Comparison of transcutaneous tibial nerve stimulation (TTNS) protocols for women with refractory overactive bladder (OAB): A prospective randomised trial

OBJECTIVES

Transcutaneous tibial nerve stimulation (TTNS) is a noninvasive method used in OAB treatment. Purpose of this study is to compare the effectiveness of the TTNS procedure applied once a week and three times a week in women diagnosed with wet type refractory OAB.

METHODS

A total of 60 patients diagnosed with wet type OAB that was refractory to medical treatment were included in the study. Participants were equally and randomly divided into two groups: TTNS treatment was performed with a duration of 30 minutes for 12 weeks, once a week to Group I and three times a week to Group II. Pretreatment and posttreatment OAB-V8/ICIQ-SF scores and voiding frequencies recorded in the bladder diary were compared between groups.

RESULTS

Four patients in Group 1 and eight in Group 2 left the study without completing the treatment. TTNS was performed in both groups for 12 weeks. There was a significant decrease in the voiding frequency, OAB-V8, ICIQ-SF scores in both group 1 and group 2 (P < .001). A significant decrease in the OAB-V8 score was observed in the 5th week in Group 1, and in the 3rd week in Group 2. Complete response was observed in 6 patients (23.1%) in Group 1 after 12 weeks of TTNS procedure. In Group 2, 10 patients (45.5%) had a complete response. After the 12-week TTNS procedure, no significant difference was observed between the groups in terms of treatment response.

CONCLUSION

TTNS can be safely used before invasive treatments in resistant OAB. TTNS procedure three times a week seems more effective than performing it once a week. What's known TTNS is one of the effective alternative treatments in resistant OAB treatment. What's new As the number of sessions is increased in TTNS treatment, the success of the treatment can increase.

Management of neurogenic detrusor overactivity

INTRODUCTION Neurogenic lower urinary tract dysfunction (NLUTD) refers to altered function of the urinary bladder, bladder outlet, and external urinary sphincter related to a confirmed neurologic disorder. Neurogenic detrusor overactivity (NDO) is a subset of NLUTD that frequently results in incontinence and may be associated with elevated bladder storage and voiding pressures resulting in upper urinary tract damage.

MATERIALS AND METHODS

This article provides an update on the evaluation and management of patients with NDO. Basic bladder physiology as well as classification of NLUTD, initial urologic evaluation, and management options ranging from the most conservative to surgical interventions will be covered.

RESULTS

NDO may be managed by conservative, pharmacologic, and surgical methods. Untreated or inadequately managed NDO may result in significant urologic morbidity and mortality, making careful evaluation and lifelong management necessary to optimize quality of life and prevent secondary complications.

CONCLUSIONS

Patients with NDO should have life-long urologic surveillance and follow up. The extent of regular evaluation and testing should be based on the principal of risk stratification. Treatment for NDO should be considered not only for clinical symptoms such as incontinence, but also aimed at preserving renal function.

Comparison of Pelvic Floor Muscle Training With Connective Tissue Massage to Pelvic Floor Muscle Training Alone in Women With Overactive Bladder: A Randomized Controlled Study

OBJECTIVE

The purpose of this study was to compare the effects of a 6-week program of pelvic floor muscle training (PFMT) plus connective tissue massage (CTM) to PFMT alone in women with overactive bladder (OAB) symptoms on those symptoms, pelvic floor muscle strength, and quality of life.

METHODS

Thirty-four participants were randomly divided into PFMT+CTM (n = 17) and PFMT (n = 17) groups. PFMT was applied every day and CTM was applied 3 days a week for 6 weeks. Before treatment, at week 3, and after treatment (week 6), we assessed pelvic floor muscle strength (with a perineometer), bladder symptoms (with a urine diary), OAB symptom severity (with the 8-item Overactive Bladder Questionnaire [OAB-V8]), urgency (with the Patient Perception of Intensity of Urgency Scale [PPIUS]), and quality of life (with King's Health Questionnaire [KHQ]). The Mann-Whitney U test, χ² test, Friedman test, and Dunn multiple comparison test were used for analysis.

RESULTS

In both groups, pelvic floor muscle strength increased, whereas OAB symptoms and PPIUS and KHQ scores decreased after treatment (P < .05). Although the OAB-V8, PPIUS, and KHQ scores decreased at week 3, frequency, OAB-V8, and PPIUS scores, in addition to some parameters of the KHQ, decreased after treatment in the PFMT+CTM group compared to the PFMT group (P < .05).

CONCLUSION

Compared to PFMT alone, PFMT+CTM achieved superior outcomes in reducing OAB symptoms in the early and late periods.

Transcutaneous electrical nerve stimulation and solifenacin succinate versus solifenacin succinate alone for treatment of overactive bladder syndrome: A double-blind randomized controlled study

OBJECTIVE

We evaluated a combination of transcutaneous electrical nerve stimulation (TENS) and solifenacin succinate versus solifenacin alone in the treatment of overactive bladder (OAB).

METHODS

Ninety-seven female outpatients with OAB were screened for this double-blind randomized controlled study. Eighty-six patients who met our inclusion criteria were divided randomly into two groups. In group A (43 patients), patients received oral solifenacin and "fake" TENS on the foot; in group B (43 patients), patients received oral solifenacin and effective TENS on the foot. Improvements in OAB symptoms were assessed by Overactive Bladder Symptom Score (OABSS), Overactive Bladder Questionnaire (OAB-q), voiding diaries and urodynamic tests. 70 of 86 patients (36 in group A, 34 in group B) completed the 2 months of treatment and 3 months of follow-up.

RESULTS

Statistically, the maximum bladder volume and OAB symptoms of both groups improved significantly after treatment. The improvement in group B was significantly better than that in group A, as indicated by the maximum bladder volume, OAB-q score and voiding diary. Some mild adverse effects were observed, including dry mouth, stomach upset, constipation, muscle pain and local paresthesia.

CONCLUSION

The combination of TENS and solifenacin was more effective in improving OAB symptoms than solifenacin alone.

Treatment for overactive bladder: A meta-analysis of transcutaneous tibial nerve stimulation versus percutaneous tibial nerve stimulation

BACKGROUND

We aim to compare the safety and effectiveness of transcutaneous tibial nerve stimulation (TTNS) versus percutaneous tibial nerve stimulation (PTNS) in treating overactive bladder.

METHODS

A systematical search on PubMed, Embase, clinicalTrial.gov, and Cochrane Library Central Register of Controlled Trials from January 1, 1999 to November 1, 2020 was performed. The primary outcomes were the changes in a 3-day voiding diary. Quality of life scores were also evaluated. Review Manager 5.3 (Cochrane Collaboration, Oxford, UK) was applied to conduct all statistical analyses.

RESULTS

A total of 4 trials (2 randomized controlled trials, 1 retrospective study, and 1 before-after study) with 142 patients were eventually enrolled. Compared with PTNS, TTNS had a similar performance in the voiding frequency in 24 hours (mean difference [MD] = -0.65, 95% confidence interval [CI]: -1.35 to 0.05, P = .07), the number of urgency episodes in 24 hours (MD = 0.13, 95% CI: -0.36 to 0.62, P = .60), the number of incontinence episodes in 24 hours (MD = 0.01, 95% CI: -0.13 to 0.14, P = .93), as well as in the nocturia frequency (MD = -0.14, 95% CI: -0.52 to 0.24, P = .47). Moreover, comparable results were observed regarding HRQL scores (P = .23) and incontinence quality of life scores (P = .10) in both groups. The total complication rate in the current study was 2.1% (3/142). No adverse events were identified in the TTNS group.

CONCLUSION

Current data supported that TTNS is as effective as PTNS for the treatment of overactive bladder, moreover, with no reported adverse events. However, the evidence is low-grade and well-designed prospective studies with a large sample size are warranted to verify our findings.

Shifting the treatment paradigm in idiopathic overactive bladder

PURPOSE

Overactive Bladder (OAB) is a common condition that is known to have a significant impact on Health Related Quality of Life (HRQoL). Whilst all patients will initially benefit from lifestyle modifications and behavioural therapy in the first instance drug therapy remains integral in management pathways. The purpose of this review paper is to reappraise the evidence based approach to the management of OAB in addition to exploring a new treatment algorithm for the escalation of treatment in those patients with refractory symptoms.

DESIGN

Literature Review RESULTS: Antimuscarinic drugs are currently the most commonly used medication although the introduction of mirabegron, a β3 agonist, has provided an alternative and also allowed combination therapy in those patients who have failed to improve on primary therapy or who have troublesome side effects. For those patients with symptoms of refractory OAB more invasive therapies including OnabotulinumtoxinA, sacral neuromodulation and Percutaneous Tibial Nerve Stimulation (PTNS) may be indicated.

CONCLUSION

We propose a new, evidence based, treatment algorithm for the management of OAB in patients who remain refractory to first line therapy.

Efficacy of cinnamon patch treatment for alleviating symptoms of overactive bladder: A double-blind, randomized, placebo-controlled trial

BACKGROUND

Current treatments for overactive bladder (OAB) have limited efficacy, low persistence and a high rate of adverse events commonly leading to treatment cessation in clinical practice. Clinicians in Asia commonly use traditional Chinese medicine as an alternative for OAB treatment despite it having uncertain efficacy and safety. To evaluate the efficacy and safety of cinnamon patch (CP) treatment for alleviating symptoms of OAB, a double-blind randomized, placebo-controlled trial was conducted in the present study.

MATERIALS AND METHODS

In this 6-week randomized clinical trial conducted in an outpatient setting, 66 subjects diagnosed as having OAB were enrolled and treated with a placebo (n=33) or CP (n=33). The OAB symptom score (OABSS) was selected as the primary end point, and a patient perception of bladder condition (PPBC), an urgency severity scale (USS), and post-voiding residual urine (PVR) volume were selected as secondary end points. Statistical analyses were performed with IBM SPSS Statistics 20. Groups were compared using an independent sample t-test, Fisher exact test, and Chi-squared test.

RESULTS

In total, 66 participants (40 women and 26 men), 60.35 ± 12.77 years of age, were included in the intention-to-treat analyses. Baseline characteristics were comparable between the CP (n ==33) and placebo (n ==33) groups. Treatment with a CP showed statistically significant differences in reductions in OABSS scores (9.70 ± 2.20 to 6.33 ± 2.42), PPBC scores (3.36 ± 0.60 to 2.15 ± 0.83), and USS scores (2.67 ± 0.54 to 1.64 ± 0.60).

CONCLUSIONS

Compared to a placebo, treatment with CP might be considered an effective and safe complementary therapy for OAB. Further studies employing a positive control, different dosage forms, larger sample sizes, and longer treatment periods are warranted.

Comparison of transcutaneous electrical tibial nerve stimulation for the treatment of overactive bladder: a multi-arm randomized controlled trial with blinded assessment

OBJECTIVE

To compare the effectiveness of tibial nerve transcutaneous electrical nerve stimulation (TENS) for an overactive bladder, considering the sites of application and frequency of attendance.

METHODS

This multi-arm randomized controlled trial enrolled 137 adult women (61.0±9.0 years) with overactive bladder from a university hospital. They underwent 12 sessions of 30-min TENS application and were assigned to five groups: one leg, once a week (n=26); one leg, twice a week (n=27); two legs, once a week (n=26); two legs, twice a week (n=28); and placebo (n=30). Symptoms of overactive bladder and its impact on quality of life were evaluated before and after 6 or 12 weeks of treatment using the Overactive Bladder Questionnaire-V8 and voiding diary. ClinicalTrials.gov: NCT01912885.

RESULTS

The use of one leg, once a week TENS application reduced the frequency of urgency episodes compared with the placebo (1.0±1.6 vs. 1.4±1.9; p=0.046) and frequency of incontinence episodes compared with the placebo (0.7±1.4 vs.1.4±2.2; p<0.0001). The one-leg, twice a week protocol decreased the urinary frequency compared with the two legs, once a week protocol (8.2±3.5 vs. 9.0±5.1; p=0.026) and placebo (8.2±3.5 vs. 7.9±2.7; p=0.02). Nocturia improved using the two legs, once a week protocol (1.5±1.8) when compared with the one leg, twice a week protocol (1.9±2.0) and placebo (1.7±1.6) (p=0.005 and p=0.027, respectively). Nocturia also improved using the two legs, twice a week protocol when compared with the one leg, twice a week protocol (1.3±1.2 vs.1.9±2.0; p=0.011).

CONCLUSION

One-leg stimulation improved the daily urinary frequency, urgency, and incontinence, and the two-leg stimulation once and twice weekly improved nocturia.

History and current trends in the treatment of idiopathic overactive bladder

OBJECTIVE

Historical and current view on the therapy of overactive bladder.

METHODS

This review summarizes the historical approach and current therapy of overactive bladder. The articles were gathered from Pubmed and Scopus databases. Studies published before December 2020 were used for the review.

RESULTS AND CONCLUSION

Overactive bladder is a condition that quite a lot reduces the quality of life of our patients. Our therapeutic approach starts with non-pharmacological treatment, such as pelvic floor exercises. The next step is a pharmacological approach. The entry level drug is trospium. If the effect is not sufficient, propiverine, solifenacin, fesoterodine, darifenacin or mirabegron are used. Electrostimulation or botulinum toxin A application is an option only in cases that didnt respond to pharmacological treatment. It is safe to say, that in the end, there is a way of reducing the severity of overactive bladder symptoms for every  patient.

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.

Taking OAB seriously: A qualitative evaluation of primary care education on overactive bladder syndrome management

BACKGROUND

Overactive bladder (OAB) syndrome has a diverse etiology that disrupts quality of life domains in affected patients. OAB is significantly under-recognised and undertreated, especially in the primary care setting. In order to educate primary care providers about OAB recognition, evaluation and management, we created a virtual live-streamed and enduring education program.

METHODS

We evaluated the impact of education on provider knowledge and self-efficacy via qualitative interviews with a sample of education participants. We analysed participant responses via constant comparative method, an iterative approach that allows for exploration of a priori issues and identification of emergent themes.

RESULTS

We identified four key themes: (a) taking OAB seriously; (b) variations in therapy; (c) patient motivation; and (d) education value. Participants were proactive about screening for and managing OAB and recognised urgency as a key symptom; some participants used diagnostic tests that are not are not considered necessary in the workup of uncomplicated OAB patients. Participants varied in their descriptions of initial approaches to treatment and most participants described a longer-than-recommended follow-up window to monitor patients. Some participants characterised patients as looking for a "quick fix" in ways that could lead to provider inaction in relation to behavioural/lifestyle interventions. Overall, participants felt that the education validated their current practice and provided new knowledge about evaluation, initiating behavioural treatment, and combination therapy.

CONCLUSIONS

Participant responses were congruent with education messages, which likely reflect their "readiness to learn". The rationale for diagnostic tests and evidence on the effectiveness of behavioural regimens represent ongoing areas of unmet educational need.

Which combination is most effective in women with idiopathic overactive bladder, including bladder training, biofeedback, and electrical stimulation? A prospective randomized controlled trial

OBJECTIVE

To evaluate the efficacy of single and combined use of biofeedback (BF) and electrical stimulation (ES) added to bladder training (BT) on incontinence-related quality of life (QoL) and clinical parameters in women with idiopathic overactive bladder (OAB).

MATERIAL AND METHODS

Seventy women were randomized into four groups as follows: Group 1 received BT alone (n = 18), Group 2 received BT + BF (n = 17), Group 3 received BT + ES (n = 18), and Group 4 received BT + BF + ES (n = 17). BF and ES were performed 3 days a week, 20 min a day, a total of 24 sessions for 8 weeks. All women were evaluated in terms of incontinence severity (pad test), pelvic floor muscles strength (perineometer), 3-day voiding diary (frequency of voiding, nocturia, incontinence episodes, and number of pads), QoL (incontinence impact questionnaire), treatment success (positive response rate), cure/improvement rate, treatment satisfaction (Likert scale), and discomfort level (visual analog scale).

RESULTS

At the end of the treatment, severity of incontinence, frequency of voiding, incontinence episodes, and treatment satisfaction significantly improved in Group 3 and Group 4 compared with the other two groups. In Group 3 and Group 4, high statistically significant values were found in cure/improvement and positive response rates as opposed to Group 1 and Group 2. In Group 2 and Group 3, statistically significant improvements were seen in nocturia and QoL compared with Group 1. Moreover, statistically significant improvements in nocturia and QoL were found in Group 4 compared with the other three groups. There was no difference in the discomfort level of application between the groups.

CONCLUSION

We conclude that in the first-line conservative treatment of women with idiopathic OAB: (i) adding BF and/or ES to BT increases treatment effectiveness, (ii) clinical efficiency is greater when the combination includes ES, (iii) BT + BF + ES (triple combination) is the most effective treatment option in reducing nocturia and improving QoL.

[Follow-up and evaluation of non-neurogenic OAB treatments]

INTRODUCTION

The purpose of monitoring a patient treated for overactive bladder (OAB) is to ensure the effectiveness of the treatment and to detect any side effects.

OBJECTIVE

To synthesize current knowledge on the follow-up and the evaluation of non-neurogenic OAB treatments.

METHOD

A systematic literature review based on Pubmed, Embase, Google Scholar was conducted in June 2020.

RESULTS

The definition of success of OAB treatments is not consensual. Definitions of success in clinical trials usually use bladder diary data. However, they cannot always be transposed into clinical practice because they do not measure the overall effectiveness of a treatment, reported by the patient, or the satisfaction with the treatment. It is then necessary to have symptom questionnaires with an assessment of quality of life. Indeed, the concept of therapeutic success is different depending on the view of the physician or the patient. It is therefore important to carefully assess with the patient, and before initiating any treatment, the objectives and expected results of the treatment. The definition of "refractory" OAB is heterogeneous but important to select candidates for second-line treatments. Monitoring a patient with OAB is essential to adapt the treatment to efficacy and tolerance, but also to detect any change in symptoms that may reveal another urological disease.

CONCLUSION

The success or failure of OAB treatments depends on the interaction of many factors, including objective criteria measured by the clinician, and subjective criteria of perception of the treatment effectiveness by the patient.

Sacral Nerve Stimulation in Parkinson's Disease Patients With Overactive Bladder Symptoms

OBJECTIVE

To assess the efficacy, safety, and outcomes of sacral nerve stimulation (SNS) for Parkinson's disease (PD) patients with overactive bladder symptoms.

METHODS

We retrospectively reviewed PD patients who underwent Stage I SNS. Demographics, urodynamic data, and baseline voiding function were analyzed. Efficacy and safety of treatment were determined by rate of progression to Stage II, explantation, and surgical revision. Long-term outcomes were assessed using voiding diaries and/or clinic notes.

RESULTS

Sixty percent (9/15) experienced ≥50% improvement in urinary parameters and proceeded to Stage II. There was no significant difference in age, body mass index, comorbidities, PD disease duration, or levodopa equivalent daily dose between successful and nonsuccessful Stage I patients. However, 100% of female patients experienced Stage I success compared to 44% of male PD patients (P = .04). Individuals with >12-month follow-up experienced an average reduction of 6 voids/day. No patients required revision or explantation of their device at latest clinic follow-up (22.2 ± 7.8 months). Higher maximal urethral closure pressures, detrusor pressure at maximum flow rate (PdetQmax), post-void residual volume, and mean bladder outlet obstruction index were observed in the Stage I trial failures.

CONCLUSION

At our institution, PD patients have a similar rate of progression to Stage II compared to the general population. SNS is an effective therapy that should be considered among the treatment options for PD patients with overactive bladder symptoms. Urodynamic parameters associated with obstruction may be predictive of SNS failure in PD patients and may help guide patient selection, however further studies are needed.

TASCI-transcutaneous tibial nerve stimulation in patients with acute spinal cord injury to prevent neurogenic detrusor overactivity: protocol for a nationwide, randomised, sham-controlled, double-blind clinical trial

INTRODUCTION

Neurogenic lower urinary tract dysfunction (NLUTD), including neurogenic detrusor overactivity (NDO) and detrusor sphincter dyssynergia, is one of the most frequent and devastating sequelae of spinal cord injury (SCI), as it can lead to urinary incontinence and secondary damage such as renal failure. Transcutaneous tibial nerve stimulation (TTNS) is a promising, non-invasive neuromodulatory intervention that may prevent the emergence of the C-fibre evoked bladder reflexes that are thought to cause NDO. This paper presents the protocol for TTNS in acute SCI (TASCI), which will evaluate the efficacy of TTNS in preventing NDO. Furthermore, TASCI will provide insight into the mechanisms underlying TTNS, and the course of NLUTD development after SCI.

METHODS AND ANALYSIS

TASCI is a nationwide, randomised, sham-controlled, double-blind clinical trial, conducted at all four SCI centres in Switzerland. The longitudinal design includes a baseline assessment period 5-39 days after acute SCI and follow-up assessments occurring 3, 6 and 12 months after SCI. A planned 114 participants will be randomised into verum or sham TTNS groups (1:1 ratio), stratified on study centre and lower extremity motor score. TTNS is performed for 30 min/day, 5 days/week, for 6-9 weeks starting within 40 days after SCI. The primary outcome is the occurrence of NDO jeopardising the upper urinary tract at 1 year after SCI, assessed by urodynamic investigation. Secondary outcome measures assess bladder and bowel function and symptoms, sexual function, neurological structure and function, functional independence, quality of life, as well as changes in biomarkers in the urine, blood, stool and bladder tissue. Safety of TTNS is the tertiary outcome.

ETHICS AND DISSEMINATION

TASCI is approved by the Swiss Ethics Committee for Northwest/Central Switzerland, the Swiss Ethics Committee Vaud and the Swiss Ethics Committee Zürich (#2019-00074). Findings will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03965299.

An Efficient Noninvasive Neuromodulation Modality for Overactive Bladder Using Time Interfering Current Method

OBJECTIVE

The present study aimed to evaluate a new tibial nerve stimulation (TNS) modality, which uses interferential currents, in terms of the stimulation electric field penetration efficiency into the body and physiological effectiveness.

METHODS

In silico experiments were performed to analyze the penetration efficiency of proposed interferential current therapy (ICT). Based on this, we performed in vivo experiments to measure excitation threshold of ICT for the tibial nerve, which is related to stimulation field near the nerve. Regarding analysis of the physiological effectiveness, in vivo ICT-TNS was performed, and changes in bladder contraction frequency and voiding volume were measured. The penetration efficiency and physiological effectiveness of ICT were evaluated by comparison with those of conventional TNS using transcutaneous electrical nerve stimulation (TENS).

RESULTS

Simulation results showed that ICT has high penetration efficiency, thereby generating stronger field than TENS. These results are consistent with the in vivo results that nerve excitation threshold of ICT is lower than that of TENS. Moreover, ICT-TNS decreased contraction frequency and increased voiding volume, and its performance was profound compared with that of TENS-TNS.

CONCLUSION

The proposed ICT is more efficient in inducing the stimulation field near the tibial nerve placed deep inside the body compared with conventional TENS and shows a good clinical effectiveness for TNS.

SIGNIFICANCE

The high efficiency of ICT increases the safety of noninvasive neurostimulation; therefore, it has clinical potential to become a promising modality for TNS to treat OAB and other peripheral neurostimulations.

Medium-term outcomes of sacral neuromodulation in patients with refractory overactive bladder: A retrospective single-institution study

Background

Sacral neuromodulation (SNM) is a minimally invasive fully reversible therapy that was approved in 1997 for overactive bladder syndrome (OAB) refractory to behavior modification and pharmacotherapy. Despite being in use for over two decades, the data on medium to long-term safety and efficacy of SNM in OAB is limited. We investigated the medium-term efficacy and safety of SNM along with the predictive factors for its success in patients with refractory OAB.

Methods

A retrospective consecutive case series of 66 patients undergoing SNM for refractory OAB between July 2009 and July 2018. All patients underwent a test period followed by permanent implantation, if there was > = 50% improvement in any symptom. The primary outcome was “success” defined as > = 50% improvement in any clinical parameter based on the subjective assessment of patient’s response. The secondary outcomes were number of pads used in 24 hours, post-operative complications and re-operation rates.

Results

66 females with an average age of 62.7 years were included. 55/66 patients (83.3%) had a successful test phase and underwent permanent implantation. After a median follow-up of 32 months, SNM was successful in 41/55 (74.5%) patients. Mean number of pads used in 24 hours decreased significantly from 3.5 preoperatively to 1.2 at last follow-up (p<0.001). 8/55 (14.5%) patients reported complications of pain, lead migration, wound dehiscence and device malfunction. 10/55 (18.2%) patients underwent revision surgeries after a median duration of 21.9 months. Device was explanted in 15/55 (27.3%) patients after a median duration of 24 months. No significant predictor for success was identified.

Conclusions

The success rate of SNM is 75% with a complication rate of 14.5% after a median follow-up of ~3 years. This study suggests medium-term efficacy and safety but a high re-operation rate of SNM in patients with refractory OAB.

PRImary care Management of lower Urinary tract Symptoms in men: protocol for development and validation of a diagnostic and clinical decision support tool (the PriMUS study)

INTRODUCTION

Lower urinary tract symptoms (LUTS) is a bothersome condition affecting older men which can lead to poor quality of life. General practitioners (GPs) currently have no easily available assessment tools to help effectively diagnose causes of LUTS and aid discussion of treatment with patients. Men are frequently referred to urology specialists who often recommend treatments that could have been initiated in primary care. GP access to simple, accurate tests and clinician decision tools are needed to facilitate accurate and effective patient management of LUTS in primary care.

METHODS AND ANALYSIS

PRImary care Management of lower Urinary tract Symptoms (PriMUS) is a prospective diagnostic accuracy study based in primary care. The study will determine which of a number of index tests used in combination best predict three urodynamic observations in men who present to their GP with LUTS. These are detrusor overactivity, bladder outlet obstruction and/or detrusor underactivity. Two cohorts of participants, one for development of the prototype diagnostic tool and other for validation, will undergo a series of simple index tests and the invasive reference standard (invasive urodynamics). We will develop and validate three diagnostic prediction models based on each condition and then combine them with management recommendations to form a clinical decision support tool.

ETHICS AND DISSEMINATION

Ethics approval is from the Wales Research Ethics Committee 6. Findings will be disseminated through peer-reviewed journals and conferences, and results will be of interest to professional and patient stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN10327305.

Urodynamics less likely to change diagnosis and management in uncomplicated overactive bladder

INTRODUCTION

Given the invasive nature of urodynamics and its unclear impact on altering patient management, we aimed to determine whether performing a urodynamic study (UDS) resulted in a change in either patient diagnosis or treatment offered in women with uncomplicated urinary incontinence.

MATERIALS AND METHODS

A retrospective review was performed of all female patients who underwent UDS for urinary incontinence at our practice between January 2014 and 2017. Patients with neurogenic lower urinary tract dysfunction, incomplete emptying, urinary retention, or prior anti-incontinence surgery were excluded. We compared the ICD-10 diagnosis and primary treatment offered in the absence of UDS to their post-UDS diagnosis and recommended therapy. Descriptive statistics, chi-squared, and multivariable analyses were performed.

RESULTS

A total of 141 patient charts were analyzed. The indications for UDS were mixed urinary incontinence (MUI) (45.3%), stress urinary incontinence (SUI) (29.1%), and overactive bladder (OAB) (25.5%). A change in diagnosis following UDS was seen in 40.4% of the entire cohort including 53.1% of patients with MUI and 48.8% of those with SUI compared to 8.3% of those with OAB. A change in treatment was seen in 32.6% of patients including 54.9% with MUI, 41.7% with SUI, and 10% with OAB. When compared to patients with SUI on adjusted multivariate logistic regression, those with OAB were less likely to have a change in either diagnosis (OR 0.06 (0.01-0.31)) or management (OR 0.15 (0.04-0.62)).

CONCLUSIONS

Diagnosis and management are unlikely to change after UDS in patients presenting with uncomplicated OAB. Conversely, UDS provided important diagnostic information that often changed management in those presenting with MUI and SUI. Our results suggest that UDS may be omitted in patients with uncomplicated refractory OAB in favor of earlier initiation of third line therapies.

Beyond the bladder: poor sleep in women with overactive bladder syndrome

BACKGROUND

Nocturnal bladder symptoms and sleep disruption commonly coexist in middle-aged and older women. Although sleep disruption is often attributed to nocturnal bladder symptoms in women with overactive bladder syndrome, nonbladder factors also may influence sleep in this population. Many women with overactive bladder are eager to identify nonpharmacologic strategies for both bladder symptoms and sleep disruption, given the potential adverse effects of sedative and anticholinergic bladder medications in this population.

OBJECTIVES

To provide greater insight into the complex relationship between nighttime overactive bladder symptoms and sleep disruption, and to evaluate the effects of a guided slow-paced respiration intervention on sleep outcomes in women with overactive bladder.

STUDY DESIGN

We conducted an ancillary study within a randomized trial of slow-paced respiration in women with overactive bladder symptoms. Ambulatory community-dwelling women who reported ≥3 episodes/day of urgency-associated voiding or incontinence were randomized to use either a portable biofeedback device (RESPeRATE; Intercure, Ltd) to practice guided slow-paced respiration exercises daily for 12 weeks (N=79) or an identical-appearing device programmed to play nonrhythmic music without guiding breathing (N=82). At baseline and after 12 weeks, bladder symptoms were assessed by voiding diary, sleep duration, and disruption were assessed by sleep diary corroborated by wrist actigraphy, and poor sleep quality was determined by a Pittsburgh Sleep Quality Index global score >5.

RESULTS

Of the 161 women randomized, 31% reported at least twice-nightly nocturia, 26% nocturnal incontinence, and 70% poor sleep quality at baseline. Of the 123 reporting any nighttime awakenings, 89% averaged 1 or more nighttime awakenings, and 83% attributed at least half of awakenings to using the bathroom. Self-reported wake time after sleep onset increased with increasing frequency of nocturnal bladder symptoms (P=.01 for linear trend). However, even among women without nocturia, average sleep quality was poor (Pittsburg Sleep Quality Index global score mean of 7.3; 95% confidence interval, 6.0-8.6). Over 12 weeks, women assigned to slow-paced respiration (N=79) experienced modest improvements in mean nocturnal voiding frequency (0.4 fewer voids/night), sleep quality (1.1 point score decrease), and sleep disruption (1.5% decreased wake time after sleep onset). However, similar improvements were detected in the music control group (N=81), without significant between-group differences.

CONCLUSIONS

Many women with overactive bladder syndrome experience disrupted sleep, but not all nocturnal awakenings are attributable to bladder symptoms, and average sleep quality tends to be poor even in women without nocturia. Findings suggest that clinicians should not assume that poor sleep in women with overactive bladder syndrome is primarily caused by nocturnal bladder symptoms. Guided slow-paced respiration was associated with modest improvements in nocturia frequency and sleep quality in this trial, but the results do not support clinician recommendation to use this technique over other behavioral relaxation techniques for improving sleep.

Update on Implantable PTNS Devices

PURPOSE OF REVIEW

There is growing evidence supporting the use of percutaneous tibial nerve stimulation to manage lower urinary tract symptoms (LUTS) such as urgency, frequency and urge incontinence, in a non-pharmacologic, minimally invasive approach. Given this, there is now an impetus to move this technology forward from an interval (i.e., weekly and/or monthly) toward a continuous dosing, using implantable devices. This review article focuses on the newest implantable devices and the most current data demonstrating safety and efficacy in the management of refractory overactive bladder.

RECENT FINDINGS

There are new studies showing that continuous (or even semi-continuous) stimulation of the tibial nerve can be of similar efficacy as other chronic neural implant devices, such as sacral neuromodulation. This includes the Blue Wind Renova, StimGuard, eCoin, and Bioness Stimrouter. While the data on these devices are still short-term, implantable tibial nerve stimulation holds promise in the field of managing LUTS and pelvic floor disorders. Durability and minimizing migration remain challenging.

Racial and Socioeconomic Factors Influence Utilization of Advanced Therapies in Commercially Insured OAB Patients: An Analysis of Over 800,000 OAB Patients

OBJECTIVE

To determine if racial and/or socioeconomic factors influence advanced therapy utilization for refractory overactive bladder (OAB) among the commercially insured.

METHODS

We queried Optum, a national claims database, between 2003 and 2017. Non-neurogenic OAB patients were identified using ICD-9/10 diagnosis codes. Demographic and treatment data were collected, including oral medication therapies (anticholinergic, beta3 agonists), and advanced therapies (OnabotulinumtoxinA [BTX], Sacral Nerve Stimulation [SNS], percutaneous tibial nerve stimulation [PTNS]). Associations between patient sociodemographic factors and advanced therapy utilization were explored.

RESULTS

Of 4,229,617 OAB patients, 807,612 (19%) received medical therapies, of which 95% received oral medications only and only 4.7% received advanced therapies. Asians had the lowest use of oral therapy use (14% vs 18%-19% in other races/ethnicities, P <0.05), and advanced therapy use (0.44% vs 0.71%-0.93%, P <0.05). Asians and Hispanics were least likely to utilize SNS therapy and most likely to use PTNS compared to Blacks and Whites. BTX use was similar between races/ethnicities (P <0.05). Female gender (OR 1.65 [CI 1.61,1.69]), younger age (<65) (OR 1.28 [1.25,1.31]), higher annual income ≥$40K (OR 1.09 [1.06,1.12]) and prior use of oral medications (OR 3.30 [3.21,3.38] for 1 medication) were significantly associated with receiving advanced therapies. Non-white race (OR 0.89 [0.87,0.91]), lower education level (less than a bachelor's degree) (OR 0.97 [0.94,0.99]), and Northeast region were associated with a lower likelihood of receiving advanced therapies (P <0.05 for all).

CONCLUSION

Among commercially insured, racial and socioeconomic factors predict utilization of advanced OAB therapies, including race/ethnicity, age, gender, education level, and region.

Does age alone negatively predict the outcome of sacral neuromodulation? A single-centre retrospective observational study

BACKGROUND

For patients over the age of 70 years, sacral neuromodulation (SNM) is often not considered a potential therapeutic option. We therefore report on our results from performing SNM in elderly patients ≥70 years.

METHODS

Between 01/09 and 12/18, a total of 95 patients with refractory overactive bladder (OAB) or chronic non-obstructive urinary retention underwent SNM testing at our department. In the overall sample, 20 patients were aged 70 years or older (21%, group B), and 75 patients were under 70 years old (79%, group A). The mean follow-up period was 50.2 ± 36.2 months. Pre-, peri- and postoperative parameters were compared between the two groups. Statistical analysis was carried out with SPSS 25.0 (p < 0.05).

RESULTS

The mean patient age was 53 ± 16 (17-76) years. The indications for SNM testing were OAB and retention in 51 and 49% of patients, respectively. A total of 56 patients (59%) [8 patients (40%) in group B, 48 patients (64%) in group A] had more than 50% improvement in the context of the test (stage 1), such that a permanent neuromodulator (stage 2) was implanted. A total of 14 patients, all under 70 years old except for one older female, needed to undergo revision due to defects or infection. Overall, the success rate was 58.3% for OAB and 59.6% for urinary retention. The success rates and complications in our patient group were independent of age and geriatric assessment.

CONCLUSION

SNM can also be successfully implemented in older patients.