A feasibility study of transcutaneous posterior tibial nerve stimulation for bladder and bowel dysfunction in elderly adults in residential care

Effects of Transcutaneous Tibial Nerve Stimulation in Women Refractory to and Never Used Pharmacological Agents for Idiopathic Overactive Bladder

INTRODUCTION AND HYPOTHESIS

The aim of this study is to compare the effectiveness of transcutaneous tibial nerve stimulation (TTNS) on quality of life (QoL) and clinical parameters related to incontinence in pharmacological agents (PhAs) naive and refractory women with idiopathic overactive bladder (iOAB).

METHODS

In this prospective nonrandomized clinical trial, women with resistance to PhAs were included in the first group (n=21), PhA-naive women were included in the second group (n=21). TTNS was performed 2 days a week, a total of 12 sessions for 6 weeks. Every session lasted 30 min. Women were evaluated for the severity of incontinence (Pad test), 3-day voiding diary (voiding frequency, nocturia, incontinence episodes, and number of pads), symptom severity (Overactive Bladder Questionnaire-V8), quality of life (Incontinence Impact Questionnaire-7), treatment satisfaction, positive response, and cure-improvement rates.

RESULTS

A statistically significant improvement was found in all parameters for each group at the 6th week compared with the baseline values (p<0.05). It was found that the severity of incontinence, incontinence episodes, symptom severity, treatment satisfaction, and QoL parameters were significantly improved in PhA-naive group compared with the PhA-resistant group at the 6th week (p<0.05). There were no statistically significant differences in the frequency of voiding, nocturia, and number of pads between the two groups (p>0.05). Positive response rates, the primary outcome measure, were statistically significantly higher in the PhA-naive group than in the PhA-resistant group.

CONCLUSIONS

Although TTNS is more effective in PhA-naive women with iOAB, it appears to be an effective therapy that can also be used in the management of PhA-resistant women with iOAB.

Long-Term Outcome of Transcutaneous Posterior Tibial Nerve Stimulation in the Treatment of Functional Non-Retentive Fecal Incontinence in Children

BACKGROUND

Functional non-retentive fecal incontinence (FNRFI) is a psychologically upsetting and embarrassing issue and affects children's quality of life negatively.

AIM OF THIS STUDY

Evaluation of the short and long-term effect of Bilateral transcutaneous posterior tibial nerve stimulation (BTPTNS) in the treatment of FNRFI in children and its impact on the quality of life (QoL). Methodology: The current randomized controlled study included 94 Children with FNRFI who were randomly allocated into two equal groups. Group A received BTPTNS and Group B Received Sham BTPTNS. Follow-up was planned for 24 months for manometric findings, incontinence score, Incontinence episodes, and the QoL.

RESULTS

The incontinence score was significantly decreases in Group A more than what was reported in Group B at 6, 12, 24 months follow up . In group A 53.2% of the included children who received BTPTNS showed a decrease in the incontinence episodes more than 75% and among them, 23.4% were fully continent. All the QoL domains were significantly improved in Group A after 6, 12, and 24 months when compared with Group B.

CONCLUSION

BTPTNS can be a good modality in the treatment of FNRFI with favorable long-term maintenance of its effect together with a remarkable positive impact on all domains of QoL.

Cost consequence analysis of transcutaneous tibial nerve stimulation (TTNS) for urinary incontinence in care home residents alongside a randomised controlled trial

BACKGROUND

Urinary incontinence (UI) is prevalent in more than half of residents of nursing and residential care homes and can have a detrimental impact on dignity and quality of life. Care homes predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous tibial nerve stimulation (TTNS) is a non-invasive, safe, low-cost intervention with demonstrated effectiveness for reducing UI in adults. We examined the costs and consequences of delivering TTNS to care home residents in comparison to sham (inactive) electrical stimulation.

METHODS

A cost consequence analysis approach was used to assemble and present the resource use and outcome data for the ELECTRIC trial which randomised 406 residents with UI from 37 care homes in the United Kingdom to receive 12 sessions of 30 min of either TTNS or sham (inactive) TTNS. TTNS was administered by care home staff over 6 weeks. Health state utility was measured using DEMQOL-U and DEMQOL-PROXY-U at baseline, 6 weeks and 18 weeks follow-up. Staff completed a resource use questionnaire at baseline, 6 weeks and 18 weeks follow-up, which also assessed use of absorbent pads.

RESULTS

HRQoL did not change significantly in either randomised group. Delivery of TTNS was estimated to cost £81.20 per participant, plus training and support costs of £121.03 per staff member. 85% of participants needed toilet assistance as routine, on average requiring one or two staff members to be involved 4 or 5 times in each 24 h. Daily use of mobility aids and other assistive devices to use the toilet were reported. The value of staff time to assist residents to use the toilet (assuming an average of 5 min per resident per visit) was estimated as £19.17 (SD 13.22) for TTNS and £17.30 (SD 13.33) for sham (per resident in a 24-hour period).

CONCLUSIONS

Use of TTNS to treat UI in care home residents did not lead to changes in resource use, particularly any reduction in the use of absorbent pads and no cost benefits for TTNS were shown. Managing continence in care homes is labour intensive, requiring both high levels of staff time and use of equipment aids.

TRIAL REGISTRATION

ISRCTN98415244, registered 25/04/2018. NCT03248362 (Clinical trial.gov number), registered 14/08//2017.

Development of a Sham Protocol to Investigate Transcutaneous Tibial Nerve Stimulation in Randomised, Sham-Controlled, Double-Blind Clinical Trials

Transcutaneous tibial nerve stimulation (TTNS) is a promising treatment for neurogenic lower urinary tract symptoms. However, the evidence is limited due to a general lack of randomised controlled trials (RCTs) and, also, inconsistency in the sham and blinding conditions. In the context of much-needed RCTs, we aimed to develop a suitable sham-control protocol for a clinical setting to maintain blinding but avoid meaningful stimulation of the tibial nerve. Three potential electrode positions (lateral malleolus/5th metatarsal/plantar calcaneus) and two electrode sizes (diameter: 2.5 cm/3.2 cm) were tested to determine which combination provided the optimal sham configuration for a TTNS approach, based on a visible motor response. Sixteen healthy volunteers underwent sensory and motor assessments for each sham configuration. Eight out of them came back for an extra TTNS visit. Sensory thresholds were present for all sham configurations, with linear regression models revealing a significant effect regarding electrode position (highest at plantar calcaneus) but not size. In addition, motor thresholds varied with the position-lowest for the 5th metatarsal. Only using this position and 3.2 cm electrodes attained a 100% response rate. Compared to TTNS, sensory and motor thresholds were generally higher for the sham configurations; meanwhile, perceived pain was only higher at the lateral malleolus. In conclusion, using the 5th metatarsal position and 3.2 cm electrodes proved to be the most suitable sham configuration. Implemented as a four-electrode setup with standardized procedures, this appears to be a suitable RCT protocol for maintaining blinding and controlling for nonspecific TTNS effects in a clinical setting.

Transcutaneous medial plantar nerve stimulation in women with idiopathic overactive bladder

PURPOSE

To define transcutaneous medial plantar nerve stimulation (T-MPNS) as a new neuromodulation method and assess the efficacy of T-MPNS on quality of life (QoL) and clinical parameters associated with incontinence in women with idiopathic overactive bladder (OAB).

MATERIALS AND METHODS

Twenty-one women were included in this study. All women received T-MPNS. Two self-adhesive surface electrodes were positioned with the negative electrode near the metatarsal-phalangeal joint of the great toe on the medial aspect of the foot and the positive electrode 2 cm inferior-posterior of the medial malleolus (in front of the medio-malleolar-calcaneal axis). T-MPNS was performed 2 days a week, 30 minutes a day, for a total of 12 sessions for 6 weeks. Women were evaluated for incontinence severity (24-h pad test), 3-day voiding diary, symptom severity (Overactive Bladder Questionnaire [OAB-V8]), QoL (Quality of Life-Incontinence Impact Questionnaire [IIQ-7]), positive response and cure-improvement rates, and treatment satisfaction at baseline and at the 6th week.

RESULTS

Statistically significant improvement was found in the severity of incontinence, frequency of voiding, incontinence episodes, nocturia, number of pads, symptom severity, and QoL parameters at the 6th week compared with baseline. Treatment satisfaction, treatment success, and cure or improvement rates were found to be high at the 6th week.

CONCLUSIONS

T-MPNS was first described in the literature as a new neuromodulation method. We conclude that T-MPNS is effective on both clinical parameters and QoL associated with incontinence in women with idiopathic OAB. Randomized controlled multicenter studies are needed to validate the effectiveness of T-MPNS.

Efficacy of Posterior Tibial Nerve Stimulation in the Treatment of Fecal Incontinence: A Systematic Review

Fecal incontinence is a condition that carries high social stigmatization and a determining factor in the quality of life of the person who suffers from it. Its etiology is multifactorial and treatment includes surgical and conservative measures, including stimulation of the posterior tibial nerve. The aim of this review is to determine whether posterior tibial nerve stimulation (PTNS) is more effective than other treatments in reducing episodes of fecal incontinence in adults. A systematic review of randomized clinical trials that analyzed different approaches and comparisons with other treatments in adults without neurological or metabolic diseases was carried out, analyzing, fundamentally, the reduction of episodes of fecal incontinence. In general, a reduction in fecal incontinence episodes is observed in the experimental groups compared with the control groups, although these differences are not significant in most studies. The results regarding the effectiveness of PTNS in reducing episodes of fecal incontinence compared to other treatments are not entirely conclusive, although benefits are observed regarding the stimulation of sacral roots. More well-designed studies with a long-term follow-up of the results are needed so that the recommendation of this treatment can be generalized.

Home-based transcutaneous tibial nerve stimulation for overactive bladder syndrome: a randomized, controlled study

Purpose

Transcutaneous posterior tibial nerve stimulation (TPTNS) for the treatment of overactive bladder syndrome (OAB), with or without urge urinary incontinence (UUI) using electrodes imbedded in the fabric of a conventional sock and an attachable battery-operated stimulation device (ZIDA^®—Exodus Innovations, Sufa, Israel), was compared for effectiveness and safety to a sham procedure in a prospective, blinded, randomized, controlled trial.

Methods

Forty patients with diagnosed with OAB were recruited from a single site. There were two groups: a treatment group (21 patients, mean age 64), which used an active ZIDA^® activation device (ZIDA) and a sham control group (SCG, 19 patients, mean age 72) randomized in a 1:1 ratio. After individual fitting of the sock and face-to-face instruction in the use of the device, patients in both groups self-administered the treatment once weekly for 30 min at home for a duration of 12 weeks. Prior to randomization and in Week 12, patients completed two 3-day bladder diaries and a quality-of-life (QOL) survey. Treatment success was defined as at least a 50% reduction in urgency voids with or without incontinence or at least a 30% reduction in 24-h frequency from baseline to Week 12. The key secondary endpoint was change in QOL from baseline to Week 12.

Results

The success rate for the primary endpoint in the ZIDA group was 80% (n = 16/20) versus 39% (n = 7/18) in the SCG (p = 0.02). For QOL, the least squares mean difference in change from baseline to Week 12 between the ZIDA and sham control arms total score was − 12.7 (95% CI − 20.2 to − 5.1). No significant adverse effects were observed.

Conclusion

TPTNS using the ZIDA home-based stimulation device offers a safe and effective treatment for patients with OAB syndrome and improves QOL.

Trial regestration

TRN: NCT04470765.

Pelvic floor rehabilitation in the treatment of mixed urinary incontinence among women

Background

Mixed urinary incontinence (MUI) is a common underreported problem among females; it has a major effect on patients’ quality of life. Treatment may be difficult since a single modality cannot be enough to alleviate both the urge and the stress symptoms. Biofeedback-assisted pelvic floor muscle training (PFMT) has a great role in strengthening the pelvic floor muscles especially when accompanied by electrical stimulation. Neuromodulation is another safe well-tolerated method that may improve symptoms of female voiding dysfunction. There are no previous studies that assessed the efficacy of biofeedback-assisted pelvic floor muscle training versus two different types of peripheral neuromodulation which are transcutaneous posterior tibial nerve stimulation (TPTNS) and anogenital neuromodulation in the treatment of mixed urinary incontinence among women. The aim of this work is to study the effectiveness of biofeedback-assisted pelvic floor muscle training with electrostimulation versus two different methods of peripheral neuromodulation techniques in the treatment of women with MUI. Patients were subjected to history taking, assessment questionnaires (Questionnaire for female Urinary Incontinence Diagnosis (QUID), Australian Pelvic Floor Questionnaire (PFQ), and International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF)), clinical examination, and manometric pressure assessment. The patients were allocated randomly into three groups. Group I received biofeedback-assisted pelvic floor muscle training and faradic electrical stimulation, group II received posterior tibial neuromodulation, and group III received anogenital neuromodulation.

Results

The present study included 68 non-virgin female patients with mixed urinary incontinence. Significant improvement was noticed in the three studied groups on the subjective and objective levels. No statistically significant difference was reported between the studied groups following the different types of intervention.

Conclusions

Biofeedback-assisted pelvic floor muscle training with electrostimulation is as effective as anogenital neuromodulation and posterior tibial neuromodulation in the treatment of mixed urinary incontinence among females.

Trial registration

PACTR, PACTR202107816829078. Registered 29 July 2021 - Retrospectively registered.

Real-life patient experiences of TTNS in the treatment of overactive bladder syndrome

Introduction and objectives:

Overactive bladder syndrome (OAB) is defined as urinary urgency, with or without urgent urinary incontinence; it is often associated with urinary frequency and nocturia, in the absence of any pathological or metabolic conditions that may cause or mimic OAB. The aim of this study was to evaluate the long-term real-life adherence of transcutaneous tibial nerve stimulation (TTNS) in the treatment of OAB, patient satisfaction of the treatment, and reasons for quitting therapy.

Materials and methods:

In this single center study, all patients who had a positive effect on percutaneous tibial nerve stimulation (PTNS) and continued to receive home-based treatment with TTNS since 2012 were included for analysis. Patients were retrospectively asked to fill out a questionnaire regarding satisfaction, reasons for quitting, and additional or next line of therapy.

Results:

We included 42 patients for this study, 81% of these patients were female (n = 34). The median age was 67 years (range 36–86). Most of the patients (64%, n = 27) were diagnosed with OAB wet. The median TTNS treatment persistence was 16 months (range 1–112 months). Reasons and percentages for stopping therapy were: 55% stopped treatment due to loss of effect, and 24% stopped because of preferring other type of neuromodulation. The mean satisfaction score (scale 1–10) in patients who continued TTNS was 6.2 (n = 9, SD 1.30) versus 5.4 (n = 29, SD 2.24) for patients who quit therapy. We did not find a statistically significant difference between the two groups (p = 0.174).

Conclusion:

TTNS, although effective in the short-term, is not effective in the long-term. In combination with a low satisfaction rate among patients, there is a need for improvement in terms of OAB treatment modalities.

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.

Do we need more patient-friendly treatment options for overactive bladder (OAB)?

Aims

To collect feedback from subjects diagnosed with overactive bladder (OAB) on its impact on their quality of life, their satisfaction with current treatment options, and to assess nonsurgical, tibial nerve stimulation as a treatment option.

Methods

Subjects were asked a variety of questions about the impact of OAB on their lives, their satisfaction with current and previous treatment approaches. Subjects evaluated the comfort of a nonworking prototype garment and were given electrical stimulation over their posterior tibial nerve to assess comfort and tolerability. Electromyographic (EMG) signals were recorded.

Results

A total of 40 subjects with OAB symptoms were evaluated in the study. Urgency (55%), frequency (47.5%), nocturia (40%), and incontinence (30%) were the most bothersome symptoms. At the time of the study only 32.5% of the subjects were treating their OAB symptoms. Of those that had tried and discontinued treatments, most had failed medications (n = 14) due to no improvements or side effects. Only 2 subjects found stimulation to be uncomfortable before an EMG signal could be detected. The most common word used to describe the feeling of stimulation was “constant,” followed by “tingling,” “vibrating,” and “comfortable.”

Conclusions

Most subjects who had tried OAB treatments were dissatisfied and discontinued their use. A new patient‐friendly approach to OAB therapy that delivers efficacy but overcomes drawbacks associated with currently available treatments is needed. Subjects found electrical stimulation over the tibial nerve to be comfortable and tolerable and this should be considered as an alternative treatment approach for OAB.

Tibial nerve stimulation compared with sham to reduce incontinence in care home residents: ELECTRIC RCT

BACKGROUND

Urinary incontinence is prevalent in nursing and residential care homes, and has a profound impact on residents' dignity and quality of life. Treatment options are limited in these care contexts and care homes predominantly use absorbent pads to contain incontinence, rather than actively treat it. Transcutaneous posterior tibial nerve stimulation is a non-invasive, safe, low-cost intervention that is effective in reducing urinary incontinence in adults.

OBJECTIVE

To determine the clinical effectiveness of transcutaneous posterior tibial nerve stimulation to treat urinary incontinence in care home residents and to determine the associated costs of the treatment.

DESIGN

A multicentre, pragmatic, participant and outcome assessor-blind, randomised placebo-controlled trial.

SETTING

A total of 37 UK residential and nursing care homes.

PARTICIPANTS

Care home residents with at least weekly urinary incontinence that is contained using absorbent pads and who are able to use a toilet/toilet aid with or without assistance.

INTERVENTIONS

Residents were randomised (1 : 1) to receive 12 30-minute sessions of transcutaneous posterior tibial nerve stimulation or sham stimulation over a 6-week period.

MAIN OUTCOME MEASURES

Primary outcome - change in volume of urine leaked over a 24-hour period at 6 weeks. Secondary outcomes - number of pads used, Perception of Bladder Condition, toileting skills, quality of life and resource use.

RESULTS

A total of 408 residents were randomised (transcutaneous posterior tibial nerve stimulation, n = 197; sham stimulation, n = 209); two exclusions occurred post randomisation. Primary outcome data were available for 345 (85%) residents (transcutaneous posterior tibial nerve stimulation, n = 167; sham stimulation, n = 178). Adherence to the intervention protocol was as follows: 78% of the transcutaneous posterior tibial nerve stimulation group and 71% of the sham group received the correct stimulation. Primary intention-to-treat adjusted analysis indicated a mean change of -5 ml (standard deviation 362 ml) urine leakage from baseline in the transcutaneous posterior tibial nerve stimulation group and -66 ml (standard deviation 394 ml) urine leakage in the sham group, which was a statistically significant, but not clinically important, between-group difference of 68-ml urine leakage (95% confidence interval 0 to 136 ml; p = 0.05) in favour of the sham group. Sensitivity analysis supported the primary analysis. No meaningful differences were detected in any of the secondary outcomes. No serious adverse events related to transcutaneous posterior tibial nerve stimulation were reported. Economic evaluation assessed the resources used. The training and support costs for the staff to deliver the intervention were estimated at £121.03 per staff member. Estimated costs for delivery of transcutaneous posterior tibial nerve stimulation during the trial were £81.20 per participant. No significant difference was found between participants' scores over time, or between transcutaneous posterior tibial nerve stimulation and sham groups at any time point, for resident or proxy quality-of-life measures.

CONCLUSIONS

The ELECTRIC (ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes) trial showed, in the care home context (with a high proportion of residents with poor cognitive capacity and limited independent mobility), that transcutaneous posterior tibial nerve stimulation was not effective in reducing urinary incontinence. No economic case for transcutaneous posterior tibial nerve stimulation was made by the cost-consequences analysis; however, the positive reception of learning about urinary incontinence for care home staff supports a case for routine education in this care context.

LIMITATIONS

Completing 24-hour pad collections was challenging for care home staff, resulting in some missing primary outcome data.

FUTURE WORK

Research should investigate transcutaneous posterior tibial nerve stimulation in residents with urgency urinary incontinence to determine whether or not targeted stimulation is effective. Research should evaluate the effects of continence training for staff on continence care in care homes.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98415244 and ClinicalTrials.gov NCT03248362.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 41. See the NIHR Journals Library website for further project information.

Randomised Crossover-Controlled Evaluation of Simultaneous-Bilateral Transcutaneous Electrostimulation of the Posterior Tibial Nerve During Urodynamic Studies on Patients With Lower Urinary Tract Symptoms

Purpose

Transcutaneous tibial nerve stimulation (TTNS) has proven to be a valuable treatment option for various lower urinary tract conditions, such as overactive bladder syndrome and neurogenic detrusor overactivity. The aim of this study was to investigate acute changes in urodynamic parameters due to bilateral TTNS.

Methods

Fifty-one patients (18–87 years; 61% female) with various lower urinary tract symptoms were enrolled in this study. They were single-blinded and randomly assigned to receive simultaneous bilateral TTNS either during their first urodynamic examination, followed by a second round using a placebo stimulation technique, or vice versa.

Results

For subjects without signs of anatomical pathologies, the filling volume at the first desire to void (FDV) increased significantly by 54 mL (interquartile range [IQR], 26–81 mL; P<0.01) under the influence of TTNS compared to placebo. The maximum cystometric capacity increased by 41 mL (IQR, 10–65 mL; P=0.02). The median micturition volume of patients with pathological postvoid residual volumes (>100 mL) increased by 76 mL compared to patients without urinary retention (IQR, 6–166 mL; P=0.03).

Conclusions

Compared to placebo, simultaneous bilateral TTNS showed significant improvements in bladder functioning, such as delayed FDV, increased maximum cystometric capacity, and reduced urinary retention. Patients with signs of anatomical pathologies did not seem to benefit from TTNS. Further studies need to be conducted to compare the effectiveness of bilateral versus unilateral TTNS.

Efficacy of percutaneous and transcutaneous tibial nerve stimulation in women with idiopathic overactive bladder: A prospective randomised controlled trial

BACKGROUND

Different studies have reported the efficacy of percutaneous tibial nerve stimulation (PTNS) and transcutaneous tibial nerve stimulation (TTNS) in treating idiopathic overactive bladder (OAB). However, no study has compared the effectiveness of PTNS and TTNS added to bladder training (BT) in idiopathic OAB.

OBJECTIVE

To compare the efficacy of PTNS and TTNS added to BT in women with idiopathic OAB.

METHODS

We randomised 60 women with idiopathic OAB into 3 groups. Group 1 (n=19) received BT, Group 2 (n=19) received PTNS in addition to BT, and Group 3 (n=20) received TTNS in addition to BT. PTNS and TTNS were performed 2 days a week, for 30 min a day, for a total of 12 sessions for 6 weeks. Patients were evaluated by incontinence severity (pad test), a 3-day voiding diary (frequency of voiding, incontinence episodes, nocturia and number of pads used), symptom severity, quality of life, treatment success (positive response rate), treatment satisfaction (Likert scale), discomfort level and preparation time for stimulation (sec).

RESULTS

At the end of treatment; severity of incontinence, frequency of voiding, incontinence episodes, nocturia, number of pads used, symptom severity and quality of life were significantly improved in Groups 2 and 3 versus Group 1 (p<0.0167). Treatment success and treatment satisfaction were higher in Groups 2 and 3 than Group 1 (p<0.001 and p<0.0167, respectively). Level of discomfort was lower, treatment satisfaction was higher and preparation time for stimulation was shorter in Group 3 than Group 2 (p<0.05).

CONCLUSION

Both the PTNS plus BT and TTNS plus BT were more effective than BT alone in women with idiopathic OAB. These 2 tibial nerve stimulation methods had similar clinical efficacy but with slight differences: TTNS had shorter preparation time, less discomfort level and higher patient satisfaction than PTNS.

Effectiveness of percutaneous posterior tibial nerve stimulation for the management of bowel dysfunction in multiple sclerosis patients

BACKGROUND

Neurogenic bowel dysfunctions (NBDs) in the form of both fecal incontinence (FI) and functional constipation (FC) are frequent in multiple sclerosis (MS) patients and significantly affect their quality of life. Therapeutic options are limited.

OBJECTIVE

To investigate effectiveness of percutaneous posterior tibial nerve stimulation (PTNS) in MS patients suffering from FI and FC.

METHODS

Prevalence and severity of FI and FC were prospectively collected among MS patients undergoing 12 weeks of PTNS for neurogenic bladder. The Cleveland Clinic Fecal Incontinence Score (CCFIS) and the Rome III criteria were used to define FI and FC, respectively. Subjective treatment satisfaction was estimated using the Benefit Satisfaction and Willingness to Continue (BSWC) questionnaire.

RESULTS

A total of 60 patients undergoing PTNS suffered from NBDs (25 FI+/FC+, 5 FI+/FC-, 30 FI-/FC+). Median CCFIS decreased after PTNS from 12.0 (11.0-13.0) to 8.5 (7.0-11.0, p < 0.001), with particular improvements in liquid and flatal incontinence, pads' need, and lifestyle restrictions. Seven patients became FC free after PTNS and no patients developed FC during the study (p = 0.023). More than 50% of the patients were satisfied and willing to continue PTNS at study end.

CONCLUSION

PTNS represents a valid minimally invasive alternative treatment for MS patients suffering from NBDs.

The role of tibial nerve stimulation for enhanced postoperative recovery after colorectal surgery: a double-blind, parallel-group, randomized controlled trial

BACKGROUND

Postoperative ileus (POI) is the most common cause of prolonged hospital stay following abdominal surgery, despite an optimized enhanced recovery after surgery (ERAS) program. The aim of the study was to evaluate the role of postoperative transcutaneous electrical tibial nerve stimulation (TTNS) in the recovery of bowel function and in shortening hospital stay after colonic resection.

METHODS

Patients having elective laparoscopic colonic surgery within an ERAS program at our institution between June 2016 and June 2019 were enrolled and randomly assigned to a treatment protocol with TTNS or sham electrical stimulation. The primary endpoint was the time of recovery of gastrointestinal motility, measured as the first passage of stool. Secondary endpoints included: first passage of flatus, length of hospital stay, and complication rate related to the use of TTNS.

RESULTS

One hundred and seventy patients who had right hemicolectomy (median age 71 years (range 43-89 years); 47.5% women) and 170 patients who had left colectomy (median age 67 years range (37-92 years); 41.5% women) were enrolled. The only factor significantly affected by TTNS was time to first passage of flatus after right hemicolectomy (reduced from 46 to 33 h, p = 0.04). However, if only patients with low compliance to early oral nutrition (63 of 340; 18.5%) were considered, a statistically significant difference in time until first flatus (p < 0.01) and first bowel movement (p < 0.0001) and a shorter time until discharge (median 5 vs 7 days) were found in both left and right colectomies groups, respectively.

CONCLUSIONS

TTNS may have a positive effect on gastrointestinal tract motility and recovery from POI after colorectal surgery in a selected group, who has low compliance with an ERAS program, without increasing the risk of complications.

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review

BACKGROUND

Fecal incontinence is a disabling condition affecting up to 20% of women.

OBJECTIVE

We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials.

METHODS

We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019.

RESULTS

In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies.

CONCLUSION

Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

Effectiveness of transcutaneous tibial nerve stimulation at two different thresholds for overactive bladder symptoms in older women: a randomized controlled clinical trial

OBJECTIVES

To compare the effectiveness of transcutaneous tibial nerve stimulation (TTNS) at two different current amplitude thresholds (sensory and motor) in terms of urinary habit, symptoms and the degree of discomfort of overactive bladder (OAB) in older women.

STUDY DESIGN

This is a randomized, controlled, 3-arm blinded trial. One hundred and one patients attending secondary care with OAB were randomized into one of three groups: group 1, TTNS sensitivity threshold (n = 39); group 2, TTNS motor threshold (n = 33); and control group 3 (n = 29).

MAIN OUTCOME MEASURES

Participants allocated to groups 1 and 2 had 8 sessions of TTNS for 30 min, twice a week. Group 3 received no intervention. The results measured were the symptoms of overactive bladder (ICIQ-OAB, overall score), bother scales (to indicate the impact of individual symptoms for the patient) and urinary habit (3-day bladder diary). A blind assessor measured outcomes at baseline and 5 weeks after randomization.

RESULTS

After five weeks, a statistically significant difference between group 3 (control) and group 1 (TTNS sensitivity threshold) and group 2 (TTNS motor threshold) was observed in the intergroup analysis, but no difference in the outcomes analyzed was detected between the two groups receiving intervention (groups 1 and 2).

CONCLUSION

TTNS is effective in the treatment of OAB in older women, with no difference between the sensitivity and motor thresholds.

CLINICAL TRIAL REGISTRATION NUMBER

Registro Brasileiros de Ensaios Clínicos (RBR-39DZ5V).

Stimulation of the tibial nerve: a protocol for a multicentred randomised controlled trial for urinary problems associated with Parkinson's disease-STARTUP

INTRODUCTION

Parkinson's disease is the second most common chronic neurodegenerative condition with bladder dysfunction affecting up to 71%. Symptoms affect quality of life and include urgency, frequency, hesitancy, nocturia and incontinence. Addressing urinary dysfunction is one of the top 10 priority research areas identified by the James Lind Alliance and Parkinson's UK.

OBJECTIVES

Conduct a randomised controlled trial (RCT) targeting people with Parkinson's disease (PwP) who have self-reported problematic lower urinary tract symptoms, investigating the effectiveness of transcutaneous tibial nerve stimulation (TTNS) compared with sham TTNS. Implement a standardised training approach and package for the correct application of TTNS. Conduct a cost-effectiveness analysis of TTNS compared with sham TTNS.

METHODS AND ANALYSIS

An RCT of 6 weeks with twice weekly TTNS or sham TTNS. Participants will be recruited in 12 National Health Service neurology/movement disorder services, using a web-based randomisation system, and will be shown how to apply TTNS or sham TTNS. Participants will receive a weekly telephone call from the researchers during the intervention period. The trial has two coprimary outcome measures: International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and the International Prostate Symptom Score. Secondary outcomes include a 3-day bladder diary, quality of life, acceptability and fidelity and health economic evaluation. Outcomes will be measured at 0, 6 and 12 weeks.A sample size of 208 randomised in equal numbers to the two arms will provide 90% power to detect a clinically important difference of 2.52 points on the Internatioanl Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) and of 3 points in the International Prostate Symptom Score total score at 12 weeks at 5% significance level, based on an SD of 4.7 in each arm and 20% attrition at 6 weeks. Analysis will be by intention to treat and pre defined in a statistical analysis plan ETHICS AND DISSEMINATION: East of Scotland Research Ethics Service (EoSRES), 18/ES00042, obtained on 10 May 2018. The trial will allow us to determine effectiveness, safety, cost and acceptability of TTNS for bladder dysfunction in PWP. Results will be published in open access journals; lay reports will be posted to all participants and presented at conferences.

TRIAL REGISTRATION NUMBER

ISRCTN12437878; Pre-results.

ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes: protocol for the ELECTRIC randomised trial

BACKGROUND

Urinary incontinence (UI) is highly prevalent in nursing and residential care homes (CHs) and profoundly impacts on residents' dignity and quality of life. CHs predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous posterior tibial nerve stimulation (TPTNS) is a non-invasive, safe and low-cost intervention with demonstrated effectiveness for reducing UI in adults. However, the effectiveness of TPTNS to treat UI in older adults living in CHs is not known. The ELECTRIC trial aims to establish if a programme of TPTNS is a clinically effective treatment for UI in CH residents and investigate the associated costs and consequences.

METHODS

This is a pragmatic, multicentre, placebo-controlled, randomised parallel-group trial comparing the effectiveness of TPTNS (target n = 250) with sham stimulation (target n = 250) in reducing volume of UI in CH residents. CH residents (men and women) with self- or staff-reported UI of more than once per week are eligible to take part, including those with cognitive impairment. Outcomes will be measured at 6, 12 and 18 weeks post randomisation using the following measures: 24-h Pad Weight Tests, post void residual urine (bladder scans), Patient Perception of Bladder Condition, Minnesota Toileting Skills Questionnaire and Dementia Quality of Life. Economic evaluation based on a bespoke Resource Use Questionnaire will assess the costs of providing a programme of TPTNS. A concurrent process evaluation will investigate fidelity to the intervention and influencing factors, and qualitative interviews will explore the experiences of TPTNS from the perspective of CH residents, family members, CH staff and managers.

DISCUSSION

TPTNS is a non-invasive intervention that has demonstrated effectiveness in reducing UI in adults. The ELECTRIC trial will involve CH staff delivering TPTNS to residents and establish whether TPTNS is more effective than sham stimulation for reducing the volume of UI in CH residents. Should TPTNS be shown to be an effective and acceptable treatment for UI in older adults in CHs, it will provide a safe, low-cost and dignified alternative to the current standard approach of containment and medication.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03248362. Registered on 14 August 2017. ISRCTN, ISRCTN98415244. Registered on 25 April 2018. https://www.isrctn.com/.

NOC/NIC Linkages to NANDA-I for Continence Care of Elderly People with Urinary Incontinence in Nursing Homes: A Systematic Review

Aim

The aim of this study was to review interventional studies conducted by nurses about elderly people with urinary incontinence in nursing homes and to match the results to standardized nursing terminology using the Nursing Interventions Classification and the Nursing Outcomes Classification Linkages to the NANDA-I diagnoses guidelines.

Method

A systematic review of quantitative intervention studies was conducted using the PRISMA statement as a guide. The interventional research in English was scanned using the MEDLINE and CINAHL databases from January 2005 to May 2015. Fourteen studies that had at least one nurse researcher were conducted in nursing homes, excluding surgical and pharmacological interventions. The Nursing Outcome Classification and Nursing Intervention Classification Linkages to NANDA-I diagnoses and the Clinical Conditions Part II-U List were used as a guide to select North American Nursing Diagnosis Association International nursing diagnoses, Nursing Outcome Classification Scales, and Nursing Interventions from the data.

Results

We found the frequency of use of various NANDA-I diagnoses, Nursing Interventions, and Nursing Outcomes based on the Nursing Outcomes Classification and Nursing Interventions Classification Linkages to NANDA-I diagnoses and the Clinical Conditions List for incontinence.

Conclusion

Using the Nursing Outcomes Classification and Nursing Interventions Classification Linkages to NANDA-I diagnoses guide may provide new nursing perspectives on non-standardized research. In future studies, this may allow a comparison of data worldwide, enabling nurses to use the results in evidence-based practices.

A systematic review and network meta-analysis comparing treatments for faecal incontinence

BACKGROUND

Although numerous treatments exist for fecal incontinence (FI), no consensus exists on the best treatment strategy. The aim was to review the literature and to compare the clinical outcomes and effectiveness of treatments available for FI.

MATERIALS AND METHOD

A systematic literature review was performed, from inception to May 2018, of the following databases: MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Library. The search terms used were "faecal incontinence" and "treatment". Only randomized controlled trials (RCTs) comparing treatments for FI were considered. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method.

RESULT

Forty-seven RCTs were included comparing 37 treatments and reporting on 3748 participants. No treatment ranked best or worst with high probability for any outcome of interest. No significant difference was identified between treatments for frequency of FI per week, or in changing the resting pressure, maximum resting pressure, squeeze pressure, and maximum squeeze pressure. Radiofrequency resulted in more adverse events compared to placebo. Sacral nerve stimulation (SNS) and zinc-aluminium improved the fecal incontinence quality of life questionnaire (FIQL) lifestyle, coping, and embarrassment domains compared to placebo. Transcutaneous posterior tibial nerve stimulation (TPTNS) improved the FIQL embarrassment domain compared to placebo. Autologous myoblasts and zinc-aluminium improved the FIQL depression domain compared to placebo. SNS, artificial bowel sphincter (ABS), and zinc-aluminium significantly improved incontinence scores compared to placebo. Injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA/Dx) resulted in more patients with ≥50% reduction in FI episodes compared to placebo.

CONCLUSION

SNS, ABS, TPTNS, NASHA/Dx, zinc-aluminium, and autologous myoblasts resulted in isolated improvements in specific outcomes of interest. No difference was identified in incontinence episodes, no treatment ranked best persistently or persistently improved outcomes, and many included treatments did not significantly benefit patients compared to placebo. Large multicentre RCTs with long-term follow-up and standardized inclusion criteria and outcome measures are needed.

A Comprehensive Review of Overactive Bladder Pathophysiology: On the Way to Tailored Treatment

CONTEXT

Current literature suggests that several pathophysiological factors and mechanisms might be responsible for the nonspecific symptom complex of overactive bladder (OAB).

OBJECTIVE

To provide a comprehensive analysis of the potential pathophysiology underlying detrusor overactivity (DO) and OAB.

EVIDENCE ACQUISITION

A PubMed-based literature search was conducted in April 2018, to identify randomised controlled trials, prospective and retrospective series, animal model studies, and reviews.

EVIDENCE SYNTHESIS

OAB is a nonspecific storage symptom complex with poorly defined pathophysiology. OAB was historically thought to be caused by DO, which was either "myogenic" (urgency initiated from autonomous contraction of the detrusor muscle) or "neurogenic" (urgency signalled from the central nervous system, which initiates a detrusor contraction). Patients with OAB are often found to not have objective evidence of DO on urodynamic studies; therefore, alternative mechanisms for the development of OAB have been postulated. Increasing evidence on the role of urothelium/suburothelium and bladder afferent signalling arose in the early 2000s, emphasising an afferent "urotheliogenic" hypothesis, namely, that urgency is initiated from the urothelium/suburothelium. The urethra has also recently been regarded as a possible afferent origin of OAB-the "urethrogenic" hypothesis. Several other pathophysiological factors have been implicated, including metabolic syndrome, affective disorders, sex hormone deficiency, urinary microbiota, gastrointestinal functional disorders, and subclinical autonomic nervous system dysfunctions. These various possible mechanisms should be considered as contributing to diagnostic and treatment algorithms.

CONCLUSIONS

There is a temptation to label OAB as "idiopathic" without obvious causation, given the poorly understood nature of its pathophysiology. OAB should be seen as a complex, multifactorial symptom syndrome, resulting from multiple potential pathophysiological mechanisms. Identification of the underlying causes on an individual basis may lead to the definition of OAB phenotypes, paving the way for personalised medical care.

PATIENT SUMMARY

Overactive bladder (OAB) is a storage symptom syndrome with multiple possible causes. Identification of the mechanisms causing a patient to experience OAB symptoms may help tailor treatment to individual patients and improve outcomes.

A systematic review of the literature reporting on randomised controlled trials comparing treatments for faecal incontinence in adults

AIM

To perform a review of the literature reporting on randomised controlled trials (RCTs) comparing treatments for faecal incontinence (FI) in adults.

METHODS

A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify RCTs reporting on treatments for FI.

RESULTS

The review included 60 RCTs reporting on 4838 patients with a mean age ranging from 36.8 to 88 years. From the included RCTs, 32 did not identify a significant difference between the treatments compared. Contradictory results were identified in RCTs comparing percutaneous posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation versus sham stimulation, biofeedback-pelvic floor muscle training (BF-PFMT) versus PFMT, and between bulking agents such as PTQ^TM versus Durasphere^®. In two separate RCTs, combination treatment of amplitude-modulated medium frequency stimulation and electromyography-biofeedback (EMG-BF), was noted to be superior to EMG-BF and low-frequency electrical stimulation alone. Combination of non-surgical treatments such as BF with sphincteroplasty significantly improved continence scores compared to sphincteroplasty alone. Surgical treatments were associated with higher rates of serious adverse events compared to non-surgical interventions.

CONCLUSIONS

The current evidence has not identified significant differences between treatments for FI, and where differences were identified, the results were contradictory between RCTs.

Transcutaneous Electrical Nerve Stimulation to Improve Female Sexual Dysfunction Symptoms: A Pilot Study

OBJECTIVES

To perform a pilot study using transcutaneous electrical nerve stimulation (TENS) on the dorsal genital nerve and the posterior tibial nerve for improving symptoms of female sexual dysfunction (FSD) in women without bladder problems. We hypothesize that this therapy will be effective at improving genital arousal deficits.

MATERIALS AND METHODS

Nine women with general FSD completed the study. Subjects received 12 sessions of transcutaneous dorsal genital nerve stimulation (DGNS; n = 6) or posterior tibial nerve stimulation (PTNS; n = 3). Stimulation was delivered for 30 min at 20 Hz. Sexual functioning was evaluated with the female sexual functioning index (FSFI), and surveys were also given on general health, urological functioning, and the Patients' Global Impression of Change (PGIC) after treatment. Surveys were given before treatment (baseline), after 6 and 12 weeks of treatment, and 6 weeks after the completion of stimulation sessions.

RESULTS

The average total FSFI score across all subjects significantly increased from 15.3 ± 4.8 at baseline to 20.3 ± 7.8 after six sessions, 21.7 ± 7.5 after 12 sessions, and 21.3 ± 7.1 at study completion (p < 0.05 for all time points). Increases were observed in both DGNS and PTNS subjects. Significant FSFI increases were seen in the subdomains of lubrication, arousal, and orgasm, each of which is related to genital arousal. Bladder and general health surveys did not change across the study. PGIC had a significant increase.

CONCLUSIONS

This study provides evidence that transcutaneous stimulation of peripheral nerves has the potential to be a valuable therapeutic tool for women with FSD.

Managing Faecal INcontinence in people with advanced dementia resident in Care Homes (FINCH) study: a realist synthesis of the evidence

BACKGROUND

Eighty per cent of care home residents in the UK are living with dementia. The prevalence of faecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes.

OBJECTIVE

To provide a theory-driven explanation of the effectiveness of programmes that aim to improve FI in people with advanced dementia in care homes.

DESIGN

A realist synthesis. This was an iterative approach that involved scoping of the literature and consultation with five stakeholder groups, a systematic search and analysis of published and unpublished evidence, and a validation of programme theories with relevant stakeholders.

DATA SOURCES

The databases searched included PubMed, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, SocAbs, Applied Social Sciences Index and Abstracts, BiblioMap, Sirius, OpenGrey, Social Care Online and the National Research Register.

RESULTS

The scoping identified six programme theories with related context-mechanism-outcome configurations for testing. These addressed (1) clinician-led support, assessment and review, (2) the contribution of teaching and support for care home staff on how to reduce and manage FI, (3) the causes and prevention of constipation, (4) how the cognitive and physical capacity of the resident affect outcomes, (5) how the potential for recovery, reduction and management of FI is understood by those involved and (6) how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Data extraction was completed on 62 core papers with iterative searches of linked literature. Dementia was a known risk factor for FI, but its affect on the uptake of different interventions and the dementia-specific continence and toileting skills staff required was not addressed. Most care home residents with FI will be doubly incontinent and, therefore, there is limited value in focusing solely on FI or on single causes of FI such as constipation. Clinical assessment, knowledge of the causes of FI and strategies that recognise the individuals' preferences are necessary contextual factors. Valuing the intimate and personal care work that care home staff provide to people living with dementia and addressing the dementia-related challenges when providing continence care within the daily work routines are key to helping to reduce and manage FI in this population.

LIMITATIONS

The synthesis was constrained by limited evidence specific to FI and people with dementia in care homes and by the lack of dementia-specific evidence on continence aids.

CONCLUSIONS

This realist synthesis provides a theory-driven understanding of the conditions under which improvement in care for care home residents living with dementia and FI is likely to be successful.

FUTURE WORK

Future multicomponent interventions need to take account of how the presence of dementia affects the behaviours and choices of those delivering and receiving continence care within a care home environment.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014009902.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Efficacy and satisfaction with transcutaneous electrostimulation of the posterior tibial nerve in overactive bladder syndrome

Objective:

Overactive bladder is a disease with a high prevalence. The management is difficult, because different demographic, social or economic aspects converge. Our objective was to evaluate the efficacy and satisfaction in patients with overactive bladder treated with transcutaneous electrostimulation of the posterior tibial nerve.

Methods:

This was a prospective and descriptive study of 45 patients with overactive bladder (with or without detrusor overactivity) resistant to pharmacological treatment. Patients received a weekly session for 12 weeks, with a duration of 30 minutes for each of the sessions. There was a screening after 12 sessions, after which if there had been no response, treatment was suspended and maintenance sessions were not continued (six twice-monthly sessions and three monthly sessions). It was considered that the treatment had been effective when it was possible to decrease the number of events, except the maximum voiding volume, the objective of which was to increase. The results were evaluated using a 3-day voiding diary, an overactive bladder short form questionnaire and a satisfaction level questionnaire. Statistical analysis was performed using IBM SPSS Statistics version 19.0. Independent variables with a normal distribution were examined using the t-test. The Wilcoxon signed-rank test was used to compare the averages of the quantitative variables without a normal distribution. Satisfaction was analysed by a binary and ordinal regression analysis, univariate and multivariate. A P value less than 0.05 was considered statistically significant.

Results:

All the parameters of the study improved to a statistically relevant degree: frequency, nocturia, urgency, maximum voided volume, urge urinary incontinence. The overactive bladder short form questionnaire score improved but was not statistically significant.

Conclusions:

The use of transcutaneous electrostimulation of the posterior tibial nerve is a safe, effective and minimally invasive alternative in the treatment of overactive bladder when pharmacological treatment has failed. Patients had a good objective and subjective response in our study.

Level of evidence:

4.

Report and Research Agenda of the American Geriatrics Society and National Institute on Aging Bedside-to-Bench Conference on Urinary Incontinence in Older Adults: A Translational Research Agenda for a Complex Geriatric Syndrome

The American Geriatrics Society, with support from the National Institute on Aging and other funders, held its ninth Bedside-to-Bench research conference, entitled "Urinary Incontinence in the Older Adult: A Translational Research Agenda for a Complex Geriatric Syndrome," October 16 to 18, 2016, in Bethesda, Maryland. As part of a conference series addressing three common geriatric syndromes-delirium, sleep and circadian rhythm disturbance, and urinary incontinence-the series highlighted relationships and pertinent clinical and pathophysiological commonalities between these conditions. The conference provided a forum for discussing current epidemiology, basic science, and clinical and translational research on urinary incontinence in older adults; for identifying gaps in knowledge; and for developing a research agenda to inform future investigative efforts. The conference also promoted networking involving emerging researchers and thought leaders in the field of incontinence, aging, and other fields of research, as well as National Institutes of Health program personnel.

Efficacy of posterior tibial nerve stimulation (PTNS) on overactive bladder in older adults

INTRODUCTION

The main objective of this retrospective study is to determine the efficacy of transcutaneous posterior tibial nerve stimulation (TPTNS) in older patients with overactive bladder (OAB) syndrome. The secondary objective is to look for predictive factors of efficacy of this treatment.

METHODS

All patients aged over 65 years with OAB syndrome for which TPTNS was introduced between 2010 and 2016 in two neuro-urology centers were included. Age, gender, etiology of OAB, urinary symptoms and detrusor overactivity (DO) were retrospectively collected. The main outcome was efficacy of TPTNS (i.e., purchase of the device between 3 and 6 months).

RESULTS

A total of 264 patients were included (mean age 74.1 ± 6.5 years; 63.3% of women), of whom 53% had neurogenic OAB. Urinary incontinence was reported by 83.7% of patients and DO was found on urodynamic studies in 154 patients. The overall efficacy of TPTNS was 45.1%. None of the tested factors were significantly predictive of efficacy, especially age (≥ 75 years, p = 0.62), associated stress urinary incontinence (p = 0.69) and presence of DO (p = 0.60), whether neurogenic or not.

CONCLUSION

TPTNS is an effective treatment in older patients with OAB syndrome. No predictive factors of efficacy were found, especially age and DO. This treatment seems to be a good alternative to antimuscarinics against overactive bladder in older adults.

Characterizing the transcutaneous electrical recruitment of lower leg afferents in healthy adults: implications for non-invasive treatment of overactive bladder

BACKGROUND

As a potential new treatment for overactive bladder (OAB), we investigated the feasibility of non-invasively activating multiple nerve targets in the lower leg.

METHODS

In healthy participants, surface electrical stimulation (frequency = 20 Hz, pulse width = 200 μs) was used to target the tibial nerve, saphenous nerve, medial plantar nerve, and lateral plantar nerve. At each location, the stimulation amplitude was increased to define the thresholds for evoking (1) cutaneous sensation, (2) target nerve recruitment and (3) maximum tolerance.

RESULTS

All participants were able to tolerate stimulation amplitudes that were 2.1 ± 0.2 (range = 2.0 to 2.4) times the threshold for activating the target nerve.

CONCLUSIONS

Non-invasive electrical stimulation can activate neural targets at levels that are consistent with evoking bladder-inhibitory reflex mechanisms. Further work is needed to test the clinical effects of stimulating one or more neural targets in OAB patients.

Tibial Nerve Stimulation to Drive Genital Sexual Arousal in an Anesthetized Female Rat

BACKGROUND

There is clinical evidence that percutaneous tibial nerve stimulation can positively benefit women with female sexual interest/arousal disorder, yet no studies have explored the potential mechanisms further.

AIM

To investigate the effect of tibial nerve stimulation on vaginal blood perfusion (VBP) in an anesthetized rat model.

METHODS

16 ketamine-anesthetized rats were surgically implanted with a nerve cuff electrode on 1 tibial nerve. The tibial nerve was stimulated for 30 minutes continuously or non-continuously at a frequency of 10 to 25 Hz.

OUTCOMES

VBP was measured with laser Doppler flowmetry and analyzed using a wavelet transform of time-frequency representations with a focus on the neurogenic energy range (0.076-0.200 Hz).

RESULTS

25 of 33 (75.8%) stimulation periods had at least a 500% increase in laser Doppler flowmetry neurogenic energy compared with baseline. This increase was most common within 20 to 35 minutes after the start of stimulation. There was no statistically significant difference for frequency used or estrous cycle stage.

CLINICAL TRANSLATION

The results of this study provide further support for percutaneous tibial nerve stimulation as an alternative treatment option for women with genital arousal aspects of female sexual interest/arousal disorder.

STRENGTHS AND LIMITATIONS

This study successfully demonstrates the ability of tibial nerve stimulation to increase VBP. However, further studies to determine parameter optimization and to illuminate neural mechanisms are needed. Further studies also are necessary to determine effects of repeated stimulation sessions.

CONCLUSION

Long-duration tibial stimulation was successful at driving increases in the neurogenic component of VBP, providing evidence that tibial nerve stimulation could be used to treat genital arousal aspects of female sexual interest/arousal disorder by improving pelvic blood flow. Zimmerman LL, Rice IC, Berger MB, Bruns TM. Tibial Nerve Stimulation to Drive Genital Sexual Arousal in an Anesthetized Female Rat. J Sex Med 2018;15:296-303.

Transcutaneous electrical stimulation of somatic afferent nerves in the foot relieved symptoms related to postoperative bladder spasms

BACKGROUND

Bladder spasm is a common side effect of urological surgery. Main treatment modalities include opioids or anticholinergic medication; however, bladder spasms still occur even after these interventions. Recent studies indicate that transcutaneous stimulation of the foot can result in 50% increase in bladder capacity in healthy adults, and inhibit bladder detrusor overactivity in spinal cord injured patients. In this study, we examined the effects of transcutaneous electrical stimulation of the foot on bladder spasms related symptoms.

METHODS

Sixty-six male patients who underwent prostate or bladder surgeries due to benign prostatic hyperplasia or bladder diseases were randomly divided into two groups: the control group (n = 36) and the treatment group (n = 30). The control group received the routine postoperative care. The treatment group received daily transcutaneous electrical stimulation of the foot during 3 days after surgery; each time lasted for 60 min. All patients were evaluated by the Visual Analogue Scale for pain sensation, frequency of bladder spasm episodes, and a total score of bladder spasms symptoms.

RESULTS

In the control group, the patients with bladder surgery had a higher Visual Analogue Scale score than patients with prostate surgery (P = 0.024). In both treatment and control groups, the Visual Analogue Scale score, spasm frequency, and total score of bladder spasm symptoms decreased from day 1 to day 3 (P <0.001). The Visual Analogue Scale score at day 2, total score of bladder spasm symptoms at day 2 and day 3 were significantly lower in the treatment group than in the control group (P <0.05).

CONCLUSION

These results provided preliminary evidence suggesting beneficial effects of stimulating somatic afferent nerves in the foot on postoperative bladder spasms.

TRIAL REGISTRATION

The study was registered with Chinese Clinical Trial Registry on June 13 2016 ( http://www.chictr.org.cn/ ) (Identifier: ChiCTR-INR-16008635).

Electrical stimulation with non-implanted electrodes for overactive bladder in adults

BACKGROUND

Several options exist for managing overactive bladder (OAB), including electrical stimulation (ES) with non-implanted devices, conservative treatment and drugs. Electrical stimulation with non-implanted devices aims to inhibit contractions of the detrusor muscle, potentially reducing urinary frequency and urgency.

OBJECTIVES

To assess the effects of ES with non-implanted electrodes for OAB, with or without urgency urinary incontinence, compared with: placebo or any other active treatment; ES added to another intervention compared with the other intervention alone; different methods of ES compared with each other.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 10 December 2015). We searched the reference lists of relevant articles and contacted specialists in the field. We imposed no language restrictions.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials of ES with non-implanted devices compared with any other treatment for OAB in adults. Eligible trials included adults with OAB with or without urgency urinary incontinence (UUI). Trials whose participants had stress urinary incontinence (SUI) were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data from eligible trials and assessed risk of bias, using the Cochrane 'Risk of bias' tool.

MAIN RESULTS

We identified 63 eligible trials (4424 randomised participants). Forty-four trials did not report the primary outcomes of perception of cure or improvement in OAB. The majority of trials were deemed to be at low or unclear risk of selection and attrition bias and unclear risk of performance and detection bias. Lack of clarity with regard to risk of bias was largely due to poor reporting.For perception of improvement in OAB symptoms, moderate-quality evidence indicated that ES was better than pelvic floor muscle training (PFMT) (risk ratio (RR) 1.60, 95% confidence interval (CI) 1.19 to 2.14; n = 195), drug treatment (RR 1.20, 95% 1.04 to 1.38; n = 439). and placebo or sham treatment (RR 2.26, 95% CI 1.85 to 2.77, n = 677) but it was unclear if ES was more effective than placebo/sham for urgency urinary incontinence (UUI) (RR 5.03, 95% CI 0.28 to 89.88; n = 242). Drug treatments included in the trials were oestrogen cream, oxybutynin, propantheline bromide, probanthine, solifenacin succinate, terodiline, tolterodine and trospium chloride.Low- or very low-quality evidence suggested no evidence of a difference in perception of improvement of UUI when ES was compared to PFMT with or without biofeedback.Low- quality evidence indicated that OAB symptoms were more likely to improve with ES than with no active treatment (RR 1.85, 95% CI 1.34 to 2.55; n = 121).Low- quality evidence suggested participants receiving ES plus PFMT, compared to those receiving PFMT only, were more than twice as likely to report improvement in UUI (RR 2.82, 95% CI 1.44 to 5.52; n = 51).There was inconclusive evidence, which was either low- or very low-quality, for OAB-related quality of life when ES was compared to no active treatment, placebo/sham or biofeedback-assisted PFMT, or when ES was added to PFMT compared to PFMT-only. There was very low-quality evidence from a single trial to suggest that ES may be better than PFMT in terms of OAB-related quality of life.There was a lower risk of adverse effects with ES than tolterodine (RR 0.12, 95% CI 0.05 to 0.27; n = 200) (moderate-quality evidence) and oxybutynin (RR 0.11, 95% CI 0.01 to 0.84; n = 79) (low-quality evidence).Due to the very low-quality evidence available, we could not be certain whether there were fewer adverse effects with ES compared to placebo/sham treatment, magnetic stimulation or solifenacin succinate. We were also very uncertain whether adding ES to PFMT or to drug therapy resulted in fewer adverse effects than PFMT or drug therapy alone Nor could we tell if there was any difference in risk of adverse effects between different types of ES.There was insufficient evidence to determine if one type of ES was more effective than another or if the benefits of ES persisted after the active treatment period stopped.

AUTHORS' CONCLUSIONS

Electrical stimulation shows promise in treating OAB, compared to no active treatment, placebo/sham treatment, PFMT and drug treatment. It is possible that adding ES to other treatments such as PFMT may be beneficial. However, the low quality of the evidence base overall means that we cannot have full confidence in these conclusions until adequately powered trials have been carried out, measuring subjective outcomes and adverse effects.

Electrical stimulation with non-implanted electrodes for overactive bladder in adults

BACKGROUND

Several options exist for managing overactive bladder (OAB), including electrical stimulation (ES) with non-implanted devices, conservative treatment and drugs. Electrical stimulation with non-implanted devices aims to inhibit contractions of the detrusor muscle, potentially reducing urinary frequency and urgency.

OBJECTIVES

To determine the effectiveness of: ES with non-implanted electrodes compared with placebo or any other active treatment for OAB; ES added to another intervention compared with the other intervention alone; different methods of ES compared with each other.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 10 December 2014). We searched the reference lists of relevant articles and contacted specialists in the field. We imposed no language restrictions.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials of ES with non-implanted devices compared with any other treatment for OAB in adults. Eligible trials included adults with OAB with or without urgency urinary incontinence (UUI). Trials whose participants had stress urinary incontinence (SUI) were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data from eligible trials and assessed risk of bias, using the Cochrane Collaboration's 'Risk of bias' tool.

MAIN RESULTS

We identified 51 eligible trials (3443 randomised participants). Thirty-three trials did not report the primary outcomes of subjective change in OAB symptoms. The majority of trials were deemed to be at low or unclear risk of selection and attrition bias and unclear risk of performance and detection bias. Lack of clarity with regard to risk of bias was largely due to poor reporting.Twenty-three trials (1654 participants) compared ES with no active treatment, placebo or sham treatment. Moderate-quality evidence indicated that OAB symptoms were more likely to improve in people receiving ES than with no active treatment, placebo or sham treatment (relative risk (RR) for no improvement 0.54, 95% confidence interval (CI) 0.47 to 0.63). Moderate-quality evidence indicated that similar numbers of people receiving ES and no active treatment, placebo or sham treatment experienced adverse effects.Eight trials (542 participants) compared ES with conservative treatment. Very low-quality evidence suggested no evidence of a difference between ES and PFMT or PFMT plus biofeedback in OAB symptoms (RR for no improvement 0.79, 95% CI 0.51 to 1.21 and 0.97, 95% CI 0.60 to 1.57 respectively). There was no evidence of a difference between ES and conservative treatment with regard to adverse effects.Sixteen trials (894 participants) compared ES with drug treatment (probanthine, tolterodine, oxybutynin, propantheline bromide, solifenacin succinate, terodiline, trospium chloride, terodiline). Moderate-quality evidence indicated that OAB symptoms were more likely to improve with ES than drug treatment (RR for no improvement 0.66, 95% CI 0.48 to 0.90). Low-quality evidence suggested a greater risk of adverse effects with oxybutynin (RR 1.26, 95% CI 1.07 to 1.49) and with tolterodine (RR 1.51, 95% CI 1.21 to 1.89) than with ES. There was insufficient evidence of a difference between ES and trospium hydrochloride (RR 0.73, 95% CI 0.43 to 1.25).Eight trials (252 participants) compared ES combined with another treatment versus the other treatment alone, two trials (48 participants) compared ES plus conservative treatment with no active treatment, placebo or sham treatment and six trials (361 participants) compared different types of ES. None of these comparisons had sufficient evidence to indicate any differences between the treatment groups in terms of OAB or adverse effects.Moderate-quality evidence suggested that ES improved OAB-related quality of life more than no active treatment, placebo or sham treatment. There was insufficient evidence of any difference between ES and any other treatment with regard to quality of life.There was insufficient evidence to determine if the benefits of ES persisted after the active treatment period stopped.

AUTHORS' CONCLUSIONS

Electrical stimulation appeared to be more effective than both no treatment and drug treatment for OAB. There was insufficient evidence to determine if ES was more effective than conservative treatment or which type of ES was more effective. This review underlines the need to conduct well-designed trials in this field measuring subjective outcomes and adverse effects.

Posterior tibial nerve stimulation for the treatment of fecal incontinence: a systematic evidence review

IMPORTANCE AND OBJECTIVES

Posterior tibial nerve stimulation (PTNS) is a potential emerging therapy for fecal incontinence (FI). The aim of this study was to systematically review the literature regarding the efficacy of PTNS as a treatment of FI.

EVIDENCE ACQUISITION

We searched MEDLINE/PubMed, EMBASE, and Cochrane databases from inception through November 2013. We included English-language full-text articles reporting outcomes for FI with either percutaneous PTNS or transcutaneous techniques (transcutaneous electrical nerve stimulation). We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to assess study quality.

RESULTS

Our search yielded 1154 citations; 129 abstracts and 17 articles were included for full-text review. There were 13 case series and 4 randomized controlled trials. Fifteen studies were of low quality, none were of fair quality, and 2 studies were of good quality based on the Grades of Recommendation, Assessment, Development, and Evaluation system. In total, 745 subjects were studied, and of those, 90% were women and 10% were men. Studies involved percutaneous PTNS in 57% (428/745) of the subjects, transcutaneous electrical nerve stimulation in 30% (223/745), and sham technique in 13% (94/745). Therapy frequency, maintenance therapy, and follow-up time varied across studies. Eleven studies assessed FI episodes and bowel movement deferment time; all but 1 showed statistical improvement after therapy. Ten of the 11 studies that used the Cleveland Clinic Florida Fecal Incontinence score reported statistically significantly improved scores after treatment.

CONCLUSIONS AND RELEVANCE

Multiple low-quality studies show improvement in FI after PTNS. High-quality studies with comparison groups and clinically meaningful outcome measures would further establish the utility of PTNS for FI.

Non-invasive transcutaneous electrical stimulation in the treatment of overactive bladder

We reviewed the literature on transcutaneous electrical nerve stimulation (TENS) used as a therapy for overactive bladder (OAB) symptoms, with a particular focus on: stimulation site, stimuli parameters, neural structures thought to be targeted, and the clinical and urodynamic outcomes achieved. The majority of studies used sacral or tibial nerve stimulation. The literature suggests that, whilst TENS therapy may have neuromodulation effects, patient are unlikely to benefit to a significant extent from a single application of TENS and indeed clear benefits from acute studies have not been reported. In long-term studies there were differences in the descriptions of stimulation intensity, strategy of the therapy, and positioning of the electrodes, as well as in the various symptoms and pathology of the patients. Additionally, most studies were uncontrolled and hence did not evaluate the placebo effect. Little is known about the underlying mechanism by which these therapies work and therefore exactly which structures need to be stimulated, and with what parameters. There is promising evidence for the efficacy of a transcutaneous stimulation approach, but adequate standardisation of stimulation criteria and outcome measures will be necessary to define the best way to administer this therapy and document its efficacy.

Transcutaneous electrical nerve stimulation in the treatment of patients with poststroke urinary incontinence

Purpose

To investigate the therapeutic effect of transcutaneous electrical nerve stimulation (TENS) on poststroke urinary incontinence (UI).

Patients and methods

Sixty-one patients with poststroke UI were enrolled at the Neurology Department in the Shanghai Tenth People’s Hospital of Tongji University between January 2010–January 2011 and were divided into treatment and control groups (n=32 and n=29, respectively). TENS was applied to the treatment group, while the control group received basic therapy. The therapeutic group completed the whole set of TENS therapy with a treatment frequency of 30 minutes once a day for 60 days. The positive electrode was placed on the second lumbar spinous process, and the negative electrodes were inside the middle and lower third of the junction between the posterior superior iliac spine and ischia node. The overactive bladder symptom score, Barthel Index, and urodynamics examination were estimated before and after therapy in both groups.

Results

The daily micturition, nocturia, urgent urination, and urge UI in the treatment group significantly improved compared to the control group (P<0.05). The patients in the treatment group were superior in the self-care ability of daily living and also had an advantage over the indexes on maximum cystometry volume, flow rate, and the pressure of detrusor in the end of the filling phase.

Conclusion

TENS improved incontinence symptoms, enhanced the quality of life, and decreased adverse effects; hence, it is recommended in treating poststroke UI.