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Bosch-Ramírez M, Sánchez-Guillén L, Alcaide-Quirós MJ, Aguilar-Martínez MM, Bellón-López M, López Delgado A, López-Rodríguez-Arias F, Muñoz-Duyos A, Barber-Valles X, Arroyo A. Long-term efficacy of percutaneous tibial nerve stimulation for faecal incontinence and a new approach for partial responders. Tech Coloproctol 2023; 27:443-451. [PMID: 36222850 PMCID: PMC10169891 DOI: 10.1007/s10151-022-02711-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 09/30/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The aim of the present study was to evaluate the long-term efficacy of percutaneous tibial nerve stimulation (PTNS) for patients with faecal incontinence (FI) refractory to conservative treatment. Secondary aims were to identify predictors of response and validate new treatment pathways for partial responders. METHODS A prospective, interventional study was carried out in a specialist defecatory disorder unit from a university hospital between January 2010 and June 2017 on patients > 18 years old with FI refractory to conservative treatment. Thirty-minute PTNS sessions were performed in three phases (weekly, biweekly and monthly) up to a year, with clinical reassessment at 3, 6, 12 and 36 months. Patients were classified as optimal responders when their pretreatment Wexner score decreased > 50%; partial responders when it decreased 25-50%; and insufficient responders if it decreased < 25%. Only optimal and partial responders progressed into successive phases. RESULTS Between 2010 and 2017, 139 patients (110 women, median age 63 years [range 22-82 years]) were recruited. After the first phase, 4 patients were optimal responders, 93 were partial responders and 36 were insufficient responders. At 6 and 12 months, 66 and 89 patients respectively were optimal responders, with an optimal response rate of 64% at the end of treatment. A total of 93.3% patients with a partial response initially finally became optimal responders. Furthermore, at 36 months, 71.9% of patients were still optimal responders without supplementary treatment, although their quality of life did not improve significantly. Baseline Wexner scores ≤ 10 and symptom duration < 1 year were identified as predictive factors for positive responses to PTNS. CONCLUSIONS Patients undergoing PTNS for 1 year following this protocol had optimal long-term responses. PTNS sessions for up to 1 year in patients who were partial responders prevents a high percentage of them from needing more invasive treatments, and maintains long-term continence in patients who were optimal responders.
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Affiliation(s)
- M. Bosch-Ramírez
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - L. Sánchez-Guillén
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - M. J. Alcaide-Quirós
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - M. M. Aguilar-Martínez
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - M. Bellón-López
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - A. López Delgado
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - F. López-Rodríguez-Arias
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - A. Muñoz-Duyos
- Department of General Surgery, Colorectal Unit, Mútua Terrassa University Hospital, University of Barcelona, Terrassa, Barcelona Spain
| | - X. Barber-Valles
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
- Center for Operations Research, University Miguel Hernández of Elche, Elche, Alicante Spain
- Joint Research Unit on Statistical Methods in Health Sciences UMH-FISABIO, University Miguel Hernández of Elche, Elche, Spain
| | - A. Arroyo
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
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Jin Q, Zhu Y, Yin P, Li X. Tibial nerve electrical stimulation for fecal incontinence: a systematic review and meta-analysis. Updates Surg 2022:10.1007/s13304-022-01444-w. [DOI: 10.1007/s13304-022-01444-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
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Mazor Y, Prott GM, Sequeira C, Jones M, Ejova A, Kellow JE, Schnitzler M, Malcolm A. A novel combined anorectal biofeedback and percutaneous tibial nerve stimulation protocol for treating fecal incontinence. Therap Adv Gastroenterol 2020; 13:1756284820916388. [PMID: 32577132 PMCID: PMC7288816 DOI: 10.1177/1756284820916388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/09/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND/AIMS Fecal incontinence (FI) is a common, debilitating condition that causes major impact on quality of life for those affected. Non-surgical treatment options include anorectal biofeedback therapy (BF) and percutaneous tibial nerve stimulation (PTNS), usually performed separately. The aims of the current study were to determine the feasibility, tolerability, safety, and efficacy of performing a combined BF and PTNS treatment protocol. METHODS Female patients with urge FI were offered a novel pilot program combining BF with PTNS. The treatment protocol consisted of 13 weekly sessions: an educational session, followed by 5 combined BF and PTNS sessions, 6 PTNS and a final combined session. Anorectal physiology and clinical outcomes were assessed throughout the program. For efficacy, patients were compared with BF only historical FI patients matched for age, parity, and severity of symptoms. RESULTS A total of 12/13 (93%) patients completed the full program. Overall attendance rate was 93% (157/169 sessions). Patient comfort score with treatment was rated high at 9.8/10 (SD 0.7) for PTNS and 8.6/10 (SD 1.7) for the BF component. No major side effects were reported. A reduction of at least 50% in FI episodes/week was achieved by 58% of patients by visit 6, and 92% by visit 13. No physiology changes were evident immediately following PTNS compared with before, but pressure during sustained anal squeeze improved by the end of the treatment course. Comparing outcomes with historical matched controls, reductions in weekly FI episodes were more pronounced in the BF only group at visit 6, but not week 13. CONCLUSIONS In this pilot study, concurrent PTNS and anorectal biofeedback therapy has been shown to be feasible, comfortable, and low risk. The combined protocol is likely to be an effective treatment for FI, but future research could focus on optimizing patient selection.
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Affiliation(s)
| | - Gillian M. Prott
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Carol Sequeira
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Michael Jones
- Psychology Department, Macquarie University, Sydney, NSW, Australia
| | - Anastasia Ejova
- Psychology Department, Macquarie University, Sydney, NSW, Australia
| | - John E. Kellow
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW, Australia,Kolling Institute of Medical Research, Sydney, NSW, Australia,Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Margaret Schnitzler
- Department of Colorectal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia,Kolling Institute of Medical Research, Sydney, NSW, Australia,Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW, Australia,Kolling Institute of Medical Research, Sydney, NSW, Australia,Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
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Abstract
Neuromodulation encompassing sacral and peripheral modalities is an established, effective, and safe higher-order treatment option approved in the USA for managing refractory overactive bladder, non-obstructive urinary retention, and fecal incontinence. This review highlights the most recent literature, indications, treatment durability, and the latest innovations in this field. Regarding sacral neuromodulation (SNM), recent work suggests improved parameters for optimal lead placement, increased data to support the lasting effects of treatment, and novel applications of this technology to other pelvic disorders. In addition, there are emerging technologies with smaller MRI compatible devices. Newer data on percutaneous tibial nerve stimulation (PTNS) suggests it may be more beneficial for certain patients. With new technology, implantable tibial nerve stimulators are ushering in a new frontier of nerve stimulation in the comfort of the patient's home.
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Affiliation(s)
- Courtenay K Moore
- Glickman Urologic and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Q-10, Cleveland, OH, 44195, USA.
| | - Jessica J Rueb
- Glickman Urologic and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Q-10, Cleveland, OH, 44195, USA
| | - Samir Derisavifard
- Glickman Urologic and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Q-10, Cleveland, OH, 44195, USA
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