Evaluation of Percutaneous Tibial Nerve Stimulation for Treatment of Refractory Painful Bladder Syndrome

Our 11-Year Experience With Percutaneous Tibial Nerve Stimulation in Men and Women for the Treatment of Interstitial Cystitis/Bladder Pain Syndrome

OBJECTIVE

To evaluate the effect of percutaneous tibial nerve stimulation (PTNS) in interstitial cystitis/bladder pain syndrome (IC/BPS).

METHODS

Retrospective chart review was completed for patients with at least 10 weekly treatments of PTNS from January 2010 to October 2021. PTNS success was defined as conversion to PTNS maintenance therapy following 12weeks of PTNS induction therapy. Data were analyzed using GraphPad.

RESULTS

Over the 11-year study period, 27 out of 34 patients (mean age 52.9 ± 16.8years; 25 females, 9 males) completed 12weeks of PTNS induction therapy, and 48.1% (13/27) successfully converted to PTNS maintenance therapy. Following 12weeks of PTNS induction therapy, significant improvements were noted in the urgency severity scale (range 0-4: 2.9 ± 1.2 before vs 1.1 ± 1.1 after PTNS, P = .001) and nocturnal urinary frequency (number of voids: 3.3 ± 1.9 before vs 2.2 ± 1.6 after PTNS, P = .041); and nonsignificant improvements were noted in daytime void frequency (hours: 1.5 ± 0.7 before vs 2.0 ± 0.9 after PTNS, P = .090) and the pain domain of the interstitial cystitis symptoms index (question 4, range 0-4: 2.5 ± 1.4 before vs 1.3 ± 1.8 after PTNS, P = .082).

CONCLUSION

Our sample size is among the largest sample of PTNS in IC/BPS from a single center. While PTNS achieved nonsignificant improvements in pain and daytime void frequency, significant improvements were observed in urinary urgency and nocturia. PTNS appears to be a plausible option in the multimodal approach to managing IC/BPS.

Neuromodulation in Chronic Pelvic Pain: A Narrative Review

Chronic primary pelvic pain syndrome (CPPPS) is a heterogeneous disease with unknown pathogenesis and a lack of distinct pathological features, which complicates diagnosis and therapy and has a significant impact on patients' daily life. Because pharmacological management is ineffective and long-term use may result in additional system damage, developing a more effective treatment is critical. Neuromodulation has advanced rapidly over the last few decades, and various types of neuromodulations have demonstrated efficacy in the treatment of CPPPS. In this article we discuss the evolution of neuromodulation technology in the treatment of chronic pelvic pain, its application to various subtypes of chronic pelvic pain, and the comparison of relevant efficacy and parameter differences, as well as assess the relative advantages and disadvantages of sacral neuromodulation, percutaneous tibial nerve stimulation , transcutaneous electrical nerve stimulation, electroacupuncture, and pudendal neuromodulation. Furthermore, it was noted that chronic pelvic pain should be evaluated in terms of pain, associated symptoms, psychological problems, and quality of life. Although neuromodulation approaches have been shown to be effective in treating chronic pelvic pain, more extensive multicenter trials are required to confirm this.

Efficacy of transcutaneous tibial nerve stimulation in the treatment of bladder pain syndrome

Background

This study aimed to demonstrate the effectiveness of transcutaneos tibial nerve stimulation (TTNS) in the treatment of bladder pain syndrome (BPS).

Materials and methods

The data of 16 female patients, diagnosed with BPS in our clinic between 2019 and 2021 and had TTNS twice a week for 12 weeks, were retrospectively analyzed.

Results

The mean age of the patients was 46.00 ± 13.11 years, and the mean body mass index was 26.43 ± 3.07 kg/m². After the treatment, the median day time frequency of the patients decreased from 13.37 (3.69) to 10.25 (4.56) (p < 0.001). Nocturia also decreased after treatment from 4.37 (1.81) to 3.00 (1.94) (p = 0.001). The median voiding volume increased by 26.5 mL (p = 0.001). The median of the patients' visual analog scale scores decreased after treatment (median of visual analog scale score changed from interquartile range 8 [1] to 7 [4]) (p = 0.001). In addition, the median interquartile range interstitial cystitis symptom index scores decreased from 17 (4) to 15 (10) (p = 0.002).

Conclusions

In this study it was demonstrated that TTNS is an alternative method that can be successfully applied before invasive methods in the treatment of BPS.

Pathophysiology, assessment, and treatment of overactive bladder symptoms in patients with interstitial cystitis/bladder pain syndrome

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is prevalent, difficult to treat, and has close symptom overlap with overactive bladder (OAB). A review of the pathophysiology, assessment, and treatment of IC/BPS patients with overlapping OAB symptoms has not been summarized recently in the published literature.

METHODS

A review of the published literature on the overlap of IC/BPS and OAB was conducted using MeSH terminology (1992-2022).

RESULTS

The pathophysiology of IC/BPS is not fully understood. Animal research has found the bladder trigone and base are richly populated by afferent fibers, including many small unmyelinated C-fibers that may be upregulated in IC/BPS. Successful therapies with multimodal effects on OAB symptoms in patients with IC/BPS are likely to exert beneficial effects on both pain and lower urinary tract symptoms. Potentially efficacious therapies for the treatment of OAB in IC/BPS include pelvic floor physical therapy, oral pharmacotherapy (antimuscarinics and beta-3 agonists), sacral neuromodulation, percutaneous tibial nerve stimulation, and botulinum toxin A (BTA). Antimuscarinics and beta-3 agonists have yielded partial efficacy in IC/BPS, although may help differentiate symptoms of OAB from those associated with IC/BPS. The transvaginal trigone treatment (T3) intradetrusor injection approach allows for delivery of therapeutics to the bladder without the need for a cystoscope and appears to be feasible.

CONCLUSIONS

Further research is needed to understand the pathophysiology of IC/BPS and symptom overlap with OAB, which in turn should enable the development of more personalized therapeutics.

Current role of neuromodulation in bladder pain syndrome/interstitial cystitis

Neuromodulation is recommended by major international guidelines as a fourth-line treatment in bladder pain syndrome/interstitial cystitis (BPS/IC) patients after failure of behavioural, oral and intravesical pharmacological treatments, including hydrodistension. A non-systematic review of studies identified by electronic search of MEDLINE was performed with no time limitation. A narrative synthesis of the existing evidence regarding the results of sacral, tibial and pudendal nerve stimulation in the management of BPS/IC was developed. Neuromodulation in pelvic chronic pain disorders, including BPS/IC, is a useful tool for refractory patients to conventional treatments. Sacral neuromodulation may be effective in patients with BPS without Hunner's lesions, and the effect seems to be maintained in the mid- and long-term. Posterior tibial nerve stimulation can be offered to patients with BPS/IC in the context of a multidisciplinary approach. When pudendal neuralgia is suspected, selective pudendal nerve stimulation has a high response rate. The aetiology of the pain can influence the outcomes in the mid- and long-term of the different neuromodulation approaches, thus careful diagnosis is recommended.

First-line treatment posterior tibial nerve stimulation in patients with interstitial cystitis/bladder pain syndrome

Introduction

The aim of this study was to determine the effects of first-line treatment posterior tibial nerve stimulation (PTNS), applied once a week for a 12 week period, as a treatment modality for patients with Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS).

Material and methods

A total of 39 female patients with IC/BPS were enrolled in the study. Patients had one 30-minute session of PTNS per week for 12 weeks and symptoms were assessed before and after the treatment sessions by the use of a voiding diary, visual analog scale (VAS) for pain, O'Leary-Sant interstitial cystitis symptom index (ICSI), and O'Leary-Sant interstitial cystitis problem index (ICPI).

Results

The mean age of the patients was 38.9 ±7.1 years. The improvements in voiding diary parameters after 12 weeks of PTNS treatment were statistically significant compared to baseline but the changes in nocturia, and average voiding volume were not statistically significant. Mean parametric improvements after 12 weeks of PTNS treatment compared to baseline included a daytime frequency decrease by 3.8 voids daily, urgency episodes decrease by 4.7 episodes daily, nocturia decrease by 0.3 voids and voided volume improvement by a mean of 8.4 ml. The difference for ICSI, ICPI and VAS between baseline and the 12^th week of PTNS treatment scores demonstrated statistically significant improvements in pain severity, symptom and problem index.

Conclusions

The findings in this study demonstrated the improvements of voiding diaries, ICSI, ICPI and VAS scores in patients with IC/BPS after 12 weeks PTNS. PTNS treatment is a beneficial firs-line treatment option to IC/BPS symptom amelioration.

Percutaneous tibial nerve stimulation for the treatment of interstitial cystitis/bladder pain syndrome: a pilot study

OBJECTIVES

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic pain condition that requires multimodal management. The American Urologic Association includes sacral neuromodulation in the treatment algorithm for refractory IC/BPS. We sought to determine the rate of overall symptom improvement of IC/BPS symptoms, using validated measures, after treatment with percutaneous tibial nerve stimulation (PTNS), a form of peripheral neuromodulation.

METHODS

This was a single-arm, dual-center, pilot study examining a standard PTNS protocol in subjects with IC/BPS. Our primary outcome was subject response of "moderately" or "markedly improved" on the Global Response Assessment (GRA) scale after 12-weekly PTNS sessions. Assuming a 60% response rate, 24 subjects were needed to detect a response rate between 40 and 80% with 95% confidence. Secondary objectives included change in urinary frequency on a 24-h bladder diary, bladder pain as measured by VAS and responses to validated questionnaires for pelvic pain and IC/BPS.

RESULTS

Of 21 subjects enrolled, 16 initiated and 10 completed the PTNS treatment course. The GRA response rate was 40% at week 6 and 30% at week 12. Seventy percent of the cohort had some degree of improvement. There were no adverse events.

CONCLUSIONS

While only a minority of subjects with IC/BPS were responders to PTNS per GRA criteria, 70% of the cohort had some degree of improvement. Due to low recruitment and loss to follow-up, we did not achieve our predetermined significance. However, our promising findings add to the limited literature on this subject.

Benefits and Harms of Electrical Neuromodulation for Chronic Pelvic Pain: A Systematic Review

CONTEXT

Patients with chronic pelvic pain (CPP) may have pain refractory to conventional pain management strategies. Neuromodulation could provide relief of pain.

OBJECTIVE

To evaluate the benefits and harms of neuromodulation for CPP.

EVIDENCE ACQUISITION

A comprehensive search of EMBASE, PUBMED, and SCOPUS was performed for the entire database to January 2018. Studies were selected, data were extracted, and quality was assessed by two independent reviewers. A meta-analysis was used to combine randomized controlled trials (RCTs); otherwise, a narrative analysis was used.

EVIDENCE SYNTHESIS

After screening 1311 abstracts, 36 studies including eight RCTs were identified, enrolling 1099 patients. Studies covered a broad range in terms of phenotypes of CPP and methods of neuromodulation. A meta-analysis was possible for percutaneous tibial nerve stimulation and transcutaneous electrical nerve stimulation, which showed improvement in pain. Only narrative synthesis was possible for other modalities (sacral nerve stimulation, spinal cord stimulation, intravaginal electrical stimulation, and pudendal nerve stimulation) which appeared to reduce pain in patients with CPP. Treatments generally improved quality of life but with variable reporting of adverse events. Many studies showed high risks of bias and confounding.

CONCLUSIONS

While electrical neuromodulation may improve symptoms in CPP, further work is needed with high-quality studies to confirm it.

PATIENT SUMMARY

Neuromodulation may be useful in reducing pain and improving quality of life in patients with chronic pelvic pain, but more research is needed.

[Diagnosis and treatment of interstitial cystitis (IC/PBS) : S2k guideline of the German Society of Urology]

In this review article, the authors describe all relevant aspects of the new S2k guideline from the German Society of Urology (Deutschen Gesellschaft für Urologie, DGU) for the diagnosis and treatment of IC/PBS (interstitial cystitis/painful bladder syndrome). A list of necessary and optional examinations and the necessity of diagnosis of exclusion are summarized and evaluated. The treatment options listed (ranging from conservative, oral drug, and complementary medicine to interventional surgical procedures) also give the reader a good overview of the contents of the guideline and possible therapeutic approaches. Finally, the recommendations including consensus of the guideline group are also summarized in various information boxes.

[Diagnosis and treatment of interstitial cystitis (IC/PBS) : S2k guideline of the German Society of Urology]

In this review article, the authors describe all relevant aspects of the new S2k guideline from the German Society of Urology (Deutschen Gesellschaft für Urologie, DGU) for the diagnosis and treatment of IC/PBS (interstitial cystitis/painful bladder syndrome). A list of necessary and optional examinations and the necessity of diagnosis of exclusion are summarized and evaluated. The treatment options listed (ranging from conservative, oral drug, and complementary medicine to interventional surgical procedures) also give the reader a good overview of the contents of the guideline and possible therapeutic approaches. Finally, the recommendations including consensus of the guideline group are also summarized in various information boxes.

Neuromodulation for Pelvic and Urogenital Pain

Chronic pain affecting the pelvic and urogenital area is a major clinical problem with heterogeneous etiology, affecting both male and female patients and severely compromising quality of life. In cases where pharmacotherapy is ineffective, neuromodulation is proving to be a potential avenue to enhance analgesic outcomes. However, clinicians who frequently see patients with pelvic pain are not traditionally trained in a range of neuromodulation techniques. The aim of this overview is to describe major types of pelvic and urogenital pain syndromes and the neuromodulation approaches that have been trialed, including peripheral nerve stimulation, dorsal root ganglion stimulation, spinal cord stimulation, and brain stimulation techniques. Our conclusion is that neuromodulation, particularly of the peripheral nerves, may provide benefits for patients with pelvic pain. However, larger prospective randomized studies with carefully selected patient groups are required to establish efficacy and determine which patients are likely to achieve the best outcomes.