Posterior tibial nerve stimulation vs parasacral transcutaneous neuromodulation for overactive bladder in children

At-home use of parasacral transcutaneous electrical nerve stimulation for pediatric voiding dysfunction: a randomized controlled trial to assess its safety and feasibility

Introduction

Treating pediatric voiding dysfunction involves behavioral changes that require significant time or medications that are often avoided or discontinued due to side effects. Using parasacral transcutaneous electrical nerve stimulation (PTENS) has shown to have reasonable efficacy, but the safety and feasibility of its off-label use for pediatric voiding dysfunction are not well-established. Concerns have also been raised over treatment adherence. In-home therapy might improve adherence compared with office-based therapy; however, no studies have evaluated in-home feasibility to date. This study aims to assess the safety and feasibility of off-label use of PTENS for pediatric voiding dysfunction.

Materials and methods

A single-institution prospective, randomized controlled study was conducted from March 2019 to March 2020. Participants aged 6-18 years diagnosed with voiding dysfunction, overactive bladder, or urinary incontinence were eligible for the study. Those with known neurologic disorders, implanted electrical devices, anatomic lower urinary tract abnormality, and recurrent urinary tract infections and those taking bladder medications were excluded. Children with primary monosymptomatic nocturnal enuresis were also excluded due to previous work suggesting a lack of efficacy. Participants were randomly assigned to receive 12 weeks of urotherapy alone (control) or urotherapy plus at-home PTENS treatment. Families were contacted weekly to assess for adverse events (AEs) and treatment adherence. The primary and secondary outcomes were safety, defined as the absence of AEs and treatment adherence, respectively.

Results

A total of 30 eligible participants were divided into two groups, with 15 participants in each arm. The median age was 9.4 years (interquartile range: 7.7-10.6). In total, 60% were male. Baseline demographics and urotherapy compliance were similar between the two groups. With PTENS use, two AEs were reported, including mild pruritus at the pad site and discomfort when removing pads, while no AEs were noted in the control group. In total, 60% of patients completed three 30-min sessions per week, and all participants were able to complete treatment sessions for at least 10 weeks, involving 30 min of PTENS treatment each time.

Conclusion

This randomized controlled study confirms that at-home use of PTENS is feasible with reasonable treatment adherence and minimal AEs. Future collaborative, multi-institutional studies may better determine the efficacy of this treatment modality.

Updates of Overactive Bladder in Pediatrics

Overactive bladder (OAB) is clinically defined as urinary urgency with or without urinary incontinence. It is associated with daytime frequency or constipation and has a prevalence of approximately 5%-12% among 5- to 10-year-olds. The appropriate functional exchange between the pontine micturition center, periaqueductal gray matter, and prefrontal cortex is important for proper micturition control. Several studies on pediatric cases observed a link between OAB and neuropsychiatric problems, such as anxiety, depression, and attention deficit, and treatment of these comorbidities improved patient symptoms. In this review, we present the pathophysiology of OAB, its associated conditions, and aspects related to updates in OAB treatment, and we propose a step-by-step treatment approach following this sequence: behavioral therapy, medical treatment, and invasive treatment. Although anticholinergic drugs are the mainstay of OAB medical treatment, beta-3 agonists and alpha-blockers are now recommended as a result of significant advancements in pharmacologic treatment in the last 10 years. Electrical stimulation techniques and botulinum toxin are also effective and can be used, especially in conventional treatment-refractory cases.

Agreement between the visual analogue scale (VAS) and the dysfunctional voiding scoring system (DVSS) in the post-treatment evaluation of electrical nerve stimulation in children and adolescents with overactive bladder

INTRODUCTION

Electrical nerve stimulation is one of the most commonly used and well-tolerated treatments for overactive bladder (OAB); however, different studies have used different instruments to assess patients' response to treatment.

OBJECTIVE

To analyze agreement between use of the visual analogue scale (VAS) and the Dysfunctional Voiding Scoring System (DVSS) for assessing improvement in urinary symptoms following electrical nerve stimulation treatment in children and adolescents with OAB.

STUDY DESIGN

A cross-sectional analytical study including children and adolescents of 4-17 years of age diagnosed with OAB who underwent 20 sessions of transcutaneous (TENS) or percutaneous (PENS) electrical nerve stimulation. The DVSS and the VAS were used to assess daytime urinary symptoms before and following treatment. While the DVSS was always applied by a physician, the VAS was applied separately by a physiotherapist and then by a physician. Treatment was considered successful when the DVSS score was zero and the VAS score was ≥90%. Correlations between post-treatment VAS and DVSS scores were evaluated using the kappa coefficient. The VAS scores evaluated by the different professionals were compared for agreement using intraclass correlation and the Bland-Altman plot.

RESULTS

Data from 49 cases were available for analysis. Of these, 27 (55.1%) were girls. Mean age was 7.1 ± 2.6 years. There was agreement between the two instruments used, the DVSS and the VAS, in 36/49 patients (73.5%), with a moderate Kappa of 0.44. There was moderate agreement between the VAS scores applied by the two different professionals.

DISCUSSION

imitations of the present study include the small sample size and the fact that the inter-observer evaluation was conducted following a single sequence, i.e. all the patients were first evaluated by the physiotherapist and then by the physician, which may have biased answers and the post-treatment VAS scores. Furthermore, although the child participated actively in completing the questionnaires, in cases of divergent answers, the questions were redirected to the responsible adult, and the final answer may not fully represent the patient's true situation.

CONCLUSION

The present study found moderate agreement between the DVSS and the VAS, and moderate agreement between VAS scores when the instrument was applied by two different professionals. Although both tools appear to be important, and possibly complementary, a DVSS score of zero precludes the need to apply the VAS.

Treatment for overactive bladder: A meta-analysis of tibial versus parasacral neuromodulation

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.

Electric nerve stimulation for overactive bladder: an umbrella review

Numerous systematic reviews and meta-analyses have reported the effect of electrical nerve stimulation (ENS) on overactive bladder (OAB). However, these results are contradictory. We conducted an umbrella review to summarize the evidence and evaluate the effectiveness of ENS for OAB by using an umbrella review methodology from multiple perspectives with sufficient methodological quality. We searched the PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL and PsycINFO databases and two Chinese databases (CNKI and CBM) to identify articles written in English or Chinese that were published up to 15 February 2021. Two authors of this review independently selected the studies, assessed their quality, and extracted the data from all the included studies. We performed a quality assessment of eligible reviews using the AMSTAR 2.0 tool and estimated the summary effect size, 95% confidence intervals, 95% prediction intervals and heterogeneity. Ten systematic reviews and meta-analyses covering 89 randomized controlled trials and 16 prospective cohort studies with a total population of 5004 participants that investigated the effect of ENS for OAB in terms of 17 different outcomes were identified. ENS seems effective and safety for OAB, with our results showing weak evidence of clinical efficacy and no evidence of side effects. To recommend ENS as a practical treatment option for OAB, however, more high-quality research is needed.

Dysfunctional voiding: update on evaluation and treatment

PURPOSE OF REVIEW

This review will be covering dysfunctional voiding, its diagnosis, and treatment options. This will focus primarily on dysfunctional voiding rather than all lower urinary tract dysfunction and we will focus on some of the newer findings and progress within this disease.

RECENT FINDINGS

Dysfunctional voiding is the inappropriate sphincter and pelvic floor constriction during voiding in an otherwise neurologically normal child. This has a wide spectrum of symptoms and can lead to a number of complications such as chronic kidney disease and poor quality of life if not appropriately addressed. Dysfunctional voiding is diagnosed with a careful examination and history with further imaging including a renal ultrasound and uroflowmetry to confirm the diagnosis. Urotherapy and biofeedback are the first and second-line treatments respectively and lead to significant improvement or cure in the majority of patients. For refractory patients, additional therapy options include use of α-blockers, botulinum injection, and electroneurostimulation, though the majority of the literature surrounding the use of these therapies consists of small studies with heterogenous causes of voiding dysfunction.

SUMMARY

Dysfunctional voiding is a common urologic complaint that has many excellent options for improving the patient's voiding issues and should be considered in patients with voiding dysfunction.

Comparing the outcomes of parasacral transcutaneous electrical nerve stimulation for the treatment of lower urinary tract dysfunction in children: A systematic review and meta-analysis of randomized controlled trials

AIMS

Despite published evidence in recent decades suggesting improvement in lower urinary tract symptoms (LUTS) with the use of parasacral transcutaneous electrical nerve stimulation (PTENS), no consensus guidelines for therapy exist. This study systematically reviews the literature to assess the effect of PTENS in children with LUTS.

METHODS

A database search conducted up to December 2019 included Medline, EMBASE, and the Cochrane Library. From the literature review, 6 randomized controlled studies (234 participants) comparing PTENS and standard treatment (urotherapy/anticholinergics) were considered. From each study, the success rates were available for PTENS and the control group. The ratio of success rates was computed-that is, the risk ratio (RR) and the risk difference (RD).

RESULTS

The overall success rate with PTENS was 1.92 times that of children undergoing standard urotherapy alone (RR: 1.92, 95% confidence interval [CI: 1.02, 3.61]) and 1.56 for those undergoing either urotherapy alone or with pharmacotherapy (anticholinergics; RR: 1.56, 95% CI [1.04, 2.40]). No difference in the success rate was found when PTENS was used in patients failing previous treatment (urotherapy and pharmacological therapy; RR: 0.175, 95% CI [0.02, 1.45]).

CONCLUSIONS

Current evidence suggests that PTENS is beneficial in children with LUTS. The chance of success is 1.92 times that of children undergoing standard urotherapy. However, in children who have failed urotherapy and pharmacological therapy, PTENS monotherapy has a limited role and should be an adjunct. Literature shortcomings included small numbers of patients, differing inclusion criteria, and PTENS protocols. A need exists for quality multicenter randomized controlled trials to prove the efficacy of PTENS in children with LUTS.

Effects of tibial and parasacral nerve electrostimulation techniques on women with poststroke overactive bladder: study protocol for a randomized controlled trial

BACKGROUND

Neurogenic bladder (NB) can affect people after stroke episodes. NB features changes in the normal voiding pattern at the bladder filling and emptying phases. Overactive NB is characterized by urgency symptoms, with or without urinary incontinence, caused by NB. This disorder affects many domains of life (physical, social, psychological, domestic, sexual) that limit personal autonomy and degrade the quality of life. Among the several treatments available, the conservative physical therapy intervention through tibial nerve electrostimulation (TNES) and parasacral electrostimulation (PSES) can help improve patient conditions with a smaller number of collateral effects than those of interventions based on medication. The aim of the present study is to compare the effects of TNES and PSES techniques in women with overactive NB after stroke episodes to assess the impact of urinary incontinence in these women, on their number of incontinence episodes, daytime and nocturnal urinary frequency, and quality of life.

METHODS

This is a prospective clinical study to compare two randomized groups based on parallel and blind conditions. Forty-four women who have had a stroke episode at least 30 days before the trial and who have developed overactive NB will be recruited for the trial. All patients will be subjected to initial evaluation and randomly divided into two groups, TNES and PSES. Subsequently, the two groups will be subjected to a 12-session intervention protocol, twice a week. A new evaluation will be performed after the intervention.

DISCUSSION

The results of this study will contribute to the physiotherapeutic treatment of women with NB after a stroke episode since such results will add information about the benefits of this treatment, urinary control, and the improvements in the quality of life of these women.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (REBEC) RBR-2bn2z4 . Registered on December 11, 2018.

Trends and relevance in the bladder and bowel dysfunction literature: PlumX metrics contrasted with fragility indicators

INTRODUCTION

The concepts of fragility index (FI) and fragility quotient (FQ) have been previously described. PlumX metrics encompass online "footprints" of research in addition to traditional citations. Herein we explore PlumX metrics against the quality of BBD literature.

OBJECTIVE

To explore altmetrics against the quality of bladder and bowel dysfunction (BBD) literature.

STUDY DESIGN

A literature search was conducted using Pubmed, Medline, Embase for BBD and related terms. A total of 54,045 abstracts were screened, followed by 693 full text reviews and data extraction from 126. Studies were included if they reported on 2 groups being compared, had dichotomous outcomes, and had significant results.

RESULTS

The median FI score was 4 (0-500) and there were 20 studies which had a FI of 0. The FQ had a median of 0.04 (0-0.32). PlumX usage was 263 ± 540, captures were 45 ± 60 and social media attention was 2 ± 2. Overall, 42% of papers were clinical trials (RCTs). When compared to other study designs, we noted a significant difference in PlumX captures (57 ± 72 RCT vs. 35 ± 47 other; p = 0.03). RCTs had higher usage, social media engagement and citations however, the differences were not significant. H-Index had a significant correlation with FI (p = 0.036), however correlations for PlumX usage and captures, while modestly positive (0.04-0.10) for the FI and FQ, were not significant. A comparison of FI and FQ by topic can be reviewed in the Summary Table.

DISCUSSION

When considering the FI and FQ robustness indicators of the BBD literature, we found similarities when compared to other studies. It was reported that overall, the hydronephrosis literature was fragile with many studies requiring only a few events to nullify significance, regardless of the study design. Similarly, in a review of pediatric vesicoureteral reflux (VUR) clinical trials, results were also fragile. When comparing fragility measures to altmetric variables we noted that despite the growing popularity of altmetrics, citation counts, and h-indices remain the traditional measures to monitor research consumption. There has been a reported correlation between manuscript citation counts, author h-index, altmetrics measures in several specialties and across many domains of research including medical sciences, arts, and the humanities, however in the present study only weak correlations were noted.

CONCLUSION

The body of BBD comparative studies is fragile in keeping with other pediatric urology literature populations. Despite fragile results, RCTs generate slightly moreattention as measured by select PlumX metrics. These results suggest the need for including fragility measures in our literature, aiming to focus attention towards more robust articles.

Comparison of parasacral transcutaneous electrical stimulation and transcutaneous posterior tibial nerve stimulation in women with overactive bladder syndrome: A randomized clinical trial

OBJECTIVE

To compare the effects of parasacral transcutaneous electrical stimulation with the effects of transcutaneous posterior tibial nerve stimulation in women with overactive bladder syndrome (OAB).

STUDYDESIGN

A randomized clinical trial was performed with 50 women aged 40-76 years with symptoms of OAB, divided into two groups: the parasacral transcutaneous electrical stimulation (PS) group and the transcutaneous posterior tibial nerve stimulation (PTN) group. Both groups underwent the same protocol, at home, for 6 weeks, applying electrical stimulation three times per week. The tools used for evaluation were the King's Health Questionnaire (KHQ), the Overactive Bladder-Validated 8-question Awareness Tool (OAB-V8) and the Incontinence Severity Index (ISI). Statistical analysis was undertaken using independent t-test, Mann-Whitney test, Chi-squared test and generalized estimating equations.

RESULTS

After 6 weeks of treatment, OAB-V8 showed a significant improvement in the PTN group compared with the PS group (Mann-Whitney test, p = 0.019). Post-intervention, no between-group differences were seen in terms of KHQ domains, average KHQ symptom scale and proportions of categories of ISI. All variables showed a significant effect of time after 6 weeks of treatment for both groups (p < 0.005).

CONCLUSION

Both forms of transcutaneous electrical stimulation seem to be effective and safe for home treatment of women with OAB.

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.

Transcutaneous tibial nerve stimulation versus parasacral stimulation in the treatment of overactive bladder in elderly people: a triple-blinded randomized controlled trial

OBJECTIVES

To evaluate the effect of transcutaneous tibial nerve stimulation (TTNS) and transcutaneous parasacral stimulation on the treatment of overactive bladder (OAB) in elderly people and to compare the final results between groups.

METHODS

Fifty female volunteers, mean age 68.62 (±5.9) years, were randomly allocated into two groups: those receiving TTNS (G1, N=25) and those receiving transcutaneous parasacral stimulation (G2, N=25). The primary outcome was the International Consultation on Incontinence Questionnaire (ICIQ-OAB) score, and secondary outcomes were the International Consultation on Incontinence Questionnaire - short form (ICIQ-SF) score and 3-day bladder diary measurements. Volunteers were assessed before and after the treatment. Clinical Trials (ReBeC): RBR-9Q7J7Y.

RESULTS

Both groups' symptoms improved as measured by the ICIQ-OAB (G1 = <0.001; G2 = <0.001) and ICIQ-SF (G1 = <0.001; G2 = <0.001). In the 3-day bladder diary assessments after treatment, G1 showed a reduced number of nocturia (p<0.001), urgency (p<0.001) and urge urinary incontinence episodes (p<0.001), whereas G2 showed only a reduced number of nocturia episodes (p<0.001). No difference between groups was found.

CONCLUSION

Both of the proposed treatments were effective in the improvement of OAB symptoms, but TTNS showed a reduction in a greater number of symptoms as measured by the 3-day bladder diary. No differences were found between groups.

A Urodynamic Comparison of Neural Targets for Transcutaneous Electrical Stimulation to Acutely Suppress Detrusor Contractions Following Spinal Cord Injury

Objectives

To assess and compare the effect of transcutaneous Dorsal Genital Nerve Stimulation (DGNS), Tibial Nerve Stimulation (TNS), Sacral Nerve Stimulation (SNS), and Spinal Stimulation (SS) on Neurogenic Detrusor Overactivity (NDO) and bladder capacity in people with Spinal Cord Injuries (SCI).

Materials and Methods

Seven male participants with supra-sacral SCI were tested. Standard cystometry (CMG) was performed to assess bladder activity at baseline and with stimulation applied at each site. This was conducted over four separate sessions. All stimulation was monophasic, 15 Hz, 200 μS pulses and applied at maximum tolerable amplitude. Results were analysed against individual control results from within the same session.

Results

Dorsal Genital Nerve Stimulation increased bladder capacity by 153 ± 146 ml (p = 0.016) or 117 ± 201%. DGNS, TNS and SNS all increased the volume held following the first reflex contraction, by 161 ± 175, 46 ± 62, and 34 ± 33 ml (p = 0.016, p = 0.031, p = 0.016), respectively. SS results showed small reduction of 33 ± 26 ml (p = 0.063) from baseline bladder capacity in five participants. Maximum Detrusor Pressure before leakage was increased during TNS, by 10 ± 13 cmH₂O (p = 0.031) but was unchanged during stimulation of other sites. DGNS only was able to suppress at least one detrusor contraction in five participants and reduced first peak detrusor pressure below 40 cmH₂O in these 5. Continuous TNS, SNS, and SS produced non-significant changes in bladder capacity from baseline, comparable to conditional stimulation. Increase in bladder capacity correlated with stimulation amplitude for DGNS but not TNS, SNS or SS.

Conclusion

In this pilot study DGNS acutely suppressed detrusor contractions and increased bladder capacity whereas TNS, SNS, and SS did not. This is the first within individual comparison of surface stimulation sites for management of NDO in SCI individuals.

"Posterior Tibial Nerve" or "Tibial Nerve"? Improving the reporting in health papers

AIMS

The primary objective of this study is to identify which term is the most appropriate to use according to anatomical nomenclature: "posterior tibial nerve" or "tibial nerve." Furthermore, this paper intends to show how the use of these terms in papers indexed in important health databases is numerous and to describe the anatomical characteristics of such nerve, to improve future scientific publications.

METHODS

This is a descriptive study about the importance of standardizing the use of the terms "posterior tibial nerve" and "tibial nerve" and its anatomy. It comprises three phases: the first is a search in the main databases to identify the use of the terms "posterior tibial nerve" and "tibial nerve." The second phase refers to the consultation of international anatomical terminology to identify the most appropriate term to refer to the nerve, while the third phase is related to the study of the anatomy of this nerve.

RESULTS

The term "tibial nerve" is more commonly used, but the use of the term "posterior tibial nerve" is still very substantial. According to international anatomical terminology, the correct term is "tibial nerve," which is a branch of the sciatic nerve.

CONCLUSIONS

"Tibial nerve" is the term standardized by international anatomical terminology. The use of terms in accordance with Terminologia Anatomica is important to facilitate the process of teaching and learning, as well as to improve the reporting and interpretation of papers regarding health, and the evidence-based clinical practice.

Traditional Biofeedback vs. Pelvic Floor Physical Therapy-Is One Clearly Superior?

PURPOSE OF REVIEW

Pelvic floor physical therapy is a worldwide accepted therapy that has been exclusively used to manage many pelvic floor disorders in adults and children. The aim of this review is to suggest to clinicians an updated understanding of this therapeutic approach in management of children with non-neuropathic voiding dysfunction.

RECENT FINDINGS

Today, pelvic floor muscle training through biofeedback is widely used as a part of a voiding retraining program aiming to help children with voiding dysfunction which is caused by pelvic floor overactivity. Biofeedback on its own, without a pelvic floor training component, is not an effective treatment. Biofeedback is an adjunct to the pelvic floor training. In the current review, we develop the role of pelvic floor physical therapy in management of children with non-neuropathic voiding dysfunction and compare it with biofeedback therapy alone.

EMG biofeedback or parasacral transcutaneous electrical nerve stimulation in children with lower urinary tract dysfunction: A prospective and randomized trial

AIMS

Evaluate the efficacy of biofeedback and parassacral electric nerve stimulation (TENS) for the treatment of children with lower urinary tract (LUT) dysfunction.

METHODS

A prospective, randomized study was approved by our Hospital Ethics Committee. We enrolled 64 children, 43 girls and 21 boys, average age of 9.39 years. The initial evaluation consisted of history, physical examination, urine analyses, voiding diary, uroflow, and ultrasound. Dysfunction voiding symptom score (DVSS) questionnaires were applied pre- and post-treatment. The children were divided into two treatment groups independent of the predominant type of voiding dysfunction (dysfunctional or overactive bladder): biofeedback group and TENS group. The criteria for assessing the effectiveness of the techniques was the resolution of daytime and nighttime symptoms including urinary leakage, improvements in voiding diary, DVSS, and changes in uroflow. After 6 months, the children were reassessed with the same work-up of baseline.

RESULTS

Regarding daytime symptoms, results for complete response were similar between the two groups (P = 0.483); 54.9% of children treated by the biofeedback group and 60.6% in the TENS group. The same have been observed in the nighttime incontinence with complete resolutions in 29.6% and 25%, respectively ( P = 0.461). Analyzing the voiding diary, uroflow and DVSS questionnaires both groups had significant improvement ( P = 0.001) after treatment. The biofeedback group required fewer sessions than TENS group, 10.9 and 18.1, respectively ( P < 0,001).

CONCLUSIONS

Both biofeedback and the TENS are equally effective for treating non-neurogenic voiding dysfunction. Biofeedback seems to require a lower number of sessions to obtain similar results of the TENS.

Diagnosis and Management of Bladder Dysfunction in Neurologically Normal Children

Normal bladder and urethral sphincter development as well as neural/volitional control over bladder-sphincter function are essential steps for regular lower urinary tract function. These maturational sequences are clinically evident by the age of 5 years. However, in 17-22% of children, symptoms persist beyond that age, characterizing lower urinary tract dysfunction (LUTD). The clinical spectrum is wide and includes overactive bladder, voiding postponement, underactive bladder, infrequent voiding, extraordinary daytime only urinary frequency, vaginal reflux, bladder neck dysfunction, and giggle incontinence. LUTD may lead to vesicoureteral reflux and recurrent urinary tract infections, increasing the likelihood of renal scarring. LUTD is often associated with constipation and emotional/behavioral disorders such as anxiety, depression, aggressiveness, and social isolation, making diagnosis, and treatment imperative. Diagnosis of LUTD is essentially based on clinical history, investigation of bladder storage, voiding symptoms (urinary frequency, daytime incontinence, enuresis, urgency) and constipation. Dysfunctional Voiding Score System (DVSS) is a helpful tool. Physical examination focuses on the abdomen to investigate a distended bladder or palpable fecal mass, the lumbosacral spine, and reflex testing. Bladder diaries are important for recording urinary frequency and water balance, while uroflowmetry is used to assess voided volume, maximum flow, and curve patterns. Bladder ultrasonography to measure post-void residual urine volume and urodynamics are used as supplemental tests. Current first line treatment is urotherapy, a combination of behavioral measures to avoid postponing micturition, and a restricted diet for at least 2 months. Anticholinergics, β3 agonists and neuromodulation are alternative therapies to manage refractory overactive bladder. Cure rates, at around 40%, are considered satisfactory, with daytime symptoms improving in 32% of cases. Furthermore, children who are also constipated need treatment, preferentially with polyethylene glycol at doses of 1-1.5 g/kg in the 1st 3 days and 0.25-0.5 g/kg thereafter until the 2-month period of behavioral therapy is complete. If urotherapy fails in cases of dysfunctional voiding, the next step is biofeedback to teach the child how to relax the external urethral sphincter during micturition. Success rate is around 80%. Children with underactive bladder usually need a combination of clean intermittent catheterization, alpha-blockers, biofeedback and neuromodulation; however, cure rates are uncertain.

Overactive Bladder in Children

Overactive bladder (OAB) is clinically defined as the presence of urinary urgency and may be associated with diurnal urinary incontinence, frequency, and enuresis, and/or constipation. In children aged 5–10 years, the prevalence is 5–12%. Association with emotional disorders is widely described in the literature. Constipation is associated with voiding symptoms because of crosstalk between the gastrointestinal tract and the urinary tract. OAB is believed to be multifactorial. Correct functioning between the pontine micturition centre, the periaqueductal grey matter, anterior cingulate gyrus, and prefrontal cortex is important for correct voiding development and the process of maturation. Patients with OAB have greater anterior cingulate gyrus activity and deactivation of the pontine micturition centre urinary inhibition process, leading to a greater frequency of bladder repletion sensation. Urotherapy is the first treatment to be initiated and aims to change behavioural patterns inthese patients. Other treatment options are anticholinergics, with oxybutynin being the most widely studied, but also described is the use of tolterodine, darifenacin, and mirabegron. Alternative treatments, such as nerve stimulation in the parasacral or the posterior tibial area, have shown improvement of symptoms in comparative studies with conventional drug treatment, and, in refractory cases, botulinum toxin A is an option. In this article, we review the pathophysiology, associated conditions, and aspects related to diagnosis and treatment of OAB.

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.

Electroneurostimulation for the management of bladder bowel dysfunction in childhood

Both non-invasive and invasive electroneurostimulation (ENS) modalities for bladder bowel dysfunction have been studied and reported in children. A summary of the proposed mechanism of actions and the more commonly used and recently reported techniques and outcomes are described. This includes transcutaneous electrical nerve stimulation, functional electrical nerve stimulation, intravesical electrical nerve stimulation, percutaneous tibial nerve stimulation and sacral neuromodulation in conditions including overactive bladder, enuresis, dysfunctional voiding, constipation, combined bladder bowel dysfunction and neuropathic bladder and bowel dysfunction. There is a need for further high quality randomised trials as well as long-term outcomes to establish whether ENS is able to alter the long-term trajectory for an individual child with bladder bowel dysfunction.

Overactive bladder in children

Overactive bladder (OAB) is a ubiquitous syndrome that is defined by urinary urgency with, or without urinary incontinence. OAB is observed in all parts of the world, with a prevalence of 5-12% in children (5-10 years of age) and a prevalence of 0.5% in older adolescents (16-18 years of age). Published data indicate that around a third of children with OAB are likely to become adults with similar complaints. Studies in children and in adults with OAB indicate that these individuals are more likely to also have anxiety, depression and attention deficit problems, and that appropriate treatment of these comorbidities can often improve the patient's OAB symptoms. Furthermore, data from twin studies and familial surveys seem to indicate a genetic component of OAB. Pharmacological treatments of OAB in children have improved in the past 5 years, moving beyond anticholinergic agents and including the off-label use of α-blockers, β3-agonists and intravesical botulinum toxin. Use of several different electrical stimulation techniques is also effective, both as first-line treatments, and for patients with treatment-refractory symptoms. Overall the outlook of children with OAB seems to be improving, with a greater understanding of the pathophysiology of this syndrome. Treatment modalities that target the source of the underlying problem, especially in children, are likely to provide the best patient outcomes.

Pathophysiological and Therapeutic Considerations for Non-Neurogenic Lower Urinary Tract Dysfunction in Children

Non-neurogenic lower urinary tract dysfunction (LUTD) in children is very common in clinical practice and is important as an underlying cause of lower urinary tract symptoms, urinary tract infection and vesicoureteral reflux in affected children. LUTD in children is caused by multiple factors and might be related with a delay in functional maturation of the lower urinary tract. Behavioral and psychological problems often co-exist in children with LUTD and bowel dysfunction. Recent findings in functional brain imaging suggest that bladder bowel dysfunction and behavioral and psychiatric disorders in children might share common pathophysiological factors in the brain. Children with suspected LUTD should be evaluated properly by detailed history taking, validated questionnaire on voiding and defecation, voiding and bowel diary, urinalysis, screening ultrasound, uroflowmetry and post-void residual measurement. Invasive urodynamic study such as videourodynamics should be reserved for children in whom standard treatment fails. Initial treatment of non-neurogenic LUTD is standard urotherapy comprising education of the child and family, regular optimal voiding regimens and bowel programs. Pelvic floor muscle awareness, biofeedback and neuromodulation can be used as a supplementary purpose. Antimuscarinics and α-blockers are safely used for overactive bladder and dysfunctional voiding, respectively. For refractory cases, botulinum toxin A injection is a viable treatment option. Prudent use of urotherapy and pharmacotherapy for non-neurogenic LUTD should have a better chance to cure various problems and improve self-esteem and quality of life in affected children.

The effectiveness of transcutaneous electrical neural stimulation therapy in patients with urinary incontinence resistant to initial medical treatment or biofeedback

OBJECTIVE

While there are many options for children with treatment refractory urinary incontinence, there is no single accepted method. This study's aim was to prospectively evaluate the effect of transcutaneous electrical nerve stimulation in children with urinary incontinence resistant to standard medical, urological therapy and/or biofeedback.

PATIENTS & METHODS

This study was performed at a university hospital. For inclusion, patients >5 years of age first underwent evaluation with urinary ultrasonography, uroflow-electromyogram and voiding diaries. Treatment with biofeedback, alpha adrenergic blockers, anticholinergics and/or urotherapy was commenced according to uroflow-EMG and voiding diary findings. Patients with partial or no response to this standard therapy were then included in this study, performed between April 2012 and February 2014. Patients with anatomical or neurological causes for urinary incontinence were excluded. TENS was performed on S3 dermatome, every day for 3 months. Each session lasted 20 min with a frequency of 10 Hz and generated pulse of 350 μs. Intensity was determined by the child's sensitivity threshold. Medical treatment and urological therapy was continued during TENS. Uroflow parameters (voiding volume as percentage of expected bladder capacity, Qmax, Qave, flow and voiding time, postvoiding residual urine) and urinary system symptoms (presence of urinary tract infection, frequency, urge incontinence, fractionated voiding and constipation) were compared immediately before commencement and immediately after the completion of 3 months of TENS.

RESULTS

Twenty-seven patients were included in this study (4 males, 23 females). Patients' average age was 7.2 years, 11 had overactive bladder and 16 had dysfunctional voiding. Comparison of urinary system symptoms and uroflow parameters before and after TENS are shown in Table. After 3 months of TENS; a statistically significant decrease was observed in the number of patients with frequency, urge incontinence, urinary tract infections and constipation. There was a decrease in the number of patients with fractionated voiding, although this change was not statistically significant. Similarly, for uroflow-EMG parameters; bladder capacity, Qmax, Qave and flow time increased while voiding time and PVR decreased. Changes seen in bladder capacity, Qmax and PVR were statically significant, while other changes were not. Patients' response rates after 3 months of TENS were; complete response in 70.4%, partial response in 22.2% and no response in 7.4%.

CONCLUSION

This study has shown that transcutaneous electrical nerve stimulation is a promising treatment option for standard-treatment refractory children with urinary incontinence.

Neuromodulation for Neurogenic Bladder

Although neuromodulation is well established for the treatment of non-neurogenic lower urinary tract symptoms, recent literature supports its use in the patient having LUTS associated with a neurologic condition. Sacral neuromodulation, in particular, may see new use as a modality to facilitate neurologic remodeling in spinal cord injured patients as well as children. As a therapeutic option, sacral neuromodulation and dorsal genital nerve stimulation may one day become more effective and more efficient utilizing the concept of closed-loop feedback, where electro-neurogram and bladder pressure data are incorporated into stimulation routines. In addition, some older therapies are reviewed that have recently demonstrated success in this patient population.

Posterior tibial nerve stimulation as treatment for the overactive bladder

OBJECTIVE

To evaluate the efficacy of posterior tibial nerve stimulation (PTNS) as a treatment for the overactive bladder (OAB) resistant to medical treatment.

PATIENTS AND METHODS

The study included 60 patients, comprising 55 women (92%) and five men (8%) with a mean (SD) age of 41.4 (10.8) years, who presented to the Urology Department of Benha University Hospital from June 2010 to October 2012. All patients were assessed initially by taking a history, a physical examination, urine analysis, routine laboratory investigations, and a urodynamic evaluation in the form of flowmetry, cystometry, and a pressure-flow study in some cases. A voiding diary (daytime and night-time frequency, voiding volume, and leakage episodes) was completed by all patients, and all underwent 12 sessions of PTNS using a personal computer-based system, and were reassessed after the sixth session, at the end of the course, and at 3 and 6 months after the last session, using the same methods as in the baseline visit.

RESULTS

There was a statistically significant improvement in all the variables assessed. No infection or failure of the PTNS mechanism was detected while using the technique, but there were rare instances of minor bleeding and a temporary painful feeling at the insertion site.

CONCLUSION

PTNS is safe, and gives statistically significant improvements in the patient's assessment of OAB symptoms.