Transcutaneous Electrical Nerve Stimulation Combined with Oxybutynin is Superior to Monotherapy in Children with Urge Incontinence: A Randomized, Placebo Controlled Study

Updates of Overactive Bladder in Pediatrics

Overactive bladder (OAB) is clinically defined as urinary urgency with or without urinary incontinence. It is associated with daytime frequency or constipation and has a prevalence of approximately 5%-12% among 5- to 10-year-olds. The appropriate functional exchange between the pontine micturition center, periaqueductal gray matter, and prefrontal cortex is important for proper micturition control. Several studies on pediatric cases observed a link between OAB and neuropsychiatric problems, such as anxiety, depression, and attention deficit, and treatment of these comorbidities improved patient symptoms. In this review, we present the pathophysiology of OAB, its associated conditions, and aspects related to updates in OAB treatment, and we propose a step-by-step treatment approach following this sequence: behavioral therapy, medical treatment, and invasive treatment. Although anticholinergic drugs are the mainstay of OAB medical treatment, beta-3 agonists and alpha-blockers are now recommended as a result of significant advancements in pharmacologic treatment in the last 10 years. Electrical stimulation techniques and botulinum toxin are also effective and can be used, especially in conventional treatment-refractory cases.

Agreement between the visual analogue scale (VAS) and the dysfunctional voiding scoring system (DVSS) in the post-treatment evaluation of electrical nerve stimulation in children and adolescents with overactive bladder

INTRODUCTION

Electrical nerve stimulation is one of the most commonly used and well-tolerated treatments for overactive bladder (OAB); however, different studies have used different instruments to assess patients' response to treatment.

OBJECTIVE

To analyze agreement between use of the visual analogue scale (VAS) and the Dysfunctional Voiding Scoring System (DVSS) for assessing improvement in urinary symptoms following electrical nerve stimulation treatment in children and adolescents with OAB.

STUDY DESIGN

A cross-sectional analytical study including children and adolescents of 4-17 years of age diagnosed with OAB who underwent 20 sessions of transcutaneous (TENS) or percutaneous (PENS) electrical nerve stimulation. The DVSS and the VAS were used to assess daytime urinary symptoms before and following treatment. While the DVSS was always applied by a physician, the VAS was applied separately by a physiotherapist and then by a physician. Treatment was considered successful when the DVSS score was zero and the VAS score was ≥90%. Correlations between post-treatment VAS and DVSS scores were evaluated using the kappa coefficient. The VAS scores evaluated by the different professionals were compared for agreement using intraclass correlation and the Bland-Altman plot.

RESULTS

Data from 49 cases were available for analysis. Of these, 27 (55.1%) were girls. Mean age was 7.1 ± 2.6 years. There was agreement between the two instruments used, the DVSS and the VAS, in 36/49 patients (73.5%), with a moderate Kappa of 0.44. There was moderate agreement between the VAS scores applied by the two different professionals.

DISCUSSION

imitations of the present study include the small sample size and the fact that the inter-observer evaluation was conducted following a single sequence, i.e. all the patients were first evaluated by the physiotherapist and then by the physician, which may have biased answers and the post-treatment VAS scores. Furthermore, although the child participated actively in completing the questionnaires, in cases of divergent answers, the questions were redirected to the responsible adult, and the final answer may not fully represent the patient's true situation.

CONCLUSION

The present study found moderate agreement between the DVSS and the VAS, and moderate agreement between VAS scores when the instrument was applied by two different professionals. Although both tools appear to be important, and possibly complementary, a DVSS score of zero precludes the need to apply the VAS.

Physical Agent-Based Treatments for Overactive Bladder: A Review

Almost one-fifth of the people in the world experience a decrease in quality of life due to overactive bladder (OAB) syndrome. The main bothersome symptoms are urgency accompanied by urinary frequency and nocturia. This chronic, disabling condition is first managed by reducing fluid intake and pelvic floor muscle training, supplemented with antimuscarinic drugs, if necessary. However, refractory cases often still occur. In more severe cases, invasive surgical interventions can be considered; yet, the success rate is still inconsistent, and there is a high complication rate. This condition is frustrating for patients and challenging for the medical staff involved. Although its pathophysiology has not been fully elucidated, peripheral autonomic somatic and sensory afferent receptors are considered to be involved in this condition. Hence, currently, physical agent-based treatments such as neuromodulation have taken a significant place in the third-line therapy of OAB. The efficacy and safety profiles of electrical and magnetic stimulation continue to evolve. Physical-based agents provide an appealing option owing to their effectiveness and minimal side effects. In addition, more physical therapies using light and shock energy are currently being investigated. Thus, a comprehensive understanding of these modalities is an extremely important aspect to provide the most suitable modalities for patients.

Effectiveness of a Practical, At-Home Regimen of Parasacral Transcutaneous Electrical Nerve Stimulation in Pediatric Overactive Bladder

OBJECTIVE

To describe and evaluate efficacy of a more practical, at-home regimen of parasacral transcutaneous electrical nerve stimulation (TENS) for pediatric overactive bladder (OAB).

METHODS

We prospectively enrolled patients with OAB.

INCLUSION CRITERIA

age 5-13 years and willingness to try TENS.

EXCLUSION CRITERIA

urinary tract anatomic abnormalities, current use of OAB medications, neurologic condition, and elevated post-void residual. Patients were instructed to complete 20-minute sessions 2x/day for one month.

RESULTS

We enrolled 21 patients (3 male, 18 female; median age 9.9 years). We had complete VSS data on 17 patients and frequency-volume chart data on 12 patients. Median % of TENS sessions completed was 98%.

CONCLUSION

In our cohort of medically-refractory OAB pediatric patients, nearly half reported subjective improvement with our regimen, despite modest objective improvement. Our compliance rates suggest this regimen is practical but may be best used as an adjunct to other therapies.

Electric nerve stimulation for overactive bladder: an umbrella review

Numerous systematic reviews and meta-analyses have reported the effect of electrical nerve stimulation (ENS) on overactive bladder (OAB). However, these results are contradictory. We conducted an umbrella review to summarize the evidence and evaluate the effectiveness of ENS for OAB by using an umbrella review methodology from multiple perspectives with sufficient methodological quality. We searched the PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL and PsycINFO databases and two Chinese databases (CNKI and CBM) to identify articles written in English or Chinese that were published up to 15 February 2021. Two authors of this review independently selected the studies, assessed their quality, and extracted the data from all the included studies. We performed a quality assessment of eligible reviews using the AMSTAR 2.0 tool and estimated the summary effect size, 95% confidence intervals, 95% prediction intervals and heterogeneity. Ten systematic reviews and meta-analyses covering 89 randomized controlled trials and 16 prospective cohort studies with a total population of 5004 participants that investigated the effect of ENS for OAB in terms of 17 different outcomes were identified. ENS seems effective and safety for OAB, with our results showing weak evidence of clinical efficacy and no evidence of side effects. To recommend ENS as a practical treatment option for OAB, however, more high-quality research is needed.

Transcutaneous electrical nerve stimulation as add-on therapy in children receiving anticholinergics and/or mirabegron for refractory daytime urinary incontinence: A retrospective cohort study

AIMS

To investigate if children with daytime urinary incontinence (DUI) and overactive bladder (OAB) refractory to standard urotherapy and medicinal treatment, would experience improvement in symptoms after add-on treatment with transcutaneous electrical nerve stimulation (TENS).

METHODS

Children were retrospectively enrolled from tertiary referral centers at Aarhus and Aalborg University Hospitals. All data were retrieved from the patients' journals. All children were prescribed TENS as an add-on treatment to the highest-tolerable dose of medicinal treatment in a standardized regime of 2 h a day for around 3 months. Primary endpoints were the number of wet days per week (WDPW) and incontinence episodes per day. Effect of treatment was defined as greater or equal to 50% reduction in the frequency of DUI episodes. Secondary endpoints were to establish predictive factors for the effect of treatment using logistic regression.

RESULTS

Seventy-six children diagnosed with DUI and OAB refractory to treatment with standard urotherapy and pharmacological treatment, at the age of 5-16 years were included from February 2017 to February 2020. A reduction in WDPW (from 6.31 [5.86-6.61] to 4.27 [3.45-4.90], p < 0.05) and incontinence episodes per day (from 2.45 [1.98-2.91] to 1.43 [1.07-1.80], p < 0.05) was observed. Twelve patients became completely dry. At 6 months follow-up, seven of the 12 complete responders had relapsed while five remained dry. A history of constipation before TENS was a predictor of poor treatment response (p = 0.016).

CONCLUSIONS

TENS as add-on to anticholinergic treatment seems effective in a number of children with treatment-refractory DUI.

Comparing the outcomes of parasacral transcutaneous electrical nerve stimulation for the treatment of lower urinary tract dysfunction in children: A systematic review and meta-analysis of randomized controlled trials

AIMS

Despite published evidence in recent decades suggesting improvement in lower urinary tract symptoms (LUTS) with the use of parasacral transcutaneous electrical nerve stimulation (PTENS), no consensus guidelines for therapy exist. This study systematically reviews the literature to assess the effect of PTENS in children with LUTS.

METHODS

A database search conducted up to December 2019 included Medline, EMBASE, and the Cochrane Library. From the literature review, 6 randomized controlled studies (234 participants) comparing PTENS and standard treatment (urotherapy/anticholinergics) were considered. From each study, the success rates were available for PTENS and the control group. The ratio of success rates was computed-that is, the risk ratio (RR) and the risk difference (RD).

RESULTS

The overall success rate with PTENS was 1.92 times that of children undergoing standard urotherapy alone (RR: 1.92, 95% confidence interval [CI: 1.02, 3.61]) and 1.56 for those undergoing either urotherapy alone or with pharmacotherapy (anticholinergics; RR: 1.56, 95% CI [1.04, 2.40]). No difference in the success rate was found when PTENS was used in patients failing previous treatment (urotherapy and pharmacological therapy; RR: 0.175, 95% CI [0.02, 1.45]).

CONCLUSIONS

Current evidence suggests that PTENS is beneficial in children with LUTS. The chance of success is 1.92 times that of children undergoing standard urotherapy. However, in children who have failed urotherapy and pharmacological therapy, PTENS monotherapy has a limited role and should be an adjunct. Literature shortcomings included small numbers of patients, differing inclusion criteria, and PTENS protocols. A need exists for quality multicenter randomized controlled trials to prove the efficacy of PTENS in children with LUTS.

Role of Transcutaneous Electrical Nerve Stimulation in Treating Children With Overactive Bladder From Pooled Analysis of 8 Randomized Controlled Trials

Purpose

Transcutaneous electrical neural stimulation (TENS), as a non-invasive modality, has been clinically used as an alternative treatment for children with overactive bladder (OAB). We conducted a pooled analysis to explore the effect of TENS on OAB.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-analysis guideline was followed in this study. The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases, as well as the reference lists of the retrieved studies, were used to find trials relevant for assessing the use of TENS to treat OAB.

Results

Of the 246 records identified, 8 publications were analyzed in our study. Our analysis found that TENS resulted in a greater decrease of wet days/wk, daily voiding frequency, daily incontinence episodes, and daily number of voids than was observed in the control group. Furthermore, TENS-treated patients showed similar visual analogue scale (VAS) scores to patients in the control group, demonstrating that the application of TENS did not increase patients’ discomfort and pain. TENS had a relative advantage in the number of partial responses, but no clear differences were found in frequency of no response or a full response compared to the control group. In urodynamic testing, TENS led to obvious improvements in average voided volume and maximum voided volume in children with OAB.

Conclusions

TENS had a remarkable effect on the improvement of urodynamic indexes and objective OAB symptoms without a significant increase in VAS scores for children with OAB.

Do overactive bladder symptoms and their treatment-associated changes exhibit a normal distribution? Implications for analysis and reporting

AIMS

To explore the use of means vs medians (assuming or not the presence of normal distribution) in studies reporting overactive bladder syndrome symptoms and to test for normal distribution of basal values and treatment-associated changes thereof in two large noninterventional studies.

METHODS

Systematic review of all original studies reporting on at least one overactive bladder syndrome symptom published in four leading urology journals in 2016 to 2017. Testing of the normal distribution of urgency, incontinence, frequency, and nocturia in two large noninterventional studies (n = 1335 and 745).

RESULTS

Among 48 eligible articles, 86% reported means (assuming a normal distribution), 6% medians (not making this assumption), and 8% a combination thereof. Baseline values for all four symptoms and treatment-associated alterations thereof deviated from a normal distribution (P < .0001 in all cases). Means overestimated basal value and absolute changes thereof as compared with medians, for example, basal number of incontinence episodes in study 1 5.1 vs 4. Differences between means and medians for percentage changes of symptoms were small and did not consistently favor means over medians.

CONCLUSIONS

Dominant reporting of means implies the assumption of a normal distribution of overactive bladder syndrome symptoms but our data from two noninterventional studies do not support this assumption. We recommend that basal values and absolute symptom changes should be reported as medians and subjected to nonparametric analysis; means may be appropriate for the reporting of percentage changes of symptoms.

'Rapid transit' constipation in children: a possible genesis for irritable bowel syndrome

Children with chronic idiopathic constipation (CIC) often end up at the surgeon when medical treatments have failed. This opinion piece discusses a recently described pattern of CIC called 'Rapid transit constipation (RTC)' first identified in 2011 as part of surgical workup. RTC was identified using a nuclear medicine gastrointestinal transit study (NMGIT or nuclear transit study) to determine the site of slowing within the bowel and to inform surgical treatment. Unexpectedly, we found that RTC occured in 29% of 1000 transit studies in a retrospective audit. Irritable bowel syndrome (IBS) occurs in 7-21% of the population, with a higher prevalence in young children and with constipation type dominating in the young. While 60% improve with time, 40% continue with symptoms. First-line therapy for IBS in adults is a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols which reduces symptoms in > 70% of patients. In children with functional gastrointestinal disorders, fructose intolerance occurs in 35-55%. Reducing fructose produced significant improvement in 77-82% of intolerant patients. In children with RTC and a positive breath test upon fructose challenge, we found that exclusion of fructose significantly improved constipation, abdominal pain, stool consistency and decreased laxative use. We hypothesise that positive breath tests and improvement of pain and bowel frequency with sugar exclusion diets in RTC suggest these children have IBS-C. These observations raise the possibility that many children with CIC could be treated by reducing fructose early in their diet and this might prevent the development of IBS in later life.

Conservative interventions for treating functional daytime urinary incontinence in children

BACKGROUND

In children, functional daytime urinary incontinence is the term used to describe any leakage of urine while awake that is not the result of a known underlying neurological or congenital anatomic cause (such as conditions or injuries that affect the nerves that control the bladder or problems with the way the urinary system is formed). It can result in practical difficulties for both the child and their family and can have detrimental effects on a child's well-being, education and social engagement.

OBJECTIVES

To assess the effects of conservative interventions for treating functional daytime urinary incontinence in children.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains studies identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 11 September 2018). We also searched Chinese language bibliographic databases: Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and Wanfang. No language restrictions were imposed.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised, multi-arm studies, cross-over studies and cluster-randomised studies that included children aged between 5 and 18 years with functional daytime urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened records and determined the eligibility of studies for inclusion according to predefined criteria. Where data from the study were not provided, we contacted the study authors to request further information. Two review authors assessed risk of bias and processed included study data as described in the Cochrane Handbook for Systematic Reviews of Interventions. Where meta-analysis was possible, we applied random-effects meta-analysis using the Mantel-Haenszel method for dichotomous outcomes.

MAIN RESULTS

The review included 27 RCTs involving 1803 children. Of these, six were multi-arm and one was also a cross-over study. Most studies were small, with numbers randomised ranging from 16 to 202. A total of 19 studies were at high risk of bias for at least one domain. Few studies reported data suitable for pooling due to heterogeneity in interventions, outcomes and measurements.Individual conservative interventions (lifestyle, behavioural or physical) versus no treatmentTranscutaneous electrical nerve stimulation (TENS) versus sham (placebo) TENS. More children receiving active TENS may achieve continence (risk ratio (RR) 4.89, 95% confidence interval (CI) 1.68 to 14.21; 3 studies; n = 93; low-certainty evidence).One individual conservative intervention versus another individual or combined conservative interventionPelvic floor muscle training (PFMT) with urotherapy versus urotherapy alone. We are uncertain whether more children receiving PFMT with urotherapy achieve continence (RR 2.36, 95% CI 0.65 to 8.53, 95% CI 25 to 100; 3 studies; n = 91; very low-certainty evidence).Voiding education with uroflowmetry feedback and urotherapy versus urotherapy alone. Slightly more children receiving voiding education with uroflow feedback and urotherapy may achieve continence (RR 1.13, 95% CI 0.87 to 1.45; 3 studies; n = 151; low-certainty evidence).Urotherapy with timer watch versus urotherapy alone. We are uncertain whether urotherapy plus timer watch increases the number of children achieving continence compared to urotherapy alone (RR 1.42, 95% CI 1.12 to 1.80; 1 study; n = 58; very low-certainty evidence).Combined conservative interventions versus other combined conservative interventionsTENS and standard urotherapy versus PFMT with electromyographic biofeedback and standard urotherapy. We are uncertain whether there is any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 1.11, 95% CI 0.73 to 1.68; 1 study; n = 78; very low-certainty evidence).PFMT with electromyography biofeedback and standard urotherapy versus PFMT without feedback but with standard urotherapy. We are uncertain whether there is any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 1.05, 95% CI 0.72 to 1.52; 1 study; n = 41; very low-certainty evidence).Individual conservative interventions versus non-conservative interventions (pharmacological or invasive, combined or not with any conservative interventions)PFMT versus anticholinergics. We are uncertain whether more children receiving PFMT than anticholinergics achieve continence (RR 1.92, 95% CI 1.17 to 3.15; equivalent to an increase from 33 to 64 per 100 children; 2 studies; n = 86; very low-certainty evidence).TENS versus anticholinergics. We are uncertain whether there was any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 0.81, 95% CI 0.05 to 12.50; 2 studies; n = 72; very low-certainty evidence).Combined conservative interventions versus non-conservative interventions (pharmacological or invasive, combined or not with any conservative interventions)Voiding education with uroflowmetry feedback versus anticholinergics. We are uncertain whether there was any evidence of a difference between treatment groups in the proportion of children achieving continence (RR 1.02, 95% CI 0.58 to 1.78; 1 study; n = 64; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The review found little reliable evidence that can help affected children, their carers and the clinicians working with them to make evidence-based treatment decisions. In this scenario, the clinical experience of individual clinicians and the support of carers may be the most valuable resources. More well-designed research, with well-defined interventions and consistent outcome measurement, is needed.

EMG biofeedback or parasacral transcutaneous electrical nerve stimulation in children with lower urinary tract dysfunction: A prospective and randomized trial

AIMS

Evaluate the efficacy of biofeedback and parassacral electric nerve stimulation (TENS) for the treatment of children with lower urinary tract (LUT) dysfunction.

METHODS

A prospective, randomized study was approved by our Hospital Ethics Committee. We enrolled 64 children, 43 girls and 21 boys, average age of 9.39 years. The initial evaluation consisted of history, physical examination, urine analyses, voiding diary, uroflow, and ultrasound. Dysfunction voiding symptom score (DVSS) questionnaires were applied pre- and post-treatment. The children were divided into two treatment groups independent of the predominant type of voiding dysfunction (dysfunctional or overactive bladder): biofeedback group and TENS group. The criteria for assessing the effectiveness of the techniques was the resolution of daytime and nighttime symptoms including urinary leakage, improvements in voiding diary, DVSS, and changes in uroflow. After 6 months, the children were reassessed with the same work-up of baseline.

RESULTS

Regarding daytime symptoms, results for complete response were similar between the two groups (P = 0.483); 54.9% of children treated by the biofeedback group and 60.6% in the TENS group. The same have been observed in the nighttime incontinence with complete resolutions in 29.6% and 25%, respectively ( P = 0.461). Analyzing the voiding diary, uroflow and DVSS questionnaires both groups had significant improvement ( P = 0.001) after treatment. The biofeedback group required fewer sessions than TENS group, 10.9 and 18.1, respectively ( P < 0,001).

CONCLUSIONS

Both biofeedback and the TENS are equally effective for treating non-neurogenic voiding dysfunction. Biofeedback seems to require a lower number of sessions to obtain similar results of the TENS.

Percutaneous electrical stimulation for overactive bladder in children: a pilot study

PURPOSE

The purpose of this was to evaluate the efficacy (tolerance and safety) of once-a-week parasacral percutaneous electrical nerve stimulation (PENS) to treat overactive bladder (OAB) in children.

MATERIALS AND METHODS

This is a prospective case series of children aged 4-14 years who underwent PENS for OAB. Acupuncture needles were used bilaterally and symmetrically at S3 for sacral nerve stimulation (Figure). Eighteen children with pure OAB underwent PENS weekly for 20 weeks. Frequency was 10 Hz. Intensity varied up to a maximum of 10 mA, as tolerated by the participant, but without reaching the motor threshold. Pulse width was 600 μs Patients' voiding history was assessed before treatment using a structured questionnaire. The dysfunctional voiding scoring system (DVSS) was used before and after treatment to quantify symptoms of lower urinary tract dysfunction. A visual analog scale (VAS) was used to evaluate treatment outcome.

RESULTS

Seven boys and eleven girls (mean age, 7.82 ± 2.45 years) were included. According to the VAS, symptoms were resolved in 66% of patients. Urinary urgency, present in all children at baseline, was resolved in 84% (P = 0.001). The proportion of patients with involuntary loss of urine without urgency decreased from 77% before treatment to 27% (P = 0.04). Urge incontinence resolved in 13 of 16 patients after treatment (P = 0.001). Only one of the 12 children with frequent urination at baseline reported this complaint after treatment (P = 0.04). All cases of recurrent urinary tract infection were resolved (P = 0.001). Regarding nocturnal enuresis, treatment was successful in 9 of 14 children (P = 0.004).

DISCUSSION

The theory behind this new method is that when skin impedance is overcome through the use of acupuncture needles and greater proximity is attained between the tip of the electrode and the sacral nerves, a more effective stimulus is achieved, with enough energy to provide the same benefits as parasacral transcutaneous electrical nerve stimulation with the advantage that treatment can be given only once a week.

CONCLUSIONS

Percutaneous electrical nerve stimulation seems to be an effective and safe treatment for OAB over the short term. Furthers studies with a control group are needed.

Overactive Bladder in Children

Overactive bladder (OAB) is clinically defined as the presence of urinary urgency and may be associated with diurnal urinary incontinence, frequency, and enuresis, and/or constipation. In children aged 5–10 years, the prevalence is 5–12%. Association with emotional disorders is widely described in the literature. Constipation is associated with voiding symptoms because of crosstalk between the gastrointestinal tract and the urinary tract. OAB is believed to be multifactorial. Correct functioning between the pontine micturition centre, the periaqueductal grey matter, anterior cingulate gyrus, and prefrontal cortex is important for correct voiding development and the process of maturation. Patients with OAB have greater anterior cingulate gyrus activity and deactivation of the pontine micturition centre urinary inhibition process, leading to a greater frequency of bladder repletion sensation. Urotherapy is the first treatment to be initiated and aims to change behavioural patterns inthese patients. Other treatment options are anticholinergics, with oxybutynin being the most widely studied, but also described is the use of tolterodine, darifenacin, and mirabegron. Alternative treatments, such as nerve stimulation in the parasacral or the posterior tibial area, have shown improvement of symptoms in comparative studies with conventional drug treatment, and, in refractory cases, botulinum toxin A is an option. In this article, we review the pathophysiology, associated conditions, and aspects related to diagnosis and treatment of OAB.