Feasibility and acceptability of transcutaneous tibial nerve stimulation for the treatment of bladder storage symptoms among people with multiple sclerosis

Background

Neurogenic lower urinary tract dysfunction is an abnormality in the presence of underlying neurologic disease. A recent systematic review and meta-analysis demonstrated that storage phase symptoms are the predominant symptoms among people with multiple sclerosis (PwMS). Transcutaneous tibial nerve stimulation (TTNS) is a non-invasive treatment for bladder storage symptoms; however, the potential efficacy of stimulation among PwMS is based on a small number of studies with the absence of high-quality evidence. The aim of this study was to evaluate the feasibility, acceptability, and safety of TTNS in PwMS using an affordable transcutaneous electrical nerve stimulation (TENS) unit.

Methods

A total of 23 participants with MS enrolled in the study. The primary outcomes included recruitment/retention rate, completion of the outcomes and the intervention, adherence to the protocol, adverse events, and acceptability of the intervention. The primary outcomes were assessed using diaries and a satisfaction questionnaire. The secondary outcomes included changes in urinary symptoms and quality of life assessed using a set of validated outcome measures including a 3-day bladder diary, PPIUS, ICIQ-OAB, and KHQ at baseline and post-intervention.

Results

Twenty participants completed the study. Three participants (13.04%) withdrew. All 20 participants completed the 6-week intervention and all the outcome measures (100%), with no reported adverse events. Participants were satisfied and found the unit acceptable. Three-day bladder diary showed changes in urinary frequency from a daily median of 10 times to 8 times and daily median urgency changed from 6 times at baseline to 2 times post-intervention. PPIUS showed changes in daily median sever urgency from 3 points (IQR=4) to 1 point (IQR=1) post-intervention. ICIQ-OAB total scores changed from 8 points (IQR=2.25) to 4 points (IQR=2.5) post-intervention. Median and mean scores of KHQ showed a clinical meaningful change of QoL in part-two and part-three of the questionnaire.

Conclusions

TTNS is feasible, safe, and acceptable for PwMS. Changes of urinary symptoms scores and QoL post-intervention suggested improvements. Future implications need to consider the treatment protocol including frequency of treatment sessions, duration of treatment, and the electrical stimulation parameters as well as the outcome measures followed in the current study for the implementation of the future pilot RCT.

Trial registration

ClinicalTrials.gov NCT04528784. Registered on 27 August 2020. https://register.clinicaltrials.gov/prs/app/action/LoginUser?ts=1&cx=-jg9qo4.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01120-1.

Management strategies for neurogenic lower urinary tract dysfunction: a qualitative study of the experiences of people with multiple sclerosis and healthcare professionals

PURPOSE

Urinary symptoms are highly prevalent among people with MS. This study aimed to explore the experiences of people with MS and HCPs in managing urinary symptoms and explore their views on using TTNS to treat urinary symptoms.

MATERIALS AND METHODS

Audio-recorded semi-structured, interviews were employed with people with MS and HCPs. All transcribed interviews were exported to NVivo software (Version 12) and analyzed using a reflexive approach to thematic analysis.

RESULTS

Four main themes were identified; The wide-ranging negative impacts of urinary symptoms ("It's limited everything else"), Gaps in urinary services ("Is there somebody like that, sort of specialized in that area?"), Management strategies ("I don't go too far from the toilet in case I need to use one"), and optimism about TTNS ("Are you giving Me Hope?").

CONCLUSION

Urinary symptoms are common and very troublesome for people with MS. Despite their prevalence, many people with MS continue to suffer in silence. People with MS require skilled multidisciplinary services guided by clinical care pathways to improve service provision and to address urinary symptoms. HCP's and people with MS are open to the use of TTNS for urinary symptoms and have clear preferences for location and duration of intervention delivery.Implications for rehabilitationUrinary symptoms are very common and troublesome for people with multiple sclerosis, yet many continue to suffer in silence.People with multiple sclerosis lack knowledge about treatment options for urinary symptoms.There is an on-going need for healthcare provider education on guidelines for screening and managing urinary symptoms in people with MS and the role of specialist urinary service providers.HCP's and people with MS are open to the use of TTNS for urinary symptoms.

Transcutaneous tibial nerve stimulation for the treatment of bladder storage symptoms in people with multiple sclerosis: Protocol of a single-arm feasibility study

Background: Neurogenic lower urinary tract dysfunction (NLUTD) is common among people with multiple sclerosis (MS) with a pooled prevalence of 68.41% using self-report measures and 63.95% using urodynamic studies. Transcutaneous tibial nerve stimulation (TTNS) is a non-invasive option to manage bladder storage symptoms; however, the potential efficacy of TTNS among people with MS is based on a small number of studies with the absence of high-quality evidence relating to efficacy, and lack of clarity of the optimal electrical stimulation parameters and frequency, duration and number of treatment sessions. This study aims to assess whether TTNS is feasible and acceptable as a treatment for bladder storage symptoms in people with MS. Methods: We will use a single-arm experimental study to explore the feasibility and acceptability of TTNS in the treatment of bladder storage symptoms in MS. The CONSORT extension for pilot and feasibility studies will be followed to standardise the conduct and reporting of the study. The recruitment plan is twofold: 1) Open recruitment for people with MS through MS Ireland's communication channels; 2) recruitment from a convenience sample of people with MS who have previously participated in a qualitative interview study of urinary symptoms. We will assess recruitment/retention rates, the urinary symptoms changes and the effect on quality of life pre and post intervention using ICIQ-OAB, 3-day bladder diary, King's Health Questionnaire and collect self-reported data on adherence and adverse events. Acceptability of using TTNS will be evaluated at the end of intervention. This study has been reviewed and approved by the Education and Health Science's Faculty Research Ethics Committee, University of Limerick [2020_06_07_EHS].  Conclusion: It is anticipated that assessing the feasibility and acceptability of TTNS for storage bladder symptoms in MS will inform the development of a definitive randomised trial. Trial registration: ClinicalTrials.gov NCT04528784 27/08/2020.

Prevalence of Lower Urinary Tract Symptoms in People with Multiple Sclerosis: A Systematic Review and Meta-analysis

BACKGROUND

No published study, to our knowledge, has systematically reviewed the prevalence estimates of lower urinary tract symptoms (LUTSs) and LUTS types in the general multiple sclerosis (MS) population. Therefore, a systematic review and a meta-analysis were conducted to determine the totality of literature investigating the prevalence of LUTSs and LUTS types in the general MS population according to International Continence Society definitions.

METHODS

Various electronic databases were searched between January 4, 2018, and February 12, 2018. This review included observational studies involving adults (18 years or older) with a confirmed diagnosis of MS recruited from the general MS population using self-report and/or objective outcome measures for LUTSs.

RESULTS

Twelve studies were included in the meta-analysis. The results showed that LUTSs were prevalent in people with MS, with a pooled prevalence of 68.41% using self-report and 63.95% using the objective measure of urodynamics. When considering LUTS types, urinary frequency was the predominant symptom, with a pooled prevalence estimate of 73.45%, followed by urgency assessed using self-report measures at 63.87%. Detrusor overactivity was found to be the most prevalent urodynamic symptom, with a pooled prevalence estimate of 42.9%, followed by detrusor sphincter dyssynergia at 35.44%.

CONCLUSIONS

This systematic review revealed that LUTSs are highly prevalent in MS. There is a need for improvement in the conduct and reporting of prevalence studies of LUTSs in MS and for the use of validated self-report outcome measures to enable pooling of data in the future.

Management strategies for lower urinary tract symptoms (LUTS) among people with multiple sclerosis (MS): a qualitative study of the perspectives of people with MS and healthcare professionals

Background: Neurogenic lower urinary tract dysfunction (NLUTD) is defined as a lower urinary tract dysfunction secondary to confirmed pathology of the nervous system. NLUTD is common in people with multiple sclerosis (MS), with prevalence estimates ranging from 49% to 92%. Managing NLUTD is complex and can be comprised of pharmacological and non-pharmacological interventions. Qualitative research exploring perspectives of people with MS and healthcare professionals on living with and managing NLUTD symptoms is sparse. This study aims to explore the perspectives of people with MS and healthcare professionals on managing NLUTD symptoms. Methods: A qualitative descriptive approach will be applied in this study using audio-recorded semi structured interviews for people with MS and healthcare professionals. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines will be used to standardize the conduct and reporting of the research. People with MS will be recruited through a gatekeeper at MS Ireland. Healthcare professionals will be recruited through gatekeepers at Irish Practice Nurses Association, Continence Foundation of Ireland, Irish Society of Chartered Physiotherapists, and Physiotherapists Interested in MS Group. Interviews will be transcribed and exported to NVivo software package (Version 12) for analysis. Data will be collectively synthesised using thematic analysis. Conclusion: It is anticipated that exploring perspectives of people with MS and healthcare professionals on managing symptoms (including current practice) of NLUTD in MS will assist in the development of an evidence-based and stakeholder informed intervention for NLUTD in people with MS.