A systematic review of clinical studies of electrical stimulation for treatment of lower urinary tract dysfunction

Efficacy of Transcutaneous Electrical Nerve Stimulation in the Management of Neurogenic Overactive Bladder: A Randomized Controlled Trial

OBJECTIVE

The aim of the study was to investigate the therapeutic effect of transcutaneous electrical nerve stimulation on neurogenic overactive bladder that is refractory to pharmacotherapy.

METHODS

This randomized trial recruited 83 participants with neurogenic overactive bladder that were nonresponsive to 3-mo first-line anticholinergic drug treatment. Participants were randomized into treatment and control groups. Transcutaneous electrical nerve stimulation current consisting of biphasic square wave with pulse durations of 150 μs and pulse frequency set at 20 Hz were applied to for 30 mins once a day for 90 days. Stimulation was provided over the lateral aspect of the sacrum bilaterally of the electrodes. Patients in the transcutaneous electrical nerve stimulation group stopped taking the anticholinergic drugs. The control group continued to receive anticholinergic drugs for 90 days. The participants' Overactive Bladder Symptom Score, the Medical Outcomes Study 36-Item Short-Form Health Survey scores, urodynamic values, and voiding diary data were assessed before and after the therapy.

RESULTS

The transcutaneous electrical nerve stimulation treatment group had significantly decreased Overactive Bladder Symptom scores compared with the control group (P < 0.001); in addition, half of the Medical Outcomes Study 36-Item Short-Form Health Survey scores were significantly improved in the transcutaneous electrical nerve stimulation group (P < 0.05). The patients treated with transcutaneous electrical nerve stimulation improved significantly voiding diary parameters at P < 0.05. Similarly, urodynamic values at P < 0.05 favored the experimental group over the control group.

CONCLUSIONS

Applying daily transcutaneous electrical nerve stimulation over the sacral region for 90 days to patient with neurogenic overactive bladder improved overactive bladder symptoms of patients whose response to anticholinergic drugs is far inferior.

TO CLAIM CME CREDITS

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CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Determine the therapeutic effect of transcutaneous electrical nerve stimulation (TENS) on neurogenic overactive bladder (NOAB); (2) Demonstrate the effectiveness of reflex suppression of the bladder using the TENS applied over the sacral region as a stimulation location; and (3) Confirm the TENS method using biphasic square waves with pulse durations of 150 μs and pulse frequencies of 20 Hz as applied is shown to be superior to anticholinergic drugs in managing NOAB.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Long-Term Effect of Early Post-operative Transcutaneous Electrical Stimulation on Voiding Function After Radical Hysterectomy: A Multicenter, Randomized, Controlled Trial

Introduction: Post-radical-hysterectomy (RH) patients suffer from a series of problems resulting from neurovascular injury, such as bladder dysfunction, which reduce their quality of life. We have designed this study to evaluate the efficacy of transcutaneous electrical stimulation (TENS) on patient rehabilitation after RH for early cervical cancer.

Materials and methods: A total of 97 patients were enrolled in a randomized-controlled trial (from January 2015 to December 2019) involving 7 medical centers nationwide. Patients were assigned to either the intervention group (n = 46), or the control group (n = 51). TENS was given to patients in the intervention group from the 7^th day after surgery for a total of 14–21 days. The control group received no TENS. Primary outcomes were measured for residual urine volume and recovery of urination function. Secondary outcomes were measures for urodynamics (UDS), pelvic floor electromyography function examination (PFEmF), and quality of life (QoL).

Results: Residual urine volume and improvement in the rate of urination were found to show no significant differences on the 14^th, 21^st, and 28^th days after surgery. The maximum flow rate (Qmax) in the intervention group was significantly higher than that in the control group on the 28^th day, but there were no significant differences in average flow rate, voiding time, time to Qmax, muscle fiber strength, muscle fiber fatigue, and the abnormal rate of A3 reflection on the 28^th day and the 3^rd mo., as well as in the QoL at 3^rd mo., 6^th mo., and 12^th mo. after surgery.

Conclusion: Our study showed no sufficient evidence to prove that TENS under the trialed parameters could improve the subject's voiding function, PFEmF, and QOL after RH. This has provided valuable data for rehabilitation after RH.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02492542.

Management of voiding dysfunction associated with pelvic malignancies

Voiding dysfunction is common after surgical and radiation treatments in patients diagnosed with non-urological pelvic malignancies. Presentation might vary with lower urinary tract symptoms and/or overactive bladder, urinary retention, or incontinence. We reviewed the most recent literature with the aim of describing various types of urinary dysfunction that manifest after radical treatments for non-urological pelvic malignancies. Radical surgical or radiation treatment adversely affect other adjacent pelvic organ function, including viscera, pelvic musculature and the peripheral nervous system. This results in direct organ and indirect functional damage to the genitourinary tract. Multiple surgical and radiation modifications are available nowadays, allowing urologists to offer various treatments for better functional lower urinary tract outcomes. Diagnosing and understanding the type and severity of voiding dysfunction plays a key role in tailoring an appropriate treatment plan. The objective to better functional results relies on maintaining adequate bladder compliance and capacity while permitting volitional emptying, ideally through voiding. Management should routinely start with conservative measures, including pelvic floor muscle training with or without a combination of oral medication for urgency incontinence and clean intermittent catheterization for the management of urinary retention. Concomitant or isolated urinary incontinence can be further managed through multiple established surgical approaches. We attempted to address various treatment available for known lower urinary tract symptoms that might have been caused secondary to non-urological pelvic surgery or radiation. We discuss different diagnostic and treatment modalities individualized for patients with various entities, to help achieve optimal urinary function and improve quality of life.

Managing overactive bladder

Overactive bladder (OAB) is a common and distressing condition which is known to increase with age and has a significant effect on quality of life. Whilst OAB is a symptomatic diagnosis, many patients will require basic investigations prior to initiating the appropriate management. This article will review the initial clinical assessment and management of women complaining of OAB including conservative measures and drug therapy, and will also focus on the role of estrogen. In addition, the management of refractory OAB will also be discussed including more invasive strategies such as neuromodulation, Botulinum Toxin, and reconstructive surgery.

Effect of different electrical stimulation protocols for pelvic floor rehabilitation of postpartum women with extremely weak muscle strength: Randomized control trial

BACKGROUND

Pregnancy is one of the main risk factor of pelvic floor muscle dysfunction. Postpartum women with extremely weak muscle strength have difficulty to do voluntary pelvic floor muscle training. This study aims to evaluate the effects of different protocols of electrical stimulation in the treatment of postpartum women with extremely weak muscle strength.

METHODS

A total of 67 women were randomized into 2 groups: group A received transvaginal electrical stimulation (TVES) for 5 times, and group B received TVES for 3 times with electromyogram (EMG)-triggered neuromuscular stimulation twice. Subjects were evaluated before and after treatment. Pelvic muscle strength was measured by both digital vaginal palpation and EMG variables, and quality of life was investigated by 4 kinds of pelvic floor disease-related questionnaires.

RESULTS

According to the intention-to-treat principle, compared with baseline, in group A, EMG of contractile amplitude of endurance phase was significantly elevated (P = .03), variation of contractile amplitude in tonic phase was more stable after treatment (P = .004), and EMG of mean value of final rest was significantly elevated after treatment (P = .047). After 5 times treatments, the incidence of correct pelvic floor muscle contraction in group A was significantly elevated (P = .045). No significant difference of muscle strength test by digital vaginal palpation was detected between the 2 groups, so did questionnaires.

CONCLUSION

For postpartum women with extremely weak muscle strength, TVES for 5 times might be more benefit for control ability of pelvic muscle contractions and elevating muscle strength even in short-time treatment.

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.

Which pelvic floor muscle functions are associated with improved subjective and objective symptoms after 8 weeks of surface electrical stimulation in women with stress urinary incontinence?

OBJECTIVE

Stress urinary incontinence (SUI) is defined as involuntary urine loss during effort, sneezing, or coughing. We investigated which pelvic floor muscle (PFM) functions (muscle strength, power, and endurance) are associated with improvement in subjective and objective symptoms after 8 weeks of surface electrical stimulation (SES) training. This study was performed to determine the effects of SES in the seated position on PFM functions and subjective and objective symptoms, and to identify predictors of improved subjective and objective symptoms after 8 weeks of SES training via secondary analysis of females with SUI.

STUDY DESIGN

The study was performed between August 2018 and December 2018. Patients with SUI were randomized into an SES group (n = 17) and a control group (n = 17). Both groups were assessed pre-intervention and after 8 weeks of intervention. The outcome measures were PFM functions (strength, power, and endurance) as measured via perineometry, the score on the urogenital distress inventory-6 (UDI-6), and the ultra-short perineal pad test result.

RESULTS

Significant differences in all PFM functions, the UDI-6 score, and the pad weight were evident both between the groups (SES vs. control group) and within the groups (pre-SES vs. post-SES). On regression of factors predicting relative changes in subjective and objective symptoms, the relative change in PFM power accounted for 15 and 13 % of the variance in the UDI-6 score (P < 0.05) and pad weight (P < 0.05), respectively.

CONCLUSIONS

SES in a seated position improved both subjective and objective symptoms in females with SUI. PFM power, the UDI-6 score, and the pad weight test result should be considered when developing intervention guidelines to improve the subjective and objective symptoms of females with SUI.

A comparison of sacral neuromodulation vs. transvaginal electrical stimulation for the treatment of refractory overactive bladder: the impact on quality of life, body image, sexual function, and emotional well-being

Overactive bladder syndrome (OAB) is defined by the presence of urinary urgency, with or without urge incontinence, usually accompanied by an increase in urinary frequency and nocturia in the absence of urinary tract infections (UTI) or other diseases. The overall prevalence of OAB symptoms in the female population is reported to be 16.6% and increases with advancing age and menopause. The aetiology of OAB is not fully understood and is likely to affect a heterogeneous population of patients due to changes to their central and peripheral nervous systems. Although OAB is frequently associated with female sexual dysfunction (FSD), its real impact on sexual function in women has been evaluated only in a few studies. The first line of treatment for OAB includes behavioural modification and physical therapy, either as monotherapies or in combination. Many patients who have not had success in managing their symptoms with more conservative therapies may decide to resort to third-line treatments for refractory OAB. These treatments include neuromodulation therapies, particularly transvaginal electrical stimulation (TES) and sacral neuromodulation (SN). The aim of this short commentary is to provide an overview of the effectiveness of these treatments and of their impact on quality of life, body image, sexual function, and emotional well-being.

Effect of integrin β1 in the treatment of stress urinary incontinence by electrical stimulation

The aim of the present study was to investigate the protective effect of integrin β1 in the treatment of stress urinary incontinence (SUI) by electrical stimulation, and the underlying mechanisms by which electrical stimulation regulates the collagen metabolism of female vaginal wall fibroblasts (FVWFs). FVWFs obtained from the vaginal wall tissue of patients with (Ingelman-Sundberg scale; grade II, n=8; grade III, n=10) or without (n=8) SUI during gynecological operations were isolated by enzymatic digestion and subsequently identified by immunocytochemistry. Following this, cultured FVWFs were treated with an inhibitor of integrin β1, recombinant human integrin β1 and electrical stimulation (100 mv/mm, 2 h, 20 Hz), followed by total mRNA and protein extraction. mRNA and protein expression levels of integrin β1, transforming growth factor (TGF)-β1 and collagen (COL) I and III in FVWFs were quantified by reverse transcription-quantitative PCR (RT-qPCR) and western blot analysis respectively. Integrin β1, TGF-β1 and COL I and III expression levels were decreased in patients with SUI compared with healthy controls, and the grade III group had lower levels than the grade II group. Following electrical stimulation treatment, the expression levels of TGF-β1, COL I and III were enhanced in the grade II group, but not in the grade III group. Nevertheless, the inhibitor of integrin β1 reduced the protective effect of electrical stimulation in the grade II group. In addition, electrical stimulation combined with recombinant human integrin β1 could also protect cells from SUI in the grade III group. The present study provides evidence for the increased degradation of the extracellular matrix and integrin β1 in the vaginal wall tissues of patients with SUI, and the protective effect of electrical stimulation against SUI via integrin β1. These results provide a novel mechanism for the treatment of SUI using electrical stimulation.

Electrical stimulation activates calpain 2 and subsequently upregulates collagens via the integrin β1/TGF-β1 signaling pathway

Stress urinary incontinence (SUI) is a public health issue attributed to weakened pelvic supporting tissues. Electrical stimulation (ES) is one of the first-line conservative treatments for SUI. However, the underlying mechanism of ES in the treatment of SUI is not clear. Here, we show that ES suppresses cell apoptosis and upregulates collagen expression by functioning as a cell growth inducer to activate the calpain 2/talin 1/integrin β1/transforming growth factor (TGF)-β1 axis. Specifically, ES promoted Ca²⁺ to flow into the cytoplasm through the calcium channel, Cav 3.2, thereby activating calpain 2. Then, the activated calpain 2 cleaved talin 1, which induced the activation of integrin β1 and upregulated the TGF-β1-mediated transcription of collagen I and III. Notably, blocking Cav 3.2 suppressed calcium influx and inhibited the activation of downstream proteins. Furthermore, the knockdown of calpain 2 resulted in the reduction of cleaved talin 1, and the shRNA-integrin β1 treatment downregulated the level of activated integrin β1 and the expression of TGF-β1-induced collagen I and III. An association of the ES-modulated collagen I and III upregulation with the therapeutic effect of the ES-Ca²⁺/calpain 2/talin 1/integrin β1/TGF-β1 axis was demonstrated in mouse fibroblast and mouse SUI models established through vaginal distension (VD). This outcome provides insight into clinical diagnosis and treatment.

Voiding Dysfunction After Non-urologic Pelvic Surgery

PURPOSE OF REVIEW

Urinary dysfunction is a common entity in patients undergoing radical pelvic surgery for non-urologic malignancies. These dysfunctions may manifest as lower urinary tract symptoms (LUTS) or signs such as urinary retention or leakage. Review of current literature is performed to describe the differing urinary dysfunctions that manifest after colorectal resection, hysterectomy, and sacrectomy.

RECENT FINDINGS

Conventional radical surgery for pelvic malignancies often will result in debilitating functional problems. As advances in surgical techniques and management options become more available, patients can have better functional outcomes, specifically in the lower urinary tract. Nerve-sparing techniques as well as vascular preservation are becoming more important to preserve function as patient survival is improving. Additionally, newer methods are being explored, such as nerve stimulation for those who are unable to empty adequately. This article also addresses different management options for specific voiding dysfunction that may result from pelvic surgery. Preventative strategies such as nerve preservation during surgery are an important concept to prevent urinary dysfunction. The goal to good functional outcomes includes maintaining reservoir compliance and capacity as well as allowing proper outlet for voiding. We discuss different modalities to help achieve a functional lower urinary tract for patients with lower urinary tract dysfunction after pelvic surgery.

Effect of transcutaneous electrical stimulation treatment on lower urinary tract symptoms after class III radical hysterectomy in cervical cancer patients: study protocol for a multicentre, randomized controlled trial

BACKGROUND

Class III radical hysterectomy (RH III)_plus pelvic lymphadenectomy is the standard surgery for early stage cervical cancer (CC) patients, the 5 year survival rate is about 90%, but pelvic floor disorders especially bladder dysfunction are common due to damaged vessels and nerve fibers following surgery. Transcutaneous electrical stimulation (TENS) treatment has been used to treat bladder disorders for many years, but its effect on cervical cancer patients, the best treatment time point and stimulated protocol, had never been assessed. The aim of this study is to investigate the efficacy of TENS treatment on lower urinary tract symptoms (LUTS) after RH III in CC patients.

METHODS/DESIGN

The study will be conducted as a clinical, multicentre, randomised controlled trial with balanced randomisation (1:1). The planned sample size is 208 participants (at 1:1 ratio, 104 subjects in each group). At 5-7 days after RH III, patients are screened according to operative and pathological findings. Enrolled participants are randomised into an intervention group (TENS plus conventional clinical care) or control group (conventional clinical care), with stratification by menopausal status (menopause vs. non-menopause) and surgical modality (laparoscopic RH or abdominal RH). Participants in both groups will be followed up at 14 days, 21 days, 28 days, 3 months, 6 months, 12 months, 18 months and 24 months after surgery. The primary endpoint is improvement rate of urination function which is defined as recovery (residual urine ≤50 ml) or improvement (residual urine 50-100 ml). Secondary endpoints include urodynamic parameter, urinary incontinence, anorectal function, pelvic function, quality of life (QOL), disease-free survival and adverse events. Primary endpoint analyses will be carried out by Cochran-Mantel-Haenszel tests taking into center effect.

DISCUSSION

To our knowledge this is the first trial to investigate the effect of TENS treatment on bladder function recovery after RH III among CC patients. This study will provide new information on TENS efficacy for bladder function recovery. Once confirmed, it may help to provide a new, non-invisive treatment for those postoperative CC patients with poor pelvic function, which would help improve their quality of life.

TRIAL REGISTRATION

The study is registered to Clinical Trials.gov ( NCT02492542 ) on June 25, 2015.

Transcutaneous tibial nerve stimulation in the treatment of lower urinary tract symptoms and its impact on health-related quality of life in patients with Parkinson disease: a randomized controlled trial

PURPOSE

A randomized controlled trial study was performed to evaluate the efficacy of transcutaneous tibial nerve stimulation (TTNS) and sham TTNS, in patients with Parkinson disease (PD) with lower urinary tract symptoms (LUTS).

DESIGN

Randomized controlled trial.

SUBJECTS AND SETTINGS

Thirteen patients with a diagnosis of PD and bothersome LUTS were randomly allocated to one of the following groups: Group I: TTNS group (n = 8) and group II: Sham group (n = 5). Both groups attended twice a week during 5 weeks; each session lasted 30 minutes.

METHODS

Eight patients received TTNS treatment and 5 subjects allocated to group II were managed with sham surface electrodes that delivered no electrical stimulation. Assessments were performed before and after the treatment; they included a 3-day bladder diary, Overactive Bladder Questionnaire (OAB-V8), and the International Consultation on Incontinence Quality of Life Questionnaire Short Form (ICIQ-SF), and urodynamic evaluation.

RESULTS

Following 5 weeks of treatment, patients allocated to TTNS demonstrated statistically significant reductions in the number of urgency episodes (P = .004) and reductions in nocturia episodes (P < .01). Participants allocated to active treatment also showed better results after treatment in the OAB-V8 and ICIQ-SF scores (P < .01, respectively). Urodynamic testing revealed that patients in the active treatment group showed improvements in intravesical volume at strong desire to void (P < .05) and volume at urgency (P < .01) when compared to subjects in the sham treatment group.

CONCLUSION

These findings suggest that TTNS is effective in the treatment of LUTS in patients with PD, reducing urgency and nocturia episodes and improving urodynamic parameters as well as symptom scores measured by the OAB-V8 and health-related quality-of-life scores measured by the ICIQ-SF.

Effects of Transcutaneous Electrical Nerve Stimulation at Two Frequencies on Urinary Incontinence in Poststroke Patients: A Randomized Controlled Trial

OBJECTIVE

The objective of this study was to compare the effects of two frequencies of transcutaneous electrical nerve stimulation (TENS) on urinary incontinence caused by stroke.

METHODS

Eighty-one patients with poststroke urinary incontinence were recruited and randomized into the following three groups with a 1:1 ratio: a 20-Hz TENS group, a 75-Hz TENS group, and a no-treatment control group (n = 27 per group). TENS currents were biphasic square waves with pulse durations of 150 μsecs and pulse frequencies of 20 Hz or 75 Hz and were applied for 30 mins once per day for 90 days. The positive electrodes were placed in the region of the second sacral level on opposite sides of the vertebral column; the negative electrodes were placed on the inside of the middle and lower third of the junction between the posterior superior iliac spine and the ischial node. Overactive Bladder Symptom Scores, Barthel Index, urodynamic values, and voiding diary parameters were assessed before and after 90 days.

RESULTS

The patients treated with 20 Hz had superior Overactive Bladder Symptom Scores, Barthel Index totals, urodynamic values, and voiding diary parameters (P < 0.05). In the 75-Hz group, values were statistically improved compared with the no-treatment group (P < 0.05), but the results were significantly inferior to those of the 20-Hz group (P < 0.05).

CONCLUSIONS

Twenty-hertz TENS improved incontinence symptoms and promoted activities of daily living better than 75-Hz TENS. These results will aid future research regarding TENS parameters.

The management of childhood urinary incontinence

The International Children's Continence Society (ICCS) has undertaken an enormous effort to standardize both the terminology and management of various aspects of incontinence in children, including enuresis, bladder overactivity, dysfunctional voiding and psychological comorbidities. A number of guidelines have been published to aid those involved in the care of children with lower urinary tract symptoms. This review addresses a number of recommended diagnostic and therapeutic strategies, including urotherapy and pharmacological treatment, with emphasis on a focused medical history, information acquired from bladder diaries and uroflow evaluations. The major role of urotherapy is underlined with supportive pharmacotherapy, when indicated. The article provides both a summary of ICCS guidelines and a brief review of recently published papers related to the contemporary management of childhood incontinence, a health issue still underestimated by both the child's caregivers and healthcare providers.

Effect of vaginal electrical stimulation on female sexual functions: a randomized study

INTRODUCTION

Female sexual dysfunction (FSD) is a common problem that may be encountered in the interruption of normal sexual functioning in the sexual response cycle. Women with a pelvic floor disorder who scored low on the Female Sexual Function Index (FSFI) showed an improvement in their sexual life following treatment by vaginal electrical stimulation (VES).

AIM

The aim of this trial was to evaluate the effectiveness of VES in women with FSD without a predominant pelvic floor disorder or urinary incontinence.

METHODS

Forty-two women with FSD were randomly allocated to VES and placebo groups. Pelvic floor muscle (PFM) assessment and the FSFI questionnaire were performed at baseline and after the completion of sessions. VES treatment was administered using a vaginal probe. The probe was inserted, and a medium-frequency (50 Hz) alternating current was administered for a duty cycle of 5 seconds on followed by a 5-second rest.

MAIN OUTCOMES MEASURES

Primary outcome measure was the improvement in FSFI score. PFM assessments were performed according to the PERFECT scheme.

RESULTS

Total FSFI scores improved significantly in both the VES group and the control group. Results show that in the VES group, there was an improvement in total score and FSFI domains that improved including arousal, desire, orgasm, and satisfaction. Similarly, control group domains that improved were desire, arousal, and orgasm. But there was no significant increase in satisfaction scores in the placebo group. No significant changes in pain or lubrication domains were seen in either group. Power, endurance, fast contractions, and repetitions were significantly improved in the VES group.

CONCLUSIONS

The lack of significant differences between the placebo and VES groups, except the satisfaction domain, puts into question the effectiveness of electrical stimulation as a monotherapy in treating primary FSD without pelvic floor disorder.

Sacral neuromodulation for neurogenic bladder and bowel dysfunction with multiple symptoms secondary to spinal cord disease

STUDY DESIGN

Retrospective case series.

OBJECTIVES

The primary aim was to assess the clinical effects of sacral neuromodulation (SNM) for neurogenic bladder and/or bowel dysfunction with multiple symptoms secondary to spinal cord disease or injury.

SETTING

Beijing, China.

METHODS

Between 2011 and 2013, 23 patients with multiple bladder and/or bowel problems secondary to spinal cord disease or injury were treated with a preliminary test SNM. If at least 50% clinical improvement occurred, then the patient underwent a permanent SNM procedure. We evaluated the patients using a bladder diary, post-void residual volume measurement and the Wexner questionnaire score for constipation before the test phase, during the test phase and after the permanent SNM.

RESULTS

In the test phase, the rate of improvement in dysuria (29.4%) was significantly lower than urgency frequency (64.7%), urinary incontinence (69.2%) and constipation (75.0%). An implant was performed in 13 (56.5%) patients, including 4 patients who still used intermittent catheterization to exclude urine after permanent SNM because the symptom of dysuria could not be improved significantly and 1 patient who achieved ⩾50% improvement in lower urinary tract dysfunction but not in constipation. During follow-up (17.5±2.0 months), 1 patient (7.7%) failed and 1 patient had bilateral vesicoureteral reflux.

CONCLUSION

Chronic SNM cannot always resolve all the bladder and bowel symptoms secondary to spinal cord disease or injury, but combined with other treatments may help improve multiple symptoms.

Managing urinary incontinence: what works?

Urinary incontinence is a common condition, which, although not life-threatening, impairs the health-related quality of life of affected individuals. All women complaining of incontinence require a basic assessment and those with complex or refractory symptoms may benefit from urodynamic studies. Initial treatment includes lifestyle advice, behavioral modifications, bladder retraining and pelvic floor muscle training. For those women with persistent stress urinary incontinence following conservative therapy, surgical management might be considered. The development of the minimally invasive, retropubic, synthetic, mid-urethral sling procedures has revolutionized stress incontinence surgery and reduced the popularity of 'traditional' procedures, such as colposuspension and autologous fascial sling. In an attempt to reduce further the morbidity, transobturator and single-incision slings have been introduced. While antimuscarinic agents are the mainstay of the current medical management of urgency urinary incontinence, a recently developed selective β3-adrenergic receptor agonist (mirabegron) offers an alternative pharmacological option. Modalities such as intravesical botulinum toxin and neuromodulation (peripheral or sacral) are available to women with refractory urgency incontinence. Finally, when all other options have been explored and proven unsuccessful, inappropriate or not feasible, reconstructive surgery or catheter insertion might be considered as a last resort. The aim of this paper is to review conservative, medical and surgical management for urinary incontinence by using the best available evidence in the literature.

Urinary Incontinence in the Young Woman: Treatment Plans and Options Available

Urinary incontinence is a common and distressing condition, which, although not life-threatening, is known to have a significant effect on quality of life. The incidence of urinary incontinence increases with age and while stress urinary incontinence is more common in younger women, symptoms suggestive of overactive bladder are more common with increasing age. All women complaining of incontinence require simple investigation, and many will benefit from conservative and medical treatments, which may be instituted in primary care. Further investigation in the secondary-care setting should be reserved for those women with refractory or unusual symptoms. The aim of this paper is to review the epidemiology and pathophysiology of common causes of urinary incontinence in younger, premenopausal women, and to review the current algorithms for investigation and management. In addition, treatment paradigms covering conservative, medical and surgical treatment for stress urinary incontinence and overactive bladder will be reviewed.

Self-induced plantar-flexion objectively reduces wave amplitude of detrusor overactivity and subjectively improve urinary urgency: a pilot study

AIMS

To estimate the effect of plantar-flexion on the wave amplitude of involuntary detrusor contraction and the severity of urinary urgency during filling cystometry in patients with detrusor overactivity (DO).

METHODS

Twenty-two consecutive patients with DO were enrolled. During urodynamics, the mean peak detrusor pressures of each contraction were documented and compared. At the beginning of the 2nd or 3rd wave, patients were asked to perform continuous plantar-flexion by pushing their tiptoes against the floor. Following each wave, patients were asked to grade the severity of the urgency by a visual analogue scale (VAS).

RESULTS

The mean peak detrusor pressure without plantar-flexion was 58 cmH2 O (95% CI: 46.3-69.7) compared to 31 cmH2 O (95% CI: 23.1-38.9) with plantar-flexion (P < 0.001). All patients reported a reduced degree of urgency during plantar-flexion reflected in a significant reduction in mean VAS score from 9.3 (95% CI: 9-9.5) to 4.7 (95% CI: 3.9-5.4; P < 0.0001).

CONCLUSIONS

Self-performed plantar-flexion maneuver might reduce the severity of urinary urgency and the magnitude of overactive detrusor contractions, which may have a role in the conservative therapy of detrusor overactivity.

Transvaginal electrical stimulation with surface-EMG biofeedback in managing stress urinary incontinence in women of premenopausal age: a double-blind, placebo-controlled, randomized clinical trial

Introduction and hypothesis

The aim of this study was to evaluate the results of conservative treatment of urodynamic stress urinary incontinence (SUI) using transvaginal electrical stimulation with surface-electromyography-assisted biofeedback (TVES + sEMG) in women of premenopausal age.

Methods

One hundred and two patients with SUI were divided into two groups: active (n = 68) and placebo (n = 34) TVES + sEMG. The treatment lasted for 8 weeks and consisted of two sessions per day. Women were evaluated before and after the intervention by pad test, voiding diary, urodynamic test, and the Incontinence Quality of Life Questionnaire (I-QOL).

Results

Mean urinary leakage on a standard pad test at the end of 8th week was significantly lower in the active than the placebo group (19.5 ± 13.6 vs. 39.8 ± 28.5). Mean urinary leakage on a 24-h pad test was significantly reduced in the active group at the end of 8th and 16th weeks compared with the placebo group (8.2 ± 14.8 vs. 14.6 ± 18.9 and 6.1 ± 11.4 vs. 18.2 ± 20.8, respectively). There was also a significant improvement in muscle strength as measured by the Oxford scale in the active vs the placebo group after 8 and 16 weeks (4.2 vs 2.6 and 4.1 vs 2.7, respectively). No significant difference was found between groups in urodynamic data before and after treatment. At the end of 8th week, the mean I-QOL score in the active vs the placebo group was 78.2 ± 17.9 vs 55.9 ± 14.2, respectively, and at the end of 16th week 80.8 ± 24.1 vs. 50.6 ± 14.9, respectively.

Conclusion

Our study showed that TVES + sEMG is a trustworthy method of treatment in premenopausal women with SUI; however, its reliability needs to be established.

The management of overactive bladder refractory to medical therapy

Overactive bladder (OAB) is a clinical syndrome describing the symptom complex of urgency, with or without urgency incontinence and is usually associated with frequency and nocturia. Whilst many women may be initially managed using a clinical diagnosis alone a number will fail primary therapy and will require further investigation. Those women with refractory symptoms following initial conservative and medical therapy may benefit from alternative treatment modalities including intravesical Botulinum toxin, neuromodulation or reconstructive surgery. This review, the second of two covering the treatment of intractable OAB symptoms in women, will focus on management following the failure of medical therapy. It will principally focus on the role of Botulinum toxin, neuromodulation and reconstructive surgery.

Neuromodulation for fecal and urinary incontinence: functional results in 57 consecutive patients from a single institution

BACKGROUND

Sacral nerve stimulation is a recognized treatment for fecal and urinary incontinence. Few articles have been published about patients presenting with both types of incontinence.

OBJECTIVE

The aim of this study was to report the functional results in patients operated on for simultaneous fecal and urinary incontinence by the use of sacral nerve stimulation.

DESIGN

This study is a retrospective analysis of prospectively collected data.

SETTINGS

The investigation was conducted in the academic departments of colorectal surgery and urology.

PATIENTS

Between January 2001 and March 2010, 57 consecutive patients (54 women) with a mean age of 58 years (range, 16-76) were included.

INTERVENTIONS

Two-stage sacral nerve modulation (test and implant) was performed.

MAIN OUTCOME MEASURES

Functional study before testing, at 6 months, and at the end of follow-up after implantation included the use of the Cleveland Clinic incontinence score, Urinary Symptoms Profile, Fecal Incontinence Quality of Life score, and the Ditrovie score. Patient satisfaction with the technique was evaluated at a median follow-up of 62.8 months.

RESULTS

: Fecal incontinence improved from 14.1/20 to 7.2/20 at 6 months and 6.9/20 at the end of follow-up. Urinary incontinence, mainly urge incontinence (47% of patients), and urgency frequency (34% of patients) improved at 6 months and end of follow-up, but not retention and dysuria. Specific quality of life was improved for fecal and urinary incontinence at 6 months and end of follow-up. At the end of follow-up, 73% patients were highly satisfied with the technique, but 9% felt their condition had deteriorated. The reoperation rate was 29%, of which 12% were indicated because of a complication.

LIMITATIONS

This study was limited by its retrospective nature and the multiple causes of incontinence.

CONCLUSION

Fecal and urinary incontinence, studied by symptoms scores and specific quality-of-life scores, are improved in patients receiving sacral nerve stimulation for double incontinence.