.98). OAB USP sub-score diminished significantly in both groups at 2 months (-3 points in the diabetic group; -1.9 points in the non-diabetic group; P=0.03 and P<0.0001, respectively). There was no significant difference between the groups, except for the rate of patients who stopped treatment at 6 months, higher in diabetic patients (100% vs. 63.5%, P=0.04).

CONCLUSION

The functional outcomes of NTPT appear to be similar in the treatment of OAB in diabetic patients and in non-diabetic patients.

LEVEL OF EVIDENCE

4.

Effectiveness of percutaneous tibial nerve stimulation in the treatment of overactive bladder syndrome

Overactive bladder syndrome (OAB) is a common condition affecting adults and children worldwide, resulting in a substantial economic and psychological burden. Percutaneous tibial nerve stimulation (PTNS) is derived from acupuncture used in Chinese traditional medicine and was first described in the early 1980s. It is a neuromodulation technique used to modulate bladder function and facilitate storage. Being a minimally invasive, easily applicable, but time-consuming treatment, future developments with implantable devices might be the solution for the logistical problems and economic burden associated with PTNS on the long term. This nonsystematic review provides a current overview on PTNS and its effectiveness in the treatment of OAB for both adults and children.

Frequency-dependent inhibition of bladder function by saphenous nerve stimulation in anesthetized rats

AIMS

Percutaneous tibial nerve stimulation (PTNS) is an effective neuromodulation therapy for treating overactive bladder (OAB). The therapeutic effects are achieved by repeatedly applying electrical stimulation through a percutaneous needle electrode that is used to target the tibial nerve (TN). Anatomical studies indicate there can be multiple saphenous nerve (SAFN) branches located near the site of electrical stimulation, and therefore we investigated the possibility of evoking a bladder-inhibitory reflex by electrically activating the SAFN.

MATERIALS AND METHODS

Acute experiments were conducted in 26 urethane-anesthetized rats. Changes in bladder contraction rate (BCR) and bladder capacity were measured in response to 10-min SAFN stimulation trials. Electrical pulses were applied at 25 µA and at stimulation frequencies between 2 Hz and 50 Hz.

RESULTS

We report that SAFN stimulation at 20 Hz was most effective at reflexively decreasing the BCR (53.8 ± 5.4% from baseline) and also increasing the bladder capacity (145.8 ± 43.5% from baseline). In contrast, SAFN stimulation at other frequencies yielded inconsistent changes in bladder function. Carry-over effects were minimized by randomizing the sequence of SAFN stimulation trials and also by allowing the bladder to return to the baseline conditions.

CONCLUSIONS

With notable changes in both the BCR and bladder capacity, our findings provide evidence of a novel bladder-inhibitory reflex in anesthetized rats that is mediated by the SAFN. Further work is needed to determine the clinical relevance of this neural pathway.

Tibial nerve stimulation to inhibit the micturition reflex by an implantable wireless driver microstimulator in cats

BACKGROUND

Traditional tibial nerve stimulation (TNS) has been used to treat overactive bladder syndrome (OAB), but there are some shortcomings. Thus, a novel alternative is needed for the treatment of OAB. The study investigated the effects of a new type of tibial nerve microstimulator on the micturition reflex in cats.

METHODS

An implantable wireless driver microstimulator was implanted around the tibial nerve in 9 α-chloralose anesthetized cats. Cystometry was performed by infusing 0.9% normal saline (NS) or 0.25% acetic acid (AA) through a urethral catheter. Multiple cystometrograms were performed before, during, and after TNS to determine the inhibitory effect of the microstimulator on the micturition reflex.

RESULTS

TNS at 2 threshold (T) intensity significantly increased the bladder capacity (BC) during NS infusion. Bladder overactivity was irritated by the intravesical infusion of 0.25% AA, which significantly reduced the BC compared with the NS infusion. TNS at 2 T intensity suppressed AA-induced bladder overactivity and significantly increased the BC compared with the AA control.

CONCLUSION

The implantable wireless driver tibial nerve microstimulator appears to be effective in inhibiting the micturition reflex during physiologic and pathologic conditions. The implantable wireless driver tibial nerve microstimulator could be used to treat OAB.